The client states, "I hate this place. I want to go home. No one listens to me, and my doctor has not been in to see me today." The client's arms are folded across his chest. His brow is furrowed, and he will not allow morning vital sign measurements. Which entry should be included in the nurse's charting?
based on the conversation with the patient, the patient is unhappy with care
upon interaction with the patient, the patient seems angry today
the patient is angry, unsatisfied with care, and wants to go home
patient states. “I hate this place want to go home. No one listens to me and my doctor has not been in to see me today"
The Correct Answer is D
A. based on the conversation with the patient, the patient is unhappy with care: This statement includes the nurse’s interpretation rather than the patient’s exact words and feelings, which is less objective for documentation.
B. upon interaction with the patient, the patient seems angry today: This phrase is subjective and vague, lacking specific patient statements or observable behaviors, making it less precise for clinical records.
C. the patient is angry, unsatisfied with care, and wants to go home: This summarizes the nurse’s opinion rather than providing direct quotes or factual observations, which is not ideal for accurate documentation.
D. patient states, “I hate this place. I want to go home. No one listens to me, and my doctor has not been in to see me today.”: This is a direct quote from the patient, providing clear, objective documentation of the patient’s feelings and statements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Patient lives with her partner in a one-story home: Living in a one-story home is not inherently a risk factor for sensory deficits. The home environment may impact mobility, but it does not directly contribute to vision, hearing, or other sensory issues.
B. Patient reports she worked in the military as an airplane mechanic: Working in the military as an airplane mechanic may expose the patient to high noise levels, which can cause hearing loss over time. Prolonged exposure to loud noises is a significant risk factor for sensory deficits, particularly for hearing.
C. Patient recently had grab rails installed in her bathroom: The installation of grab rails is a safety measure to reduce the risk of falls and is not directly related to sensory deficits. While it is a precautionary action, it does not indicate any sensory impairment or risk for deficits.
D. Patient schedules annual eye exams with her ophthalmologist: Regular eye exams are preventive measures that help detect sensory deficits early, particularly vision problems. This behavior indicates a proactive approach to maintaining eye health, not sensory deficits.
Correct Answer is D
Explanation
A. "I heard you immediately when you came in my room": In REM sleep, the brain is highly active, but the body is in a state of paralysis. A person in REM sleep is less likely to respond quickly to external stimuli, such as hearing someone enter the room.
B. "I feel really cold": Feeling cold is not typically associated with REM sleep. It could be due to other factors like body temperature regulation or environmental conditions but is not a key feature of REM sleep.
C. "It feels like I just went to sleep": This suggests the person was likely in a deeper stage of non-REM sleep. REM sleep typically has an active brain with vivid dreams, making it unlikely for the client to feel like they just fell asleep.
D. "I was having a great dream and I remember all of it": Vivid dreams and memory recall are characteristic of REM sleep. This stage is when the brain is most active in terms of dreaming, making it common for individuals to remember their dreams if they are awakened during this phase.
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