The nurse is caring for a nonverbal client who is moaning with position changes, the hands and teeth are clenched, and the skin is very diaphoretic.
The nurse interprets this as the client is experiencing pain and decides to administer an analgesic.
What is the correct term for this nursing action?

Setting priorities.

Recognizing inconsistencies.

Making inferences.

Using empathy.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Setting priorities involves deciding the order in which nursing interventions should be implemented based on the urgency and importance of the client's needs. While addressing pain is often a high priority, the term itself doesn't specifically describe the cognitive process of interpreting nonverbal cues as pain.

Choice B rationale

Recognizing inconsistencies involves identifying discrepancies between verbal and nonverbal cues, or between the client's stated condition and observed behaviors. While the nurse is observing nonverbal cues, the primary action here is interpreting those cues, not necessarily identifying inconsistencies.

Choice C rationale

Making inferences involves interpreting cues and drawing conclusions based on available data. The nurse observes the client's moaning, clenched hands and teeth, and diaphoresis, and infers that these signs indicate the presence of pain. This interpretation then guides the decision to administer an analgesic.

Choice D rationale

Using empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing care and may contribute to the nurse's interpretation of the client's distress, the specific cognitive process of interpreting the nonverbal cues as pain is termed making inferences.

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Correct Answer is C

Explanation

Choice A rationale

SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool used for verbal or written reports, focusing on concise information transfer during transitions of care or urgent situations, not a comprehensive charting system based on exceptions.

Choice B rationale

Focused charting centers on specific patient problems or concerns, using a DAR (Data, Action, Response) format. It addresses particular issues in detail rather than documenting only deviations from the norm.

Choice C rationale

Charting by exception (CBE) is a documentation system where nurses only document findings that are outside the normal range or significant changes in a patient's condition. Standardized care and expected outcomes are assumed to be met and are not routinely documented, saving time and reducing redundancy.

Choice D rationale

SOAP (Subjective, Objective, Assessment, Plan) is a problem-oriented charting method commonly used by physicians and other healthcare providers to organize patient information around specific problems identified during assessment.

A. Signing on with a password. B. Charting in privacy. C. Logging off. D. Charting in code.

Correct Answer is C

Explanation

Choice A rationale

Signing on with a password authenticates the user and allows them to enter information, but it does not prevent someone with the same password or unauthorized access from altering previously entered data. Passwords control who can access the system, not what they can do once logged in.

Choice B rationale

Charting in privacy ensures confidentiality while the nurse is documenting, preventing unauthorized individuals from viewing the information as it is being entered. However, it does not prevent authorized users from later altering the data.

Choice C rationale

Logging off the electronic documentation system after each entry is crucial for preventing unauthorized access and alterations. Once logged off, the nurse's session is closed, requiring a new login to make any changes, thus ensuring accountability for each entry.

Choice D rationale

Charting in code or using abbreviations can help maintain patient privacy to some extent but does not inherently prevent alteration of the information once it has been entered into the system. Codes can be understood by those with access. \

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The nurse is caring for a nonverbal client who is moaning with position changes, the hands and teeth are clenched, and the skin is very diaphoretic.The nurse interprets this as the client is experiencing pain and decides to administer an analgesic.What is the correct term for this nursing action?

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Naxlex Comprehensive Predictor Exams

When the nurse charts only additional treatments done, abnormal findings, changes in patient condition, and new concerns, the system of documentation is:

Correct Answer is C

Explanation

When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?

Correct Answer is C

Explanation

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The nurse is caring for a nonverbal client who is moaning with position changes, the hands and teeth are clenched, and the skin is very diaphoretic.
The nurse interprets this as the client is experiencing pain and decides to administer an analgesic.
What is the correct term for this nursing action?