Which chart entry represents appropriate documentation about the patient's pain assessment?
The patient is sleeping comfortably.
The patient rated the pain at 2 on a 0-to-10 scale.
The patient appears not to be in any pain.
The patient always complains about being in pain.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Performing a focused patient assessment at the beginning of the shift is the priority action as it allows the nurse to gather current data about the patient's condition. This assessment provides the foundation for identifying the patient's immediate needs, establishing priorities, and planning appropriate care for the shift. It ensures that any changes in the patient's status since the last shift are promptly identified and addressed.
Choice B rationale
Administering prescribed medication is an important nursing responsibility, but it should occur after the initial assessment. The assessment may reveal changes in the patient's condition that could affect the timing or appropriateness of medication administration. Prioritizing assessment ensures medication administration is safe and based on the most current patient data.
Choice C rationale
Creating the nursing plan of care is an ongoing process that is informed by the initial and subsequent patient assessments. While a plan of care guides nursing interventions, the immediate need at the start of the shift is to assess the patient's current status to ensure the plan remains relevant and addresses any new or changing needs.
Choice D rationale
Determining the patient's family history is typically part of the comprehensive admission assessment. While relevant for understanding the patient's overall health risks, it is not the priority action at the beginning of each shift. The immediate focus should be on the patient's current physical and emotional status to guide immediate care.
Correct Answer is C
Explanation
Choice A rationale
Incorrect organization of health assessment findings relates to how the nurse collects and structures patient data, which may impact the accuracy of diagnosis and care planning but is less likely to be the primary cause of frustration with a patient's cultural health practices.
Choice B rationale
While a patient's insistence on alternative remedies and spiritual practices might indicate coping mechanisms, it doesn't directly explain the nurse's frustration. The frustration likely stems from a conflict in beliefs or approaches to healthcare rather than the patient's ability to cope.
Choice C rationale
Cultural differences encompass the values, beliefs, and practices that influence a person's perception of health, illness, and healthcare. A patient's preference for herbal remedies, prayer, and a spiritual healer over conventional medical treatment reflects cultural health-related practices that may differ significantly from the nurse's professional training and beliefs, potentially leading to frustration.
Choice D rationale
Delay in psychosocial development refers to a lag in achieving expected developmental milestones related to social and emotional functioning. While it can influence a patient's health behaviors, it is less directly related to the nurse's frustration with culturally based healthcare choices. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.