A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?
Left knee incision 1 inch in length without redness, drainage, or edema.
Patient is hard to care for and refuses all treatments and medications. Family is present.
Status unchanged, doing well.
Patient seems to be in pain and states, "I feel uncomfortable."
The Correct Answer is A
A. Provides objective, specific, and measurable data. Meets legal and professional documentation standards.
B. Subjective, non-therapeutic, and judgmental; inappropriate for a legal document.
C. Vague and lacks detail; "doing well" is nonspecific.
D. "Seems to be" is vague. Better to document verbatim statements and objective observations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
A. Lack of knowledge is an internal barrier because it relates to personal understanding or awareness that can impede change.
B. Lack of facilities is an external barrier, as it relates to resources or infrastructure beyond the individual’s control.
C. Lack of defined goals is also an internal barrier as it affects an individual's ability to plan and implement change effectively.
D. Lack of social supports is an external barrier, affecting the individual’s ability to implement change based on external factors.
E. Lack of materials is an external barrier, which is beyond the individual’s personal capability to change but rather a resource issue.
Correct Answer is D
Explanation
A. Psychomotor learning refers to physical skills and actions.
B. Kinesthetic learning is related to physical movement, which does not apply to learning facts like this.
C. Affective learning involves changes in feelings, values, or attitudes.
D. Cognitive learning involves acquiring knowledge and facts. In this case, the patient learned a factual detail about normal heart rate.
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