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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. "What bothers you most about the idea of giving yourself an injection?" This open-ended question allows the patient to express specific fears or concerns, facilitating a deeper conversation to address the patient’s worries.

B. "Everyone feels like that at first. You'll get over it." This response is dismissive and may invalidate the patient’s feelings by suggesting that their concern is typical rather than unique.

C. “I know just how you feel. I would have trouble giving myself an injection." While empathetic, this response shifts focus to the nurse’s feelings rather than exploring the patient’s specific concerns.

D. "Don't be afraid. It's an easy skill for anyone to learn." This response minimizes the patient’s fear and could make them feel dismissed rather than supported.

A. avoid the use of eye contact to allow the patient to express herself without feeling stared at or demeaned. B. ask probing questions to direct the conversation and obtain the information needed as efficiently as possible. C. anticipate what the speaker is trying to say and help the patient express herself when she has difficulty with finishing a sentence. D. use nonverbal cues such as leaning forward, focusing on the speaker's face, and slightly nodding to indicate that the message has been heard.

Correct Answer is D

Explanation

A. Avoid the use of eye contact to allow the patient to express herself without feeling stared at or demeaned.
Avoiding eye contact can make the patient feel ignored or unheard and is generally not effective in active listening.

B. Ask probing questions to direct the conversation and obtain the information needed as efficiently as possible.
Active listening involves allowing the patient to lead the conversation rather than directing it with probing questions.

C. Anticipate what the speaker is trying to say and help the patient express herself when she has difficulty with finishing a sentence.
While well-intentioned, finishing sentences can prevent the patient from expressing thoughts fully.

D. Use nonverbal cues such as leaning forward, focusing on the speaker's face, and slightly nodding to indicate that the message has been heard.
Nonverbal cues like leaning forward and nodding show attentiveness and reinforce that the nurse is actively engaged in listening.

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Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient states, "I don't think I'll ever be able to give myself an injection." The best reply by the nurse is:

Correct Answer is A

Explanation

A nurse using active listening techniques would:

Correct Answer is D

Explanation

When communicating with a hearing-impaired patient, the nurse appropriately:

During the initial interview of a patient, the nurse should: (Select all that apply.)

A nurse is showing a diabetic patient how to draw insulin out of a syringe. The mode of learning that the nurse is using is:

A clinic nurse is documenting in a patient medical record about the pain that brought the patient to seek medical attention. The best description is:

A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:

Patient education for an 82-year-old patient to perform a dressing change to be done at home after discharge, the nurse would adjust the teaching session to:

When communicating with an adolescent, the nurse should be very sensitive to avoid:

The nurse can best ensure that communication is understood by: