Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?
“Taking fluids poorly, but more than yesterday."
"Apparently comfortable all night. Offers no complaints of pain."
"Patient says she is still slightly nauseated, would like to try some toast and tea."
"4 cm reddened area over sacrum. Skin intact, warm, and dry."
The Correct Answer is D
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Uses short, simple sentences.
Short, simple sentences are easier to understand and support clear communication.
B. Shouts repeatedly at the patient.
Shouting can distort sounds and may be uncomfortable or disrespectful for the patient.
C. Speaks directly into the patient's ear.
Speaking directly into the ear is not appropriate as it can invade personal space and may not improve understanding.
D. Uses long, complex sentences.
Long sentences may be harder for the patient to understand, especially if lip-reading is being used.
Correct Answer is C
Explanation
A. write down the steps as she performs them.
Writing down the steps may help the patient review later but does not actively engage the patient in learning during the procedure.
B. read the listed steps written on a poster board on the wall.
Reading steps on a poster board can provide visual support but doesn’t actively involve the patient in recalling or practicing the procedure.
C. verbalize each step until the steps are memorized.
Verbalizing each step is an active form of learning that reinforces memory and helps the patient feel more comfortable with the process, making it an effective teaching strategy.
D. close her eyes and envision the process.
Visualization can help with memory, but it may not be as effective as actively verbalizing each step for practical, hands-on tasks.
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