When a nurse is "talking through" a procedure or assisting the patient to learn, the nurse encourages the patient to:
write down the steps as she performs them.
read the listed steps written on a poster board on the wall.
verbalize each step until the steps are memorized.
close her eyes and envision the process.
The Correct Answer is C
A. write down the steps as she performs them.
Writing down the steps may help the patient review later but does not actively engage the patient in learning during the procedure.
B. read the listed steps written on a poster board on the wall.
Reading steps on a poster board can provide visual support but doesn’t actively involve the patient in recalling or practicing the procedure.
C. verbalize each step until the steps are memorized.
Verbalizing each step is an active form of learning that reinforces memory and helps the patient feel more comfortable with the process, making it an effective teaching strategy.
D. close her eyes and envision the process.
Visualization can help with memory, but it may not be as effective as actively verbalizing each step for practical, hands-on tasks.
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Correct Answer is C
Explanation
A. "Come and get me if Mr. Jones has a high heart rate." This statement lacks specificity, as “high heart rate” is vague. The assistant may not know what range constitutes “high.”
B. "I need to know if Mr. Jones' blood pressure is elevated."
This statement is also too vague, as the assistant may not understand what is considered "elevated."
C. "If Mr. Jones' heart rate is greater than 100, let me know."
This direction is clear and specific, providing a measurable parameter for the assistant to follow, making it the best option.
D. "Let me know if Mr. Jones' temperature is high."
"High" is vague, as it does not provide a specific value or range for temperature.
Correct Answer is D
Explanation
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.