The nursing process is best defined as a framework for the organization of individualized nursing care.

Choice A rationale

Data contained within a client's medical record is not for unrestricted sharing among all employees within a healthcare facility. Access to patient information is need-to-know based and role-specific, guided by HIPAA regulations and facility policies to protect patient privacy and confidentiality.

Choice B rationale

Documentation should primarily focus on objective data, nursing interventions performed, and the client's responses. The nurse's interpretation of the client's situation should be based on factual observations and assessments, clearly documented as such, rather than subjective opinions presented as facts.

Choice C rationale

A medical record serves as a legal document that can be used as evidence in a court of law. Accurate and complete documentation provides a chronological account of the patient's care, which can be crucial in legal proceedings to demonstrate the care provided and adherence to standards.

Choice D rationale

Timely, organized, and complete documentation is essential for effective communication among healthcare team members and for providing safe and quality patient care. Accurate and up-to-date records ensure continuity of care and reflect the patient's current status and interventions.

Choice E rationale

When subjective information, such as the client's feelings or statements, is documented, it should be clearly identified as such using quotes or phrases like "client states.”. This distinguishes subjective data from objective findings and ensures clarity in the medical record. .

Choice A rationale

"Patient will ambulate for 15 minutes after lunch" is a planned nursing intervention or goal, outlining a future action for the patient. It describes what is expected to happen, not what has already been implemented and documented.

Choice B rationale

"Patient selected low-sugar snacks independently" describes an observation of the patient's behavior and adherence to a dietary plan. While it reflects an action, it doesn't explicitly document a direct nursing intervention performed.

Choice C rationale

"Patient was medicated with Tylenol 500 mg PO for pain" clearly documents the implementation of a specific nursing intervention – the administration of medication. It states what was done, including the drug, dosage, route, and reason.

Choice D rationale

"Patient participated in group therapy session without prompting" describes the patient's participation in a therapeutic activity. While nurses may facilitate or encourage participation, this statement focuses on the patient's action rather than a direct nursing intervention performed on the patient. .