The patient tells the nurse about a burning sensation in the epigastric area. How should the nurse describe this type of pain when documenting the findings?
a. Referred
b. Radiating
c. Deep or visceral
d. Superficial or cutaneous
C
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A Referred pain is felt in a part of the body separate from the source of pain, such as with a myocardial infarction, in which pain may be referred to the jaw, left arm, and left shoulder.
B Radiating pain feels like it is travelling down or along a body part, such as low back pain that is accompanied by pain radiating down the leg from sciatic nerve irritation.
C Deep or visceral pain is diffuse and may radiate in several directions. Visceral pain may be described as a burning sensation.
D Superficial or cutaneous pain is of short duration and is localized, as in a small cut.
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The nurse is examining a client with congestive heart failure (CHF) who is prescribed propranolol and furosemide. The client complains of fatigue and an inability to finish tasks. Which conclusion by the nurse is the most appropriate?
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DeLaune & Ladner (2011) identified a nursing checklist that can be used to assist nurses with understanding what is expected from documentation and what reviewers are looking for when they review a chart
Which of the following is not correct regarding reviewing a chart for effectively documented information? a. Can the assessment data that triggered the nursing diagnosis be identified? b. When the defining characteristics of a specific nursing diagnosis are compared to the patient's presenting signs and symptoms, is there supporting evidence? c. Are all the charges documented and reasonable, and is there anything that seems out of line? d. Were critical questions asked during the patient interview?