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. Test the patient's reading comprehension before using visual handouts.
Testing reading comprehension can be helpful but is not sufficient on its own to assess the patient’s overall learning preferences or needs.
B. Use a hands-on approach, because it works best for most people.
While hands-on learning is effective, assuming it works best for everyone may overlook individual learning preferences.
C. Ask the patient whether he learns best visually, aurally, or kinesthetically. Asking the patient’s learning preferences enables the nurse to tailor education to the patient's strengths.
D. Use a combination of the three modes of learning to enhance learning. Combining all modes without considering the patient's preferences may not be as effective as directly addressing the patient's specific learning style.