A nurse is documenting objective findings for a patient undergoing a cardiology assessment. Which of the following entries should the nurse include in the medical record to ensure accurate and legally appropriate documentation?
Patient complains of chest pain and states it started an hour ago.
Plan to initiate beta-blocker therapy and educate patient on medication adherence.
Blood pressure measured at 142/88 mm Hg, with a regular rhythm and bounding pulse.
Observed patient appeared anxious and seemed uncomfortable during examination.
The Correct Answer is C
Choice A reason: Documenting patient complaints of chest pain is accurate, but the phrase "states it started an hour ago" is subjective. While necessary for the chart, objective documentation focuses on measurable data, whereas this entry is a mix of subjective reporting rather than a purely clinical physical assessment finding.
Choice B reason: Documentation of a plan is part of the nursing process, but it describes future intentions rather than a current objective assessment finding. Legal documentation requires a clear separation between what was physically observed during the assessment and the subsequent clinical orders or care planning steps taken.
Choice C reason: This entry is strictly objective, providing measurable hemodynamic data (blood pressure) and specific physical assessment findings (regular rhythm, bounding pulse). This level of detail is essential for legal and clinical accuracy, as it provides a verifiable record of the patient's physiological state during the examination.
Choice D reason: Describing a patient as appearing "anxious" or "seeming uncomfortable" relies on subjective interpretation of the patient's behavior. Objective documentation should describe the clinical observations that led to the conclusion, such as "patient pacing, respiratory rate 22/min, diaphoresis present," rather than using vague subjective labels.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Cranial nerve VII, the facial nerve, is primarily responsible for facial expressions, taste on the anterior two-thirds of the tongue, and lacrimation. While it has sensory and motor functions, it is not the primary nerve associated with the complex swallowing reflex mechanism, which involves the pharynx.
Choice B reason: Cranial nerve IX, the glossopharyngeal nerve, provides motor innervation to the stylopharyngeus muscle and sensory innervation to the pharynx, posterior one-third of the tongue, and tonsils. It is critical for the gag reflex and coordinating the muscular actions necessary for efficient, safe swallowing, making it the primary focus here.
Choice C reason: Cranial nerve V, the trigeminal nerve, handles motor function for muscles of mastication and sensory input from the face. While mastication is the initial stage of ingestion, dysphagia specifically related to the swallowing reflex is more directly mediated by the glossopharyngeal and vagus nerves.
Choice D reason: Cranial nerve I, the olfactory nerve, is exclusively sensory and is responsible for the sense of smell. It does not play any role in the motor function of the oropharyngeal muscles or the coordination of the swallowing reflex, thus it is irrelevant to the assessment of dysphagia.
Correct Answer is A
Explanation
Choice A reason: The S1 heart sound represents the closure of the atrioventricular valves, and S2 represents the closure of the semilunar valves. The interval between S1 and S2 corresponds to ventricular systole. Any audible turbulence or vibration detected during this specific cardiac phase is classified as a systolic murmur, often resulting from increased blood flow or valvular pathology.
Choice B reason: While S1 and S2 are considered expected heart sounds, turbulence audible during the systolic phase is considered an adventitious sound. An expected or normal heart examination typically involves clear, crisp valvular closures without audible swishing or blowing sounds, which indicate abnormal blood flow patterns.
Choice C reason: The third heart sound is a low-frequency sound occurring during the rapid filling phase of early diastole, immediately following S2. It is produced by the vibration of the ventricular walls as blood rushes into the ventricles. It is not associated with the systolic interval between S1 and S2.
Choice D reason: The fourth heart sound is a low-pitched sound heard in late diastole, just before S1. It is generated by the atrial contraction forcing blood into a stiff, non-compliant ventricle. Like the S3, this sound occurs during diastole and is not related to the turbulence occurring during the systolic interval.
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