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 C
Explanation
A. Judgmental response.
This isn’t necessarily judgmental, as it doesn't express an opinion about the patient’s feelings or concern.
B. Using clichés.
Clichés are general or overused phrases meant to provide comfort but are not present here.
C. Changing the subject.
Changing the subject dismisses the patient's concern without acknowledging it, which is evident here as the nurse diverts to breakfast without addressing the worry.
D. Giving false reassurance.
False reassurance involves saying something unrealistic to make the patient feel better, which isn't directly done here.
Correct Answer is ["A","C","D","E"]
Explanation
A. Asking probing questions. Probing questions can feel invasive, leading to discomfort or defensiveness from the patient.
B. Using nonjudgmental remarks. Nonjudgmental remarks foster open communication, so this is not a communication block.
C. Changing the subject. Changing the subject shows disregard for the patient’s thoughts or feelings, which can block effective communication.
D. Using clichés. Clichés can make patients feel as though their concerns are not truly heard or understood.
E. Giving advice. Giving advice without patient input can make the patient feel undervalued and less autonomous.
F. Offering hope. Offering realistic hope and encouragement can actually facilitate communication, as long as it’s not false reassurance.