Author Question: Which of the following are examples of high-quality nursing documentation? Select all that apply. ... (Read 163 times)

Davideckstein7 · **on:** Jul 23, 2018

Which of the following are examples of high-quality nursing documentation? Select all that apply.

a. Patient states, When I get up in the morning, I feel dizzy.
b. Patient is alert and oriented to person, place, time, and surroundings.
c. Drainage from midline abdominal incision appears normal.
d. Patient is angry with wife over arriving late for Dr. appointment.
e. Patent has no complaints of pain at this time.

Question 2

Which of the following are examples of objective data? Select all that apply.

a. Blood pressure reading 120/80 mm Hg
b. Pain rated as 6 on a pain scale of 0 to 10
c. Moderate amount of yellow drainage from right ear
d. Wife states, He has not been sleeping well at night.
e. Patient states, I have a stomach ache.

Perkypinki · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

A, B, E
Patient statements using the patient's own words, documentation of patient level of consciousness, and documentation of patient denial of pain are all examples of high-quality documentation. These statements are not subjective or vague. The statement regarding the patient's incision is vague as what is considered normal cannot be measured. Noting that the patient is angry is subjective and unclear.

Answer to Question 2

A, C
Blood pressure and yellow ear drainage are examples of objective data. These data are obtained by the nurse through assessment. Patient statements are subjective data. The wife's statement constitutes secondary data and is vague and subjective.