Fundamentals of Nursing Q 286
The nurse is recording assessment data. She writes, “The patient seems worried about his surgery. Other than that, he had a good night.” Which errors did the nurse make? Select all that apply.
A. Used a vague generality.
B. Did not use the patient's exact words.
C. Used a "waffle" word (e.g., appears).
D. Recorded an inference rather than a cue.
E. Did not record the patient’s vital signs.
Correct Answer: A, C, D & E
The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continuous collection of data; sorting, analyzing, and organizing that data; and the documentation and communication of the data collected. Subjective and objective data collection are an integral part of this process.
Option A: The nurse recorded a vague generality: “he has had a good night.” The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.
Option B: The nurse did not use the patient’s exact words, but she did not quote the patient at all, so that is not one of her errors.
Option C: The nurse used the “waffle” word, “seems” worried instead of documenting what the patient said or did to lead her to that conclusion. Asking about how the client feels and their response to those feelings is part of a psychological assessment.
Option D: The nurse recorded these inferences: worried and had a good night. The psychological examination may include perceptions, whether justifiable or not, on the part of the patient or client. Religion and cultural beliefs are critical areas to consider.
Option E: Part of the assessment includes data collection by obtaining vital signs such as temperature, respiratory rate, heart rate, blood pressure, and pain level using age or condition appropriate pain scale.