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

Question

Quizplus · Accepted Answer

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.

A Nurse Is Preparing to Document a Patient Who Has