The nurse conducts a physical assessment. What action should the nurse take when documenting a client's physical assessment?
Document by adding the date and time to the end of every entry.
Document data in a subjective manner to ensure accuracy.
Document information the previous nurse provided during report.
Document assessment findings as client care is provided.
The Correct Answer is D
A. Document by adding the date and time to the end of every entry: While dating and timing entries is required, it is only part of proper documentation practice. Accurate, timely recording of findings as they occur is more critical for safe care and communication.
B. Document data in a subjective manner to ensure accuracy: Subjective documentation captures the client’s reported experiences, but objective data from physical assessment should be recorded factually, without interpretation, to ensure accuracy and reliability.
C. Document information the previous nurse provided during report: Information from prior shifts is useful for continuity of care but should not replace the nurse’s own assessment. Documentation must reflect the current nurse’s direct findings and observations.
D. Document assessment findings as client care is provided: Recording findings in real-time ensures accuracy, timeliness, and completeness. It provides a reliable account of the client’s status, supports clinical decision-making, and facilitates safe, coordinated care.
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Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Inspection: Inspection is the first step in a respiratory assessment because it allows the nurse to observe the client’s overall respiratory effort, chest symmetry, use of accessory muscles, and breathing pattern. It is noninvasive and provides essential visual information about the client’s respiratory status before performing any physical manipulation.
• Percussion: Percussion is performed last because it involves tapping the chest to assess underlying tissue density and lung sounds, which can be uncomfortable for the client if done first. It provides additional information about areas of consolidation, fluid, or air in the lungs. Percussion is best completed after inspection, palpation, and auscultation, ensuring the assessment progresses from least to most invasive.
Correct Answer is B
Explanation
A. "Would you like me to get you pain medication?": Offering medication addresses symptom relief but does not provide information about the cause of new abdominal pain. Immediate assessment is needed before interventions to ensure safe and appropriate treatment.
B. "What were you doing when you first noticed the pain?": Asking about the onset and circumstances of the pain helps the nurse gather critical information to determine potential causes, severity, and urgency. This guides further assessment and intervention, ensuring the client’s safety.
C. "Do you think you might be constipated?": This question assumes a specific cause without a thorough assessment. While constipation may be relevant, it should not be the first inquiry when evaluating new abdominal pain, as other urgent causes must be ruled out.
D. "Can you remember what you had for dinner last evening?": Dietary history can be part of assessment, but it is less immediate than understanding the onset and characteristics of the pain. Initial priority is identifying factors related to the pain’s sudden onset.
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