A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:

"Severe pain around umbilicus, unable to sleep because of pain. Started approximately 2 hours after lunch."

"Abdominal pain, unrelieved by antacids. Had spaghetti, salad, coffee, and ice cream cake for lunch."

"Periumbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids."

"Pain at level of 7 to 8. Nothing has relieved or lessened pain, it just keeps getting worse."

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is B

Explanation

A. is packing belongings in preparation for discharge. Although discharge is an appropriate time for patient education, it may be too late to introduce complex information that requires practice or understanding. Teaching moments often occur earlier in the care process.

B. says, "How will I remember all the things about my new diet?" This is an ideal teaching moment as the patient is expressing concern and showing readiness to learn about the diet. The nurse can use this moment to provide guidance on strategies to remember dietary instructions.

C. has just returned from surgery for a deviated septum. Immediately post-surgery, the patient may be under the influence of anesthesia or pain medication, limiting their ability to absorb information. Teaching at this time may not be effective.

D. has just been told of the malignancy of his tumor. Right after receiving bad news, patients may experience shock, grief, or distress, making it difficult for them to process additional information. This may not be the right time for education.

A. “Taking fluids poorly, but more than yesterday." B. "Apparently comfortable all night. Offers no complaints of pain." C. "Patient says she is still slightly nauseated, would like to try some toast and tea." D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."

Correct Answer is D

Explanation

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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A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:

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Naxlex Comprehensive Predictor Exams

The nurse would identify an opportunity for a “teaching moment” in the situation of a patient who:

Correct Answer is B

Explanation

Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

Correct Answer is D

Explanation

When a patient states, "My son hasn't been to see me in months," the nurse's best verbal response is:

A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical record to take, because it is her personal property. An appropriate response would be:

The nurse is aware that the use of false reassurance is harmful to the nurse-patient relationship, because this communication block:

The nurse is alert to avoid using blocks to effective communication that include: (Select all that apply.)

The nurse is caring for a patient who states, "I tossed and turned last night." The nurse responds to the patient, "You feel like you were awake all night?" This is an example of:

The nurse is caring for a patient who is concerned about living alone. The best response by the nurse is:

When interacting with an older adult patient, the nurse would enhance communication by:

Patient education for an 82-year-old patient to perform a dressing change to be done at home after discharge, the nurse would adjust the teaching session to: