A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?
Client is itching from medication.
Client states, "I started to itch after taking that medication.".
It appears that the client has a rash from the medication.
Rash from medication noted.
The Correct Answer is B
The correct answer is choice B. Client states, "I started to itch after taking that medication."
Choice A rationale:
"Client is itching from medication." This statement is not a comprehensive description of the situation and lacks specific information. It doesn't provide any context about when the itching occurred or the client's own observation.
Choice B rationale:
"Client states, 'I started to itch after taking that medication.'" This choice is the correct answer because it accurately documents the client's own statement about the itching and the timing in relation to taking the medication. It includes a direct quote, which helps in maintaining accurate and patient-centered documentation.
Choice C rationale:
"It appears that the client has a rash from the medication." This statement includes an assumption and subjective language ("It appears"), which can be misleading in documentation. It's essential to provide factual and objective information in medical records.
Choice D rationale:
"Rash from medication noted." This choice lacks detail and doesn't capture the client's perspective or the timing of the symptom. It's important to include the client's statement and the time frame in which the symptom occurred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Ask the client what they already know about meal planning.
Choice A rationale:
Using pictures of different food groups can be helpful in teaching about carbohydrate counting, but it's important to assess the client's current knowledge and understanding before introducing new information. Starting with this approach might overwhelm the client or duplicate information they already possess.
Choice B rationale:
This is the correct choice. Before providing education, it's crucial to assess the client's baseline knowledge. By asking the client what they already know about meal planning, the nurse can tailor the teaching plan to fill in any gaps and avoid presenting redundant information. This approach respects the client's current understanding and focuses on addressing their specific needs.
Choice C rationale:
Giving the client a brochure with sample menus can be helpful once the nurse has assessed the client's knowledge and educational needs. However, providing the brochure as the first action might not be effective if the client already has some understanding of meal planning or if the brochure does not address the client's specific questions.
Choice D rationale:
Involving the family in the discussion of the client's meal plan is important for long-term support, but it shouldn't be the first action. First, the nurse should ensure that the client's own understanding and preferences are addressed before considering input from family members.
Correct Answer is C
Explanation
The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."
Choice A rationale:
"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.
Choice B rationale:
"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.
Choice C rationale:
"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.
Choice D rationale:
"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.
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