Which chart entry reflects the most accurate documentation of patient data?

Choice A rationale

Performing a physical examination involves the systematic assessment of a patient's body to identify signs of health or illness. Listening to lung sounds, palpating peripheral pulses, and obtaining vital signs are all fundamental components of a physical examination aimed at gathering objective data about the patient's current condition.

Choice B rationale

Establishing priorities for outcomes involves setting goals for patient care based on identified nursing diagnoses and collaborative problems. While the nurse's assessment data will inform the development of outcomes, the initial actions described focus on data collection, not outcome identification.

Choice C rationale

Demonstrating diagnostic reasoning is the cognitive process of analyzing assessment data to arrive at a nursing diagnosis or identify a collaborative problem. While the nurse is gathering data that will contribute to diagnostic reasoning, the actions described are the data collection phase itself, not the analysis.

Choice D rationale

Setting time frames for interventions involves establishing specific schedules for nursing actions aimed at achieving patient outcomes. The nurse's immediate actions upon the patient's arrival are focused on rapid assessment to understand the patient's immediate needs, not on scheduling future interventions.

Choice A rationale

"The patient is sleeping comfortably" is a subjective observation and does not provide a quantifiable measure of the patient's pain level. While comfort is important, this statement lacks specific information about the patient's pain experience and does not allow for consistent monitoring or evaluation of pain management interventions.

Choice B rationale

"The patient rated the pain at 2 on a 0-to-10 scale" is an example of appropriate pain assessment documentation. It uses a standardized pain scale, allowing the patient to quantify their pain intensity. This provides objective data that can be used to monitor changes in pain levels over time and evaluate the effectiveness of pain management strategies.

Choice C rationale

"The patient appears not to be in any pain" is a subjective interpretation by the nurse based on observation. It does not involve input from the patient about their pain experience. Pain is subjective, and a patient may be experiencing pain even if they do not outwardly appear to be in distress. Relying solely on observation can lead to underreporting and undertreatment of pain.

Choice D rationale

"The patient always complains about being in pain" is a generalization and does not provide specific information about the patient's current pain level. It can also introduce bias into future pain assessments. Each pain report should be documented objectively and based on the patient's current experience, not past complaints.