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Introduction to Patient Assessment and Documentation

  • Patient assessment is the systematic collection, analysis, and interpretation of data about a patient's health status, needs, preferences, and goals.

  • Documentation is the recording of the patient assessment data and the nursing interventions, outcomes, and evaluations in a clear, accurate, timely, and legal manner.

  • Patient assessment and documentation are essential for providing safe, effective, and individualized nursing care, as well as for communicating with other health care providers, ensuring continuity of care, evaluating the quality of care, and meeting legal and ethical standards.

Questions on Introduction to Patient Assessment and Documentation

Correct Answer is B

Explanation

<p>This order may alter bowel sounds and miss visual cues by palpating before auscultating and inspecting.</p>

Correct Answer is D

Explanation

<p>Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.</p>

Correct Answer is A

Explanation

<p>This is a tool that assesses the risk of falling in hospitalized clients based on six factors: history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status. It is not used to assess level of consciousness.</p>

<p>A chest x-ray is a diagnostic test that can confirm the presence or absence of pneumonia by showing areas of consolidation or infiltration in the lung tissue. A clear chest x-ray indicates resolution of pneumonia and effectiveness of treatment.</p>

<p>The nurse should document all relevant and objective data obtained from the assessment, including vital signs, skin condition, bowel sounds, and any other findings that reflect the client&#39;s health status.</p>

<p>The nurse should ask open-ended questions that cover the characteristics, duration, frequency, severity, precipitating and relieving factors, associated symptoms, and impact of the cough on the client&#39;s health and quality of life.</p>
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