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

Choice A rationale

The orientation phase of the interview typically involves introducing oneself, explaining the purpose of the interview, and establishing rapport with the patient. Asking about the drug list occurs after this initial introduction.

Choice B rationale

The termination phase is the concluding part of the interview, where the nurse summarizes key information and discusses the plan of care. Medication history is gathered much earlier in the assessment.

Choice C rationale

The working phase is where the nurse actively collects data about the patient's health history, current condition, medications, and other relevant information. Asking about the drug list, including herbal supplements and over-the-counter medications, is a key component of this data gathering process.

Choice D rationale

The pre-interaction phase occurs before meeting the patient and involves the nurse reviewing available information such as the patient's chart. The actual questioning of the patient happens later.

Choice E rationale

The evaluation phase occurs after interventions have been implemented to assess their effectiveness. It is not the phase where the initial assessment and data collection, including medication history, take place. .

Choice A rationale

Impaired gas exchange directly affects the patient's oxygenation and carbon dioxide elimination, which are fundamental physiological needs. Alveolar inflammation and infection in pneumonia disrupt the normal diffusion of gases in the lungs, potentially leading to hypoxemia and hypercapnia, posing an immediate threat to life if not addressed promptly. Normal partial pressure of oxygen (PaO₂) is 80-100 mmHg, and normal partial pressure of carbon dioxide (PaCO₂) is 35-45 mmHg.

Choice B rationale

Pruritus, or itching, while uncomfortable, is a symptom related to medication side effects and does not directly compromise vital physiological functions like gas exchange. Addressing the underlying cause and providing symptomatic relief are important but are a lower priority than ensuring adequate oxygenation.

Choice C rationale

Knowledge deficit regarding risk factors for pneumonia is important for long-term health management and prevention of future episodes. However, in the acute phase of pneumonia, the immediate physiological compromise of impaired gas exchange takes precedence over addressing knowledge gaps.

Choice D rationale

Activity intolerance due to fatigue and shortness of breath is a consequence of the physiological changes associated with pneumonia, primarily the impaired gas exchange. While it affects the patient's quality of life, it is a manifestation of the primary problem rather than the most immediate threat to physiological stability.