A resident in a skilled nursing facility for a short-term rehabilitation following a hip replacement says to the nurse, "I don't want to have you draw any more blood for those useless tests." When the nurse fails to convince the patient to have the blood drawn, the most appropriate documentation would be:
"Blood not drawn because tests are no longer desired by patient."
"Refuses to have blood drawn; says tests are 'useless. Doctor notified."
"Doctor notified of failure to draw ordered blood work."
"Refuses to have blood drawn. Doctor notified."
The Correct Answer is B
A. "Blood not drawn because tests are no longer desired by patient."
This statement is vague and lacks specific details regarding the patient's exact refusal and the communication with the doctor.
B. "Refuses to have blood drawn; says tests are 'useless.' Doctor notified."
This response documents the patient's refusal with their exact words ("useless") and also notes that the doctor has been informed, which is essential for clear, complete documentation.
C. "Doctor notified of failure to draw ordered blood work."
This documentation lacks the reason for the blood draw failure (patient refusal) and omits the patient’s specific wording.
D. "Refuses to have blood drawn. Doctor notified."
Although this documents the refusal and the doctor’s notification, it omits the patient’s exact words, which can provide additional context for the healthcare team.
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Correct Answer is C
Explanation
A. Test the patient's reading comprehension before using visual handouts.
Testing reading comprehension can be helpful but is not sufficient on its own to assess the patient’s overall learning preferences or needs.
B. Use a hands-on approach, because it works best for most people.
While hands-on learning is effective, assuming it works best for everyone may overlook individual learning preferences.
C. Ask the patient whether he learns best visually, aurally, or kinesthetically. Asking the patient’s learning preferences enables the nurse to tailor education to the patient's strengths.
D. Use a combination of the three modes of learning to enhance learning. Combining all modes without considering the patient's preferences may not be as effective as directly addressing the patient's specific learning style.
Correct Answer is A
Explanation
A. "What was your daughter's reaction to your desire for hospice?" This is an open-ended question as it invites the patient to share feelings or reactions in a broad, unrestricted way.
B. "Did you sleep all night without waking?" This is a closed-ended question that can be answered with a simple "yes" or "no."
C. "How many bowel movements have you had today?" This is a closed-ended question asking for a specific number.
D. “Is your pain less today than it was yesterday?" This is a closed-ended question that requires a "yes" or "no" answer.