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 B
Explanation
A. "Blood not drawn because tests are no longer desired by patient."
This statement is vague and lacks specific details regarding the patient's exact refusal and the communication with the doctor.
B. "Refuses to have blood drawn; says tests are 'useless.' Doctor notified."
This response documents the patient's refusal with their exact words ("useless") and also notes that the doctor has been informed, which is essential for clear, complete documentation.
C. "Doctor notified of failure to draw ordered blood work."
This documentation lacks the reason for the blood draw failure (patient refusal) and omits the patient’s specific wording.
D. "Refuses to have blood drawn. Doctor notified."
Although this documents the refusal and the doctor’s notification, it omits the patient’s exact words, which can provide additional context for the healthcare team.
Correct Answer is A
Explanation
A. The nurse-patient relationship ends when the patient is discharged.
The nurse-patient relationship is time-limited and often ends when the patient is discharged, which aligns with its structured, goal-oriented nature.
B. A social relationship does not have goals or needs to be met. While social relationships may not have structured goals, they can still have mutual needs or goals. In contrast, the nurse-patient relationship has specific health-related goals and objectives focused on patient care.
C. The focus is mainly on the nurse in the nurse-patient relationship. This is incorrect, as the primary focus of the therapeutic relationship is on the patient's needs and well-being, not the nurse’s.
D. A social relationship does not require trust or sharing of life experiences. Social relationships do require trust and sharing of experiences; however, they are typically not bound by the professional boundaries, goals, and time limitations that define the nurse-patient relationship.