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    Hesi rn health assessment proctored exam

    An adult male client informs the nurse that he came to the clinic to see if, "Maybe I have lung cancer or something," and wants to get checked out since, "I can't seem to get rid of this body wracking dry cough that has been hanging around for the last six weeks." Which computer documentation of this client's concerns should the nurse enter?

    Explanation & Rationale

    A. Presents with a hacking non-productive cough of 6 weeks duration. While nonproductive is a clinical term for a dry cough, the term hacking is a subjective interpretation by the nurse. Documentation should reflect what the client said, rather than the nurse's paraphrase, to ensure the most accurate clinical picture. B. An adult male presents with fears that he has "lung cancer." This focuses on the client's fear rather than the symptom. C. Expresses concern of "lung cancer" symptoms for last 6 weeks. This mixes subjective concerns with symptoms, making it less clear. D. Describes having a "body wracking dry cough" of 6 weeks duration. This is the most professional and accurate entry. It uses quotation marks to capture the client's exact description ("body wracking dry cough"), which provides insight into the severity and nature of the cough. It also includes the specific duration (6 weeks), which is a critical piece of data for the provider.

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