Ati lpn fundamentals test ch 789 caole
Ati lpn fundamentals test ch 789 caole ( 41 Questions)
Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?
“Taking fluids poorly, but more than yesterday."This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
"Apparently comfortable all night. Offers no complaints of pain."“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
"Patient says she is still slightly nauseated, would like to try some toast and tea."While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
"4 cm reddened area over sacrum. Skin intact, warm, and dry."This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.