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. Focused: A focused assessment is ongoing and directed at specific problems based on the patient’s condition (e.g., assessing pain, circulation, or respiratory status frequently).

B. Body systems: Body systems assessments are structured assessments that evaluate a particular system (e.g., cardiovascular, respiratory) rather than continuous monitoring.

C. Subjective: Subjective assessment includes patient-reported symptoms but does not define the type of continuous assessment nurses perform.

D. Complete: A complete (or comprehensive) assessment is done at admission, not continuously.

A. the patient is vulnerable to develop the problem B. there is no evidence of defining characteristics C. a condition is currently present D. it is written as a two-part statement

Correct Answer is C

Explanation

A. The patient is vulnerable to develop the problem: This describes a risk diagnosis, where the patient has the potential to develop a condition but does not currently have it.

B. There is no evidence of defining characteristics: An actual nursing diagnosis must have defining characteristics (symptoms/signs).

C. A condition is currently present: An actual nursing diagnosis means the condition is already present, with observable signs and symptoms.

D. It is written as a two-part statement: Actual nursing diagnoses use a three-part statement:

Problem (diagnosis)
Etiology (cause)
Signs and Symptoms (evidence)

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Which of the following is an example of good charting?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select the type of assessment which is performed continuously throughout nurse-patient contact:

Correct Answer is A

Explanation

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

Correct Answer is C

Explanation

Clarify the primary purpose of nursing orders:

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

The primary source of assessment information is:

In which step of the nursing process do nurses look at outcomes?

Who should document care in the patient record?

A patient with edema has a problem of fluid overload. The nurse is developing a care plan and selecting interventions that will assist the patient in reducing the fluid. An important consideration when developing the care plan is to:

Which of the following statements is correct about abbreviations?

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