Which nursing documentation demonstrates the integration of patient-centered care?
Steady gait observed when ambulating.
Social worker paged for consultation.
Nursing literature reviewed for best practice approaches.
Discussed dietary preferences with client.
The Correct Answer is D
Patient-centered care involves actively involving the patient in their care and considering their preferences, values, and goals. By discussing dietary preferences with the client, the nurse is demonstrating a patient-centered approach. This documentation indicates that the nurse took the time to engage in a conversation with the client to understand their dietary preferences,
which can help tailor the care plan to meet the client's individual needs and preferences. "Steady gait observed when ambulating" focuses on the nurse's observation and assessment but does not specifically involve the patient's preferences or goals.
"Social worker paged for consultation" indicates collaboration with another healthcare professional but does not necessarily reflect the patient's active involvement or preferences. "Nursing literature reviewed for best practice approaches" highlights evidence-based practice but does not directly involve the patient's preferences or engagement in decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
Dependent edema refers to the accumulation of fluid in the dependent parts of the body, which are areas that are most affected by gravity when a person is in a supine or sitting position for an extended period. The sacrum, which is the triangular bone at the base of the spine, is one such dependent area. It is prone to developing edema when there is increased fluid retention in the body, as seen in the patient's weight gain.
To assess for dependent edema accurately, the nurse can gently press the skin over the sacral area with their fingers and observe the skin turgor or the return of the skin to its normal position after releasing the pressure. If there is edema, the skin may have reduced elasticity and take longer to return to its normal position (poor skin turgor).
While edema can occur in other dependent areas such as the feet, ankles, and lower legs, assessing skin turgor in these areas may not provide an accurate determination of dependent edema as they are located further away from the sacrum and may be influenced by other factors.
Correct Answer is D
Explanation
The red tag is used to identify patients with critical injuries who require immediate medical attention. These individuals have life-threatening conditions that, with prompt medical intervention, have a higher chance of survival.
The triage color code system typically follows the following priority order:
1. Red tag: Immediate or emergent care needed for life-threatening injuries or conditions.
2. Yellow tag: Urgent care needed for significant injuries or conditions that are not immediately life-threatening.
3. Green tag: Non-urgent care needed for minor injuries or illnesses that can wait for medical treatment.
4. Black tag: Comfort care or deceased, as the injuries or conditions are incompatible with life or resources are not available for treatment.
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