A patient participated reluctantly, answered questions with minimal responses and rarely made eye contact during a nursing assessment. What data should be included when documenting the assessment? You may select more than one answer
a. The patient's verbal responses.
b. The observation that the patient was uncooperative.
c. A description of the patient's behavior during the interview.
d. Observations related to the patient's subjective responses.
e. Analysis of why the patient did not respond openly during the interview.
A, C, D
Document both the content and process of an interview. An objective description of patient behavior is preferable. Speculation is inappropriate.
You might also like to view...
The nurse is planning care for a pediatric client diagnosed with human immunodeficiency virus (HIV). The nurse selects Risk for Infection as a priority nursing diagnosis for this pediatric client
Based on this nursing diagnosis, which actions by the nurse are appropriate? Select all that apply. A) Administering tuberculosis skin tests every six months B) Teaching proper food-handling techniques to the family C) Instructing on the importance of consuming ample fresh fruits and vegetables D) Assessing the health status of all visitors E) Monitoring hand-washing techniques used by the famly
The nurse instructs a clinic patient on using an inhaler for his asthma attacks. Which is correct about the use of an inhaler?
a. The medication must go into the back of the nose. b. The medication must go directly into the throat. c. The medication must get to the ears. d. The medication must go into the lungs.
The nurse checks the chemical sterility indicators on two packs of instruments, noting that the indicator is black on package A and unchanged on package B. Which should the nurse do next in the operating room?
1. Replace package B. 2. Use neither package. 3. Disinfect package B. 4. Cancel the procedure.
A nurse is caring for vulnerable populations in a local community. Which patients will the nurse care for in this community? (Select all that apply.)
a. A 47-year-old immigrant who speaks only Spanish b. A 35-year-old living in own home c. A 22-year-old pregnant woman d. A 40-year-old schizophrenic e. A 15-year-old rape victim