Asked by Justin Arita on May 31, 2024
Verified
A nurse is preparing to document a patient who has chest pain. Which information is critical for the nurse to include?
A) The family is a "pain."
B) Pupils equal and reactive to light
C) Had poor results from the pain medication
D) Sharp pain of 8 on a scale of 1 to 10
Chest Pain
A sensation of discomfort or pain that is felt in the upper body, potentially indicating a variety of conditions.
Pupils Equal
Indicates that both pupils of the eyes are of the same size, which is typically a sign of normal neurological function.
Pain Medication
Drugs designed to relieve pain, ranging from over-the-counter options like aspirin to prescription opioids.
- Achieve an understanding of the documentation process, particularly the accurate charting and legal outcomes.
Verified Answer
LR
Lizbeth RubalcavaJun 02, 2024
Final Answer :
D
Explanation :
You need to ensure the information within a recorded entry or a report is complete, containing appropriate and essential information (pain of 8). Document subjective and objective assessment. While pupils equal and reactive to light is data, it does not relate to the chest pain; this information would be critical for a head injury. Derogatory or inappropriate comments about the patient or family ("pain") is not appropriate. This kind of language can be used as evidence for nonprofessional behavior or poor quality of care. Avoid using generalized, empty phrases like "poor results." Use complete, concise descriptions.
Learning Objectives
- Achieve an understanding of the documentation process, particularly the accurate charting and legal outcomes.