A charge nurse is reviewing the documentation completed by a newly licensed nurse. Which of the following entries should the charge nurse recommend for revision?
The client demonstrated proper technique when drawing up 8 units of insulin.
The client stated ‘’I struggle to see those little lines on the syringe’’
The client FBS was 95 mg/dl
The client seems to be more comfortable performing self-administration of insulin.
The Correct Answer is D
Choice D:
The client seems to be more comfortable performing self-administration of insulin: The use of the term “seems” introduces subjectivity, which weakens the clarity and objectivity of the documentation. It’s better to describe specific observations or objective findings. For instance, instead of using “seems,” the nurse could note how the client demonstrated confidence or performed the task with ease, providing concrete evidence of improvement.
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Correct Answer is D
Explanation
A) Experiencing the pain of grief:
Experiencing the pain of grief is one of the early stages of mourning, according to Worden's tasks of grieving. This task involves confronting and processing the emotional pain and sorrow that accompany the loss. However, the statement provided by the client — "I am learning how to pay my own bills" — suggests they are adapting to life changes and responsibilities, which is more aligned with the later stages of grieving. This does not reflect the immediate pain of grief, but rather a focus on adjusting to life after the loss.
B) Finding an enduring connection while embarking on a new life:
Finding an enduring connection while embarking on a new life refers to the task of establishing a continued relationship with the deceased, while simultaneously moving forward with one's life. While this task is essential in the long-term grieving process, it does not directly relate to the client's statement, which focuses on practical changes, such as learning to manage finances, rather than a spiritual or emotional connection with the deceased.
C) Accepting the reality of the loss:
Accepting the reality of the loss is another important task in Worden’s model. This involves coming to terms with the fact that the loved one is gone. However, the client's focus on learning practical tasks like paying bills indicates that they are already moving beyond the initial stages of grief, not just accepting the loss. The statement does not clearly indicate that the client is still in the phase of accepting the reality of the loss, but rather adjusting to the changes that the loss has brought.
D) Adjusting to an environment without the deceased:
The client's statement, "I am learning how to pay my own bills," suggests they are taking on new responsibilities and adjusting to the changes brought about by the death of their partner. This aligns with Worden’s task of adjusting to an environment without the deceased, which includes taking on new roles and responsibilities that the deceased partner previously managed, such as financial tasks, household duties, and other life changes.
Correct Answer is D
Explanation
A) Role-play:
Role-playing is a teaching strategy where the client or learner acts out a scenario or situation to practice certain behaviors, such as interacting with others in a social or clinical setting. In this case, the nurse is not asking the client to simulate a scenario or interact with others, but instead, to physically perform a specific task (walking with a walker).
B) Question-and-answer:
The question-and-answer method involves the nurse asking the client questions to assess understanding or clarify information. This method typically involves verbal interaction rather than performing a physical skill. In this scenario, the nurse is not simply asking questions, but rather observing the client as they perform the physical task of walking with a walker.
C) Discussion:
Discussion is a method of teaching where ideas or concepts are shared and discussed, often in a conversational format. While the nurse might use discussion as part of the overall teaching, the act of having the client physically demonstrate walking with a walker is a separate and more focused teaching strategy.
D) Return demonstration:
Return demonstration is the teaching strategy in which the nurse shows the client how to perform a task (such as walking with a walker) and then asks the client to perform the task themselves to confirm understanding and skill acquisition. This method allows the nurse to assess the client’s ability to perform the task correctly and ensures that the client has learned the skill effectively.
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