Difficulty: Medium
Average Score: 91%
Simulated
Passage / Scenario
Patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevatedThe nurse documents in the patient record, '0830 patient appears to be in severe pain and refuses to ambulate. Blood pressure and pulse are elevated. Physician notified and analgesic administered as ordered with adequate relief. J. Doe, RN.' The most significant statement about the documentation is that it is:
Correct answer
D
Rationale
The documentation (D) includes assessment (pain, vital signs), intervention (analgesic), and evaluation (relief), making it complete. A, B, and C overlook its comprehensive nature.