A nurse is caring for a client.

For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged.

Rationale:

A. Frequent use of abbreviations can lead to misinterpretation, errors, and confusion, especially if nonstandard or unclear abbreviations are used. While abbreviations can save time, safety and clarity are more important than speed in documentation.

B. Including subjective opinions rather than objective observations is not appropriate. Documentation should reflect factual, accurate, and observable data rather than personal interpretations or assumptions about the patient’s condition.

C. Using medical jargon to appear professional is not recommended, as it may reduce clarity for other healthcare providers who review the chart. Clear, precise, and standardized language improves communication and patient safety.

D. Recording findings immediately after completing the assessment ensures that information is accurate, complete, and current. Timely documentation reduces the risk of errors or omissions, provides a reliable record for other healthcare providers, and supports safe, effective continuity of care.

Rationale:

A. Otitis externa, also called "swimmer’s ear," affects the external auditory canal. Common findings include ear pain, tenderness when the outer ear is manipulated, discharge, and canal edema. It does not typically cause a bulging tympanic membrane with decreased mobility, so this option is unlikely.

B. Otitis media is an infection or inflammation of the middle ear. Classic signs include bulging, erythematous tympanic membrane, decreased mobility on pneumatic otoscopy, and sometimes fluid or pus behind the membrane. This combination of findings directly matches the nurse’s observation and is consistent with acute otitis media.

C. Tympanic membrane perforation involves a rupture or hole in the eardrum. Assessment would reveal a visible opening or defect, sometimes with drainage, but not bulging or decreased mobility. Perforation usually relieves pressure rather than causing a tense, bulging appearance.

D. Presbycusis is age-related hearing loss that affects high-frequency hearing over time. It does not cause visible changes in the tympanic membrane, such as bulging or erythema, and is not associated with decreased membrane mobility.