The nurse documents in the patient record, "0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.” The most significant statement about the documentation is that it is:
unacceptable because it is vague subjective data without supportive data
good because it shows immediate response to the problem
inadequate because the time of physician notification is not listed
acceptable because it includes assessment, intervention and evaluation
The Correct Answer is D
A. Unacceptable because it is vague subjective data without supportive data: The documentation includes objective data (BP, pulse), a physician notification, an intervention (analgesic), and an outcome.
B. Good because it shows immediate response to the problem: While the response to the problem is immediate, this choice is incomplete as it does not acknowledge that the documentation reflects all aspects of assessment, intervention, and evaluation.
C. Inadequate because the time of physician notification is not listed: While including the exact time of physician notification is best practice, the record still meets documentation standards.
D. Acceptable because it includes assessment, intervention, and evaluation: The note follows the nursing process (assessment, intervention, and response/evaluation), making it acceptable documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Patient provided data: Subjective data includes information the patient states, such as symptoms, pain level, or concerns.
B. All of the answers are correct: Not all answer choices describe subjective data.
C. Observed data: Observations made by the nurse (e.g., swelling, pallor) are objective, not subjective.
D. Measured data: Measurable data, such as vital signs, are objective, not subjective.
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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