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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Correct Answer is D
Explanation
A. Include another person in the instruction because an 82-year-old person will be unable to master the technique. This is an assumption based on age and is incorrect. Age alone does not determine learning ability; many older adults are fully capable of learning new skills.
B. Provide written material and diagrams alone. While written materials are helpful, they should be supplemented with hands-on practice and guidance, especially for skill-based learning.
C. Speed through the details because age and experience will shorten learning time. Older adults may actually require a slower pace to absorb new information, particularly for complex tasks.
D. Slow the pace and frequently ask questions to assess comprehension. Slowing the pace and asking questions helps ensure the patient has the time needed to process the information and provides the nurse with feedback on understanding.
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.