While performing a focused assessment on the client, the nurse notes a skin rash, which the nurse correctly documents as:
1. Rash on face, arms, and trunk.
2. Maculopapular rash over trunk that client says itches.
3. 2cm boil noted on the client's shoulder.
4. Erythematous butterfly-shaped rash noted over the client's cheeks and nose.
4
Rationale: The student describes the color, size, shape, and location of the butterfly rash, which is correct. Rash on face, arms, and trunk does not include shape, color, or any other properties. The boil on the shoulder gives the size but not the color or presence of drainage or discomfort. Maculopapular rash on the trunk is not specific enough in location, and does not describe the color or size. Documentation of assessment findings should be done in such a way that the reader can "see" the finding even if he hasn't yet seen the client.
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