A nurse is documenting a patient's condition in a narrative chart. The patient reports sudden onset chest pain while gardening Which of the following chart entries best exemplifies accurate and complete narrative charting?
Patient has chest pain. Needs to see a doctor.
Patient states, I suddenly felt a sharp pain in my chest while gardening Rates pain as 6/10. No radiating pain reported. Blood pressure: 145/95 mm Hg Heart rate: 100 beats/min, regular.
The patient was gardening when they got chest pain. Blood pressure high
The patient felt pain in the chest while in the garden. No further information provided
The Correct Answer is B
A. Patient has chest pain. Needs to see a doctor.: This entry is vague and lacks essential subjective and objective data. It does not include the client’s own words, pain characteristics, or vital signs. Narrative charting requires detailed, specific, and measurable information.
B. Patient states, “I suddenly felt a sharp pain in my chest while gardening.” Rates pain as 6/10. No radiating pain reported. Blood pressure: 145/95 mm Hg. Heart rate: 100 beats/min, regular.: This entry includes subjective data in the client’s own words, objective assessment findings, and relevant vital signs. It clearly documents onset, quality, severity, and associated findings. This reflects accurate, complete, and legally sound narrative charting.
C. The patient was gardening when they got chest pain. Blood pressure high: This statement lacks specific pain description, numeric values, and patient-reported details. Terms such as “high” are non-measurable and imprecise. Incomplete data limits clinical usefulness.
D. The patient felt pain in the chest while in the garden. No further information provided.: This entry is incomplete and omits critical assessment details such as pain severity, vital signs, and associated symptoms. Narrative charting must provide sufficient information to guide clinical decision-making.
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Related Questions
Correct Answer is D
Explanation
A. Nutrition: Poor nutrition increases the risk of skin breakdown over time by impairing tissue repair and skin integrity. While important, nutrition is a longer-term risk factor and does not address the client’s immediate mechanical risk.
B. Activity: Reduced mobility contributes to pressure injury development, but it is a broader category encompassing overall movement. The client’s sliding in bed specifically increases friction and shear forces, which require more immediate intervention.
C. Sensory Perception: Sensory deficits affect the client’s ability to feel discomfort and reposition independently. Although relevant, the client’s issue is primarily mechanical rather than related to sensory awareness.
D. Friction and Shear: The client frequently slides down in bed, directly increasing friction and shear on the sacral area. Addressing this category with interventions such as repositioning devices, proper support surfaces, and transfer techniques is critical to prevent immediate tissue injury.
Correct Answer is A
Explanation
A. Wipe from front to back after using the restroom: This intervention reduces the transfer of fecal bacteria (commonly E. coli) from the perineal area to the urethra, directly targeting the mode of transmission in the chain of infection. Proper hygiene interrupts the pathway for bacterial entry into the urinary tract.
B. Increase fluid intake to flush out bacteria: Drinking adequate fluids helps dilute urine and promote urinary flow, which aids in clearing bacteria. While preventive, this action affects the host defense rather than the mode of transmission.
C. Take prescribed antibiotics as directed: Completing antibiotics prevents persistence or recurrence of infection by eliminating existing bacteria. This addresses the infectious agent rather than the transmission pathway.
D. Avoid using scented hygiene products: Scented soaps or feminine hygiene sprays can irritate the urethra and alter normal flora, but this primarily affects host susceptibility rather than the mode of transmission.
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