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Assess again in 20 minutes to note whether the sound is still present:Delaying reassessment without validating the data may result in missing an important clinical finding that requires immediate attention.

Immediately notify the patient's physician:Not appropriate unless the data has been validated. Calling the physician with uncertain information could result in miscommunication.

Document the sound exactly as it was heard:Documentation should be accurate, but if the nurse is unsure, they should validate the finding first before recording it.

Financial statement:This refers to billing or cost-related information, not clinical data used in assessment.

Discharge summary:This is a summary written at the end of a hospital stay; it doesn't include real-time or initial data collection.

Admitting data:Refers to the initial data collected at admission but doesn't include ongoing objective and subjective data.

Diagnostic reasoning:Part of critical thinking, but it's more focused on identifying a diagnosis rather than the broader assessment and decision process.

Clinical Knowledge:Clinical knowledge is necessary, but alone, it doesn’t drive decision-making without critical thinking.

The Nursing Process:The nursing process is a framework, but critical thinking underpins how the process is applied.

Screening:Screening detects health problems early but doesn’t involve directly educating the patient on safety practices.

Cultural sensitivity:Important in communication but not the primary strategy for addressing polypharmacy.

Sanitation:Relates to hygiene and infection prevention, not medication safety.

"I visit the dentist annually for a checkup.":Indicates current healthy behavior, but not a readiness to change or learn something new.

"My immunizations are up to date.":Shows good health maintenance but does not reflect openness to learning or behavior change.

"I really enjoy having a smoke with my beer.":Indicates resistance to change, not readiness for intervention.

Using a helmet when riding a motorcycle:Not a typical concern or screening priority for older adults, especially at age 75. It targets younger populations involved in high-risk activities.

Injuries from rock climbing activities:Unlikely to be relevant for most 75-year-olds; this focuses on a younger, more active demographic.

Literacy and communication skills:While important, these are not primary screening focuses in elderly populations unless there is a specific concern noted.

J.M. is a 59-year-old man seeking treatment for ulcerative colitis: This documents a chronic condition, but not the acute reason for the visit (black stools).

J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked: Vague and less focused on the acute symptom prompting the visit.

J.M. came into the clinic complaining of having black stools for the past 24 hours: Avoids using the word "complaining," which can be judgmental; also doesn’t quote the patient's exact words.

"Do you wear glasses?": Useful for vision screening, but not a key aspect of functional assessment post-stroke.

"Do you have any thyroid problems?": Related to medical history, not daily functional ability.

"How many times a day do you have a bowel movement?": Important for general health, but not a key functional task affected by a stroke.

Skin appears dry:Objective data-what the nurse observes.

No lesions are obvious:Nurse’s observation, so it is objective.

Lesion is noted on the lateral aspect of the right arm:Nurse’s observation; objective data.

"How did you get to the clinic today?":Pertains to transportation or access to care, not ethnicity.

"How was your journey from Africa?":May help build rapport, but doesn’t directly address ethnicity or cultural values.

"Can you share about your current financial situation?":Personal and sensitive; not relevant to ethnicity and may be perceived as intrusive.