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 D
Explanation
A. Use unfamiliar language.
Unfamiliar language can confuse or intimidate young children, making it harder for them to understand and communicate effectively.
B. Use abstract explanations. Preschoolers are concrete thinkers and may not grasp abstract ideas, so explanations should be simple and direct.
C. Use long, complex sentences. Long, complex sentences may overwhelm a preschooler, who benefits more from short and clear sentences.
D. Consider the developmental level, using familiar words.
This approach is ideal as it aligns with the child’s cognitive abilities, helping the child feel comfortable and understand the nurse’s communication.
Correct Answer is C
Explanation
A. Share information with the patient about other patients and why they are hospitalized. Sharing information about other patients violates confidentiality and does not help establish trust. This is unprofessional and goes against HIPAA guidelines.
B. Share his own personal experiences so that the patient gets to know him as a friend. Although occasional sharing of personal experiences may enhance rapport, extensive sharing can shift focus from the patient to the nurse, which is unprofessional and can create boundary issues.
C. Act in a trustworthy and reliable manner; respect the individuality of the patient. Acting in a trustworthy, reliable manner and respecting the patient's individuality establishes rapport by building trust, ensuring the patient feels valued and respected. This is the most professional approach.
D. Identify himself by name and title each time he introduces himself. Introducing oneself by name and title is essential, but it alone does not fully establish rapport. It is part of a courteous approach, but rapport-building requires deeper engagement.