Which documentation of a patient's behavior best demonstrates a nurse's observations?
a. Isolates self from others. Frequently fell asleep during group. Vital signs stable.
b. Calmer; more cooperative. Participated actively in group. No evidence of psychotic thinking.
c. Appeared to hallucinate. Frequently increased volume on television, causing conflict with others.
d. Wore four layers of clothing. States, "I need protection from evil bacteria trying to pierce my skin."
ANS: D
The documentation states specific observations of the patient's appearance and the exact statements made. The other options are vague or subjective statements and can be interpreted in different ways.
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a. Speak to him when entering the room. b. Allow him to assist in feeding himself. c. Orient him to his immediate surroundings. d. Reassure him and allow his parents to stay with him.
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a. 0.5 FTE c. 0.9 FTE b. 0.8 FTE d. 1.0 FTE
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A) Anterior and posterior lung auscultation B) Assessment of oxygen saturation by pulse oximetry C) Analysis of carboxyhemoglobin levels D) Analysis of hemoglobin, hematocrit, and red blood cell levels