Nursing fundamentals · practice question

A 76-year-old client in a long-term care facility is being evaluated for high fall risk on a medical unit. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which documentation should the nurse record to best support safe care and communication?

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"Client fine; no changes noted."Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.Subjective opinions only without measurable findings.Copied yesterday's note without updating current assessment data.

Answer and explanation

Correct answer

B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.

Why

Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.

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A 76-year-old client in a long-term care facility is being evaluated for high fall risk on a medical unit. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which documentation should the nurse record to best support safe care and communication?

Correct answer

Why

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