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 C
Explanation
A. Motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience.
Accessing information without being the assigned caregiver is inappropriate, regardless of motivation, as it breaches confidentiality and privacy protocols.
B. Doing appropriate research about nursing care as long as information is not divulged. Even without sharing information, accessing a patient’s chart without need-to-know status is a privacy violation and does not constitute appropriate research.
C. Violating the confidentiality of the patient's record.
This choice is correct as the student is breaching confidentiality by accessing patient records without a care-related need to know. Only those involved in the patient's care should access their chart.
D. Neglecting the assigned patient load and should read the unassigned patient’s medical record only after his assigned work is completed.
Reading an unassigned patient’s record, even after finishing other duties, is still a breach of confidentiality.
Correct Answer is C
Explanation
A. "Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."
This documentation provides details but lacks specific information on the pain’s nature and duration.
B. "Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."
This statement includes diet details but lacks a pain intensity rating and specific location.
C. "Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids." This statement is the most thorough, including location, nature, intensity, duration, and lack of relief from interventions.
D. "Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."
This is incomplete, as it lacks a specific location and description of the pain’s onset.