A nurse is documenting the results of an evaluation in a client's chart. Which of the following information should the nurse include? (Select all that apply.).

The date and time of the evaluation.

The methods used to measure outcomes.

The revisions made to the plan of care.

The rationale for choosing interventions.

The comparison of outcomes with goals.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

The date and time of the evaluation are essential to document because they provide a reference point for the progress of the patient and the effectiveness of the nursing interventions. They also help to establish a timeline of events and facilitate communication among the health care team.

Choice B reason:

The methods used to measure outcomes are important to document because they show how the nurse assessed the patient's condition and whether the expected outcomes were met, partially met, or not met. They also provide evidence of the quality and consistency of care provided by the nurse.

Choice C reason:

The revisions made to the plan of care are necessary to document because they reflect the changes in the patient's status and needs, as well as the nurse's clinical judgment and decision making. They also demonstrate the ongoing evaluation and adaptation of the nursing care plan to achieve optimal outcomes for the patient.

Choice D reason:

The rationale for choosing interventions is not required to document because it is part of the planning phase of the nursing process, not the evaluation phase. The rationale for choosing interventions should be based on evidence-based practice, standards of care, and clinical guidelines, which are already established and available for reference.

Choice E reason:

The comparison of outcomes with goals is essential to document because it shows whether the nursing care plan was effective in addressing the patient's problems and improving the patient's condition. It also helps to identify areas of improvement, gaps in care, and opportunities for learning and feedback.

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Correct Answer is B

Explanation

Choice A reason:

This statement is not objective data because it is based on what the client states, not what the nurse observes or measures. This is an example of subjective data, which is information that depends on personal feelings.

Choice B reason:

This statement is objective data because it is based on what the nurse observes or measures using a thermometer and a pulse oximeter. This is an example of objective data, which is information that is factual and can be verified.

Choice C reason:

This statement is not objective data because it is based on the nurse's interpretation of the client's appearance and behavior, not on direct observation or measurement. This is an example of subjective data, which is information that represents the patient's perceptions, feelings, or concerns.

Choice D reason:

This statement is not objective data because it is based on what the client reports, not what the nurse observes or measures. This is an example of subjective data, which is information that the patient tells the nurse that cannot be measured or observed.

A. Compare data with normal values and standards. B. Organize data into clusters that have similar underlying causes. C. Validate data by using multiple sources of information. D. Document data using standardized terminology and abbreviations. E. Prioritize data according to urgency and importance.

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

Comparing data with normal values and standards is an important action for the nurse to take during the assessment phase of the nursing process. This helps the nurse to identify any deviations from normal and potential problems that need further investigation or intervention.

Choice B reason:

Organizing data into clusters that have similar underlying causes is another action that the nurse should take during the assessment phase. This helps the nurse to recognize patterns and relationships among the data and to formulate nursing diagnoses.

Choice C reason:

Validating data by using multiple sources of information is also an action that the nurse should take during the assessment phase. This helps the nurse to ensure that the data are accurate, complete, and factual, and to avoid making assumptions or errors.

Choice D reason:

Documenting data using standardized terminology and abbreviations is not an action that the nurse should take during the assessment phase of the nursing process. Although documentation is an essential part of nursing practice, it is not specific to the assessment phase. Moreover, standardized terminology and abbreviations are not always appropriate or clear for documenting data.

Choice E reason:

Prioritizing data according to urgency and importance is another action that the nurse should take during the assessment phase of the nursing process. This helps the nurse to focus on the most relevant and significant data and to plan for further assessment or intervention based on the patient's needs and priorities.

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A nurse is documenting the results of an evaluation in a client's chart. Which of the following information should the nurse include? (Select all that apply.).

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