The primary source of assessment information is:

the patient's friends

past medical records

the patient's record

the patient

Answer and Explanation

The Correct Answer is D

A. The patient's friends: While family and friends can provide secondary information, they are not the primary source of assessment data.

B. Past medical records: Past records can provide valuable history, but they do not replace real-time data from the patient.

C. The patient's record: The medical record is a collection of past documentation but is not a source of new assessment data.

D. The patient: The patient is the primary source of assessment data, as they provide information about their symptoms, medical history, and concerns.

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Correct Answer is D

Explanation

A. The insulin was administered per the nurse's testimony: In legal cases, verbal testimony alone is not sufficient without documentation.

B. None of the answers are correct: One of the answers is correct based on legal documentation principles.

C. The insulin was administered based on the witness testimony: Even though there were witnesses, medication administration must be documented for legal and clinical accountability.

D. The insulin was not administered because it was not charted: "If it wasn't documented, it wasn't done." In legal and medical practice, lack of documentation means the action cannot be verified as completed.

A. signs B. objective cues C. symptoms D. observable data

Correct Answer is C

Explanation

A. Signs: Signs are objective findings (e.g., fever, rash), observed by the nurse.

B. Objective cues: Objective cues are measurable and observable, whereas subjective data is based on the patient’s self-report.

C. Symptoms: Symptoms (e.g., pain, nausea, dizziness) are subjective because they cannot be measured directly and are reported by the patient.

D. Observable data: Observable data includes measurable signs, making it objective, not subjective.

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The primary source of assessment information is:

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Naxlex Comprehensive Predictor Exams

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

Correct Answer is D

Explanation

When discovering subjective data, recognize that they relate to:

Correct Answer is C

Explanation

Identify the two primary methods used to collect data:

Clarify the primary purpose of nursing orders:

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

The primary source of assessment information is:

Which of the following is an example of good charting?

On what form/forms should the nurse chart when administering a narcotic?

What is the major concern when using a computer for documentation?