Which of the following is an example of good charting?

"No complaints of pain or discomfort."

The patient states, "It feels like a knife stabbing me."

"Lump diminished."

"Patient's condition much better today than yesterday."

Answer and Explanation

The Correct Answer is B

thoroughly. The patient may not have verbalized pain but could still be experiencing it.

B. The patient states, "It feels like a knife stabbing me.": This documents subjective data verbatim using the patient’s exact words, which is best practice for accuracy and clarity.

C. "Lump diminished.": This lacks specificity—the exact size, texture, or other changes should be documented using precise measurements (e.g., “Lump decreased from 3 cm to 2 cm”).

D. "Patient's condition much better today than yesterday.": This is too vague and lacks measurable indicators of improvement (e.g., vital signs, pain level, mobility).

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Correct Answer is A

Explanation

A. Interview and physical examination: The two primary methods of data collection in nursing are:

Interview (subjective data: patient history, symptoms, concerns)
Physical examination (objective data: vital signs, assessment findings)

B. Review of the doctor's orders and the Kardex: This provides supplementary data but does not directly collect patient information.

C. Written report by patient and family: This may provide valuable subjective data but is not a primary method of data collection.

D. Review of the chart and the nurse’s notes: This is reviewing existing documentation, not actively collecting data.

A. a head-to-toe assessment B. subjective data collection C. objective data collection D. Maslow's Hierarchy of Needs E. Coughed up 5 mL yellow sputum

Correct Answer is A

Explanation

A. A head-to-toe assessment: A head-to-toe assessment is the most systematic approach to a complete physical exam, ensuring no body system is overlooked.

B. Subjective data collection: While subjective data is part of the process, it is not a structured approach to an entire physical exam.

C. Objective data collection: Objective data is collected during the exam, but the question asks about the approach to organizing the exam, not the data type.

D. Maslow’s Hierarchy of Needs: Maslow’s hierarchy helps prioritize care but is not a method for performing a physical assessment.

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Which of the following is an example of good charting?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Identify the two primary methods used to collect data:

Correct Answer is A

Explanation

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

Correct Answer is A

Explanation

When using the SOAP method of charting, S stands for subjective data which means:

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Which of the following is an example of good charting?

JCAHO regulates standards of care to:

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Select the proper order of the phases of the Nursing Process:

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents: