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Body systems:This type of assessment is organized by body system (e.g., cardiovascular, respiratory) and is typically used during focused or head-to-toe assessments, not continuously.

Subjective:Subjective assessments are based on what the patient reports (e.g., pain level), but they are not types of assessments performed continuously. They are sources of data.

Complete:A complete (or comprehensive) assessment is a detailed head-to-toe assessment, usually done on admission-not continuously.

Adequate forms for documentation:While having adequate forms is important, it’s not the major concern compared to protecting patient privacy.

Incorrect information:Incorrect information is always a risk in documentation, but it can occur in both paper and electronic formats. Confidentiality is a greater systemic concern in digital systems.

None of the answers are correct:This is incorrect because A is a correct and important concern.

Oxygen will be continued:This is an intervention, not an outcome. Outcomes describe patient results, not nursing actions.

The patient's coughing frequency will increase:An increase in coughing might indicate worsening status. The goal is effective airway clearance, which would result in less frequent coughing with improved breathing.

Cyanosis may be present:Cyanosis is a sign of poor oxygenation, which is a negative outcome-not desired.

Unreliable:Family data may be very reliable, especially when the patient cannot communicate. It should not be dismissed.

Not as important:Family input is crucial in forming a full picture of the patient’s history and current status.

Biased:While any source may have bias, classifying all family-provided data as biased is incorrect and dismissive of valuable information.

Planning:In the planning phase, nurses set the desired outcomes, but do not evaluate them yet.

Assessment:Assessment involves gathering data to form diagnoses, not reviewing outcomes.

Implementation:This step involves carrying out the plan of care, not analyzing whether outcomes have been met.

The patient's request for informationThis may guide care but is not objective data; it reflects a communication need, not measurable findings.

The patient's perception of provided dataThis describes subjective data, such as feelings, beliefs, or reported symptoms.

All of the answers are correctOnly C accurately defines objective data. The others describe subjective or communication-related information.

It is written as a two-part statementAn actual nursing diagnosis is written as a three-part statement (diagnosis, related to, and evidence). A risk diagnosis is two-part.

The patient is vulnerable to develop the problemThis describes a risk diagnosis, not an actual one.

There is no evidence of defining characteristicsActual diagnoses do require evidence-defining characteristics (e.g., behaviors, physical signs) must be present.

Objective cuesThese are measurable signs observed by the nurse, not reported by the patient.

Observable dataThis refers to objective data, such as vital signs or wounds.

SignsSigns are observable findings (objective), not subjective.

Knowledge deficitThis may be appropriate later in care (e.g., fall prevention), but not the priority in the presence of acute pain and injury.

Fluid volumeThere is no information provided suggesting fluid imbalance or dehydration.

Skin integrityThere’s no mention of pressure ulcers, abrasions, or wounds. It could become an issue later due to immobility, but not the most immediate need.