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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. Oral learning. Oral learning involves verbal instruction, which could be part of the teaching but isn’t the primary method when demonstrating a physical task.
B. Visual learning. Visual learning is present here, as the patient observes the nurse’s demonstration, which can be effective for understanding the technique.
C. Kinesthetic learning. Kinesthetic learning involves a hands-on approach where the patient would actively participate in the task, enhancing skill retention through doing.
D. Auditory learning. Auditory learning occurs through listening, which would be part of an oral explanation but is less emphasized here than visual or kinesthetic methods.
Correct Answer is D
Explanation
A. "I think you should live with your family." This is too directive and imposes the nurse’s opinion rather than allowing the patient to explore their own options.
B. "Why don't you live with your family?" This response may come across as judgmental or dismissive, potentially making the patient feel defensive.
C. "If you were my mom, I'd have you live with me." This statement is not helpful and shifts the focus to the nurse’s feelings rather than exploring the patient’s concerns.
D. "Where have you considered living?" This is an open-ended question that invites the patient to discuss their thoughts and feelings, facilitating a more patient-centered response.