Which of the following entries is charted correctly?
a. wound appears the same as yesterday
b. range of motion improved today
c. more oriented
d. 100-ml coffee ground-appearing emesis
D
Avoid using judgmental language such as "good," "poor," "bad," "normal," "abnormal," "decreased," "appears to be," and "seems.". Avoid evaluative statements such as patient is lazy or patient is uncooperative. Use specific statements or actions that can be observed. Remember to describe what was observed, not what the nurse did.
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A nurse would utilize guidelines from the Centers for Disease Control and Prevention (CDC) when caring for a client diagnosed with:
1. heart disease. 2. cancer. 3. a communicable disease. 4. a fatal disease.
Which is usually the only symptom of pediculosis capitis (head lice)?
a. Itching b. Vesicles c. Scalp rash d. Localized inflammatory response
The nurse is caring for several pregnant patients. Which patient should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity?
1. 37-year-old G8 P2323, works in a chemical factory 2. 23-year-old primip, low socioeconomic status, unmarried 3. 16-year-old primip, began prenatal care at 30 weeks. 4. 28-year-old G2 P1001, history of gestational diabetes
A nurse asks a patient, "If you had fever and vomiting for 3 days, what would you do?" Which aspect of the mental status examination is the nurse assessing?
a. Behavior b. Cognition c. Affect and mood d. Perceptual disturbances