Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?
“Taking fluids poorly, but more than yesterday."
"Apparently comfortable all night. Offers no complaints of pain."
"Patient says she is still slightly nauseated, would like to try some toast and tea."
"4 cm reddened area over sacrum. Skin intact, warm, and dry."
The Correct Answer is D
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.
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View Related questions
Correct Answer is D
Explanation
A. "I don't feel like walking today either."
This response shifts the focus from the patient to the nurse and does not encourage further discussion about the patient's reluctance or explore the reasons behind it.
B. "You have to walk today."
This statement sounds forceful and dismissive, and may make the patient feel pressured rather than supported. It does not invite dialogue or provide understanding.
C. "Why don't you want to walk today?"
This question can sound judgmental and may put the patient on the defensive. A more neutral response would help the nurse understand the patient's reluctance without pressure.
D. "You don't want to walk today?"
This response reflects the patient's own words back, validating their feelings and opening up the opportunity for the patient to explain their reasons. It is empathetic and nonjudgmental, which encourages therapeutic communication.
Correct Answer is C
Explanation
A. wrings her hands and paces around the room while denying that she is upset.
This example reflects incongruence. The patient's body language (pacing, wringing hands) suggests anxiety or distress, which does not match her verbal denial of being upset.
B. states she is comfortable while she frowns, and her teeth are clenched.
This example also reflects incongruence. Her facial expression and clenched teeth contradict her statement of comfort, indicating her communication is not aligned.
C. is tearful and slow in speech when talking about her husband's death.
This example reflects congruence. The patient’s verbal expression and nonverbal cues are aligned, indicating that her communication is consistent with her emotions.
D. smiles and laughs while speaking of feeling lonely and depressed.
This example reflects incongruence. Smiling and laughing contradict the verbal expression of loneliness and depression, indicating a mismatch in her communication.