Introduction to Patient Assessment and Documentation
Introduction to Patient Assessment and Documentation ( 6 Questions)
A nurse is documenting the findings of a head-to-toe assessment on a newly admitted client.
Which of the following information should the nurse include in the documentation?
It is not the only information that should be documented.
It is not the only information that should be documented.
This is a correct statement, but it is not the only information that should be documented.
The nurse should document all relevant and objective data obtained from the assessment, including vital signs, skin condition, bowel sounds, and any other findings that reflect the client's health status.
Rationale: The nurse should document all relevant and objective data obtained from the assessment, including vital signs, skin condition, bowel sounds, and any other findings that reflect the client's health status.
Incorrect options:
A) The client's vital signs are within normal limits. - This is a correct statement, but it is not the only information that should be documented.
B) The client's skin is warm, dry, and intact. - This is a correct statement, but it is not the only information that should be documented.
C) The client's bowel sounds are present in all four quadrants. - This is a correct statement, but it is not the only information that should be documented.