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    Health assessment proctored exam( texas university)

    A nurse has provided care to a client. Which entry is written correctly?

    Explanation & Rationale

    A. Client is hard to care for and refuses all treatments and medications. Family present: This entry is subjective and judgmental. Phrases like “hard to care for” are opinion-based rather than objective observations. Proper documentation should describe behaviors or refusals factually, e.g., “Client declined morning medications; family present.” B. Left abdominal incision 1 inch in length without redness, drainage, or edema: This entry is clear, concise, and objective. It documents a specific finding, including location, size, and absence of complications, without using personal opinions or vague terms. This aligns with best practices for medical documentation and provides accurate, clinically relevant information. C. "Client seems to be in pain and states, 'I feel uncomfortable.'" The phrase “seems to be in pain” is subjective and speculative. Objective documentation should report the client’s own words or quantifiable assessments, such as pain rated on a 0–10 scale. Using tentative language like “seems” reduces clarity and reliability of the record. D. Status unchanged, doing well: This entry is vague and lacks detail. It does not provide measurable or objective information about the client’s condition, interventions, or response to care, making it insufficient for professional or legal documentation standards.

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