A nurse is reinforcing teaching with a client who has a terminal illness and is considering palliative care services. Which of the following statements by the client indicates an understanding?

Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.

Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.

Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.

Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.

Choice A reason: This is incorrect. Explaining the steps of a surgical procedure to a client is not unprofessional, but a professional duty of a nurse. A nurse should provide accurate and relevant information to the client about their health condition, treatment options, and expected outcomes, in order to help them make informed decisions and prepare for the procedure¹.
Choice B reason: This is incorrect. Witnessing a client consent for a surgical procedure is not unprofessional, but a professional responsibility of a nurse. A nurse should act as a witness to the client's signature on the consent form, and ensure that the consent process was conducted properly, ethically, and legally².
Choice C reason: This is the correct answer. Confirming that a client appears competent to consent to a surgical procedure is unprofessional, as it is not within the scope of practice of a nurse. A nurse cannot assess or determine the client's mental capacity or competence to consent, as this requires a medical evaluation by a physician or a psychologist³. A nurse can only observe and report the client's behavior, mood, and cognition to the health care team.
Choice D reason: This is incorrect. Verifying that a client voluntarily gave consent to a surgical procedure is not unprofessional, but a professional obligation of a nurse. A nurse should ensure that the client's consent was given freely, without any coercion, manipulation, or undue influence from others². A nurse should also respect the client's right to withdraw or change their consent at any time².