To what does objective data refer when assessing a patient?

the provider's observed data

All of the answers are correct

the patient's perception of provided data

the patient's request for information

Answer and Explanation

The Correct Answer is A

A. The provider’s observed data: Objective data includes what the nurse or provider directly observes and measures, such as vital signs, lab results, and physical exam findings.

B. All of the answers are correct: Only option A is correct because C and D do not define objective data.

C. The patient’s perception of provided data: The patient’s perception is subjective data, not objective.

D. The patient’s request for information: A request for information is neither assessment data nor an objective finding.

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Correct Answer is ["D","E"]

Explanation

A. Wait until the end of the shift to document: Documentation should be done promptly after care is provided to ensure accuracy and completeness. Delaying documentation increases the risk of errors or omissions.

B. Cover errors with correction fluid, and write in the correct information: Errors should never be covered with correction fluid. Instead, a single line should be drawn through the mistake, followed by the correction and the nurse’s initials.

C. Use as many abbreviations as possible to save space: Only approved abbreviations should be used to avoid misinterpretation and increase clarity. Overuse of abbreviations can lead to confusion.

D. Document objective data, leaving out opinions: Documentation should be factual and objective (e.g., "Patient grimaced when moving" instead of "Patient appears to be in pain"). Subjective or opinion-based language should be avoided.

E. The date and time should be included with each entry: Every entry must have a date and time to provide an accurate timeline of care, ensuring legal protection and continuity of care.

A. not used by anyone else but the direct care providers B. concise, legal records of all care given and responses C. owned by the patient, who has a right to see the data any time he/she wishes D. confidential information and cannot be taken to court

Correct Answer is B

Explanation

A. Not used by anyone else but the direct care providers: Health records are used by multiple healthcare team members, including billing departments, insurance providers, and legal entities when required.

B. Concise, legal records of all care given and responses: Health records document all care provided, patient responses, and medical decisions. They serve as legal records in case of disputes or audits.

C. Owned by the patient, who has a right to see the data any time he/she wishes: The healthcare facility owns the records, but patients have a right to request access under HIPAA and other legal provisions.

D. Confidential information and cannot be taken to court: Health records can be subpoenaed and used in legal cases, provided they comply with confidentiality laws.

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To what does objective data refer when assessing a patient?

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Naxlex Comprehensive Predictor Exams

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)

Correct Answer is ["D","E"]

Explanation

Patient health care records are:

Correct Answer is B

Explanation

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents:

JCAHO regulates standards of care to:

The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Identify the two primary methods used to collect data:

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

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

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