Which chart entry reflects the most accurate documentation of patient data?
The patient seems lethargic.
The patient was incontinent.
The patient ate 25% of a hearty meal.
The patient voided in the urinal.
The Correct Answer is D
Choice A rationale
"Seems lethargic" is subjective and lacks specific, measurable data. Lethargy can manifest differently in patients, and this statement doesn't provide objective evidence to support the observation. Accurate documentation requires specific descriptions of observed behavior.
Choice B rationale
"The patient was incontinent" is more direct but lacks crucial details such as the type of incontinence (urinary or fecal), the amount, and any associated factors. Comprehensive documentation would include these specifics for a clear understanding of the event.
Choice C rationale
"The patient ate 25% of a hearty meal" is relatively objective and quantifiable, providing a specific measure of the patient's intake. However, "hearty" is still somewhat subjective. Specifying the type and estimated size of the meal would enhance clarity.
Choice D rationale
"The patient voided in the urinal" is a clear, objective statement of an observable action. It specifies the method of voiding and provides a concrete piece of information about the patient's urinary function. This type of documentation is precise and unambiguous.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Producing clinical pathways is an application of informatics, where data and technology are used to standardize care processes for specific conditions. However, this is a specific outcome of informatics rather than the overarching definition of the field itself. Informatics encompasses a broader scope than just the creation of these pathways.
Choice B rationale
Informatics in healthcare is fundamentally about managing knowledge. This involves the acquisition, storage, retrieval, analysis, and dissemination of information to improve decision-making, enhance patient care, and advance healthcare practice. Technology serves as the tool to facilitate this knowledge management.
Choice C rationale
While effective use of informatics tools might indirectly contribute to a more efficient workflow and potentially reduce some stressors, preventing burnout is not the primary definition of informatics. Burnout is a complex issue influenced by various factors beyond information and technology.
Choice D rationale
Providing a safe place to administer care is a fundamental goal of the entire healthcare system, encompassing many aspects beyond informatics. While informatics can contribute to safety through improved communication and access to information, it is not the defining purpose of the field itself.
Correct Answer is C
Explanation
Choice A rationale
The physician is responsible for medical diagnoses, which identify diseases or medical conditions based on the patient's signs, symptoms, and diagnostic test results. While nurses use medical diagnoses to inform their care, they do not analyze data to arrive at them.
Choice B rationale
The patient provides subjective data about their health status, which is crucial information for the nurse's assessment. However, the patient does not have the clinical knowledge and expertise to analyze and interpret this data in the context of other findings to formulate a nursing diagnosis.
Choice C rationale
The nurse is responsible for collecting, analyzing, and interpreting patient data (both subjective and objective) to identify patterns, draw conclusions about the patient's health status, and formulate nursing diagnoses. Nursing diagnoses describe the patient's responses to actual or potential health problems that nurses are qualified and licensed to treat.
Choice D rationale
Therapists, such as physical therapists, occupational therapists, or respiratory therapists, focus on specific aspects of the patient's rehabilitation and treatment based on their area of expertise. While they contribute valuable data to the patient's overall care, they are not primarily responsible for formulating nursing diagnoses.
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