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 C
Explanation
A. wrings her hands and paces around the room while denying that she is upset.
This example reflects incongruence. The patient's body language (pacing, wringing hands) suggests anxiety or distress, which does not match her verbal denial of being upset.
B. states she is comfortable while she frowns, and her teeth are clenched.
This example also reflects incongruence. Her facial expression and clenched teeth contradict her statement of comfort, indicating her communication is not aligned.
C. is tearful and slow in speech when talking about her husband's death.
This example reflects congruence. The patient’s verbal expression and nonverbal cues are aligned, indicating that her communication is consistent with her emotions.
D. smiles and laughs while speaking of feeling lonely and depressed.
This example reflects incongruence. Smiling and laughing contradict the verbal expression of loneliness and depression, indicating a mismatch in her communication.
Correct Answer is C
Explanation
A. Defensive response
A defensive response would involve protecting oneself or one's position rather than addressing the patient’s concerns. The nurse’s statement here is more dismissive than defensive.
B. Asking probing questions
Probing questions would involve persistent questioning, which does not apply here, as the nurse is not asking questions but making a dismissive comment.
C. Using clichés
"Every cloud has a silver lining" is a cliché, which may come across as dismissive and minimize the patient’s concerns. Using clichés can make the patient feel unheard and invalidated.
D. Changing the subject
Changing the subject would involve diverting attention to an unrelated topic. The nurse here is not introducing a new topic but is using a cliché instead.