A nurse has provided care to a patient. Which entry should the ...

[cherise1989]

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record?
 
  a. Patient seems to be in pain and states, I feel uncomfortable.'
  b. Status unchanged, doing well
  c. Left abdominal incision 1 inch in length without redness, drainage, or edema
  d. Patient is hard to care for and refuses all treatments and medications. Family present.

Question 2

The nurse uses the Braden Scale in the extended care facility to determine the client's risk for pressure ulcer development. Which score, based on this scale, places the client at the highest level of risk?
 
  a. 9 or below
  b. 10 to 12
  c. 13 to 14
  d. 15 to 16

[amit]

Answer to Question 1

C
Use of exact measurements establishes accuracy. Charting that an abdominal wound is 5 cm in length without redness, drainage, or edema is more descriptive than large wound healing well. Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as status unchanged or had a good day. It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. Patient is hard to care for is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, Refuses all treatments and medications.

Answer to Question 2

A
According to the Braden Scale, a lower score indicates a higher risk for pressure ulcer develop-ment. The client at highest risk would be the client with a score of 9 or lower.
According to the Braden Scale, the scores of 10 to 12 would indicate that the client would be at a high risk for pressure ulcer development.
According to the Braden Scale, the scores of 13 to 14 would indicate that the client would be at a moderate risk for pressure ulcer development.
According to the Braden Scale, the scores of 15 to 16 would indicate that the client would be at a low risk for pressure ulcer development.

[cherise1989]

Gracias!

[bulacsom]

Excellent