Pathophysiology · practice question

A 59-year-old client in the intensive care unit is being evaluated for nursing care related to fluid volume excess and deficit. Assessment data include the client reports worst headache of life with neck stiffness. Which documentation should the nurse record to best support safe care and communication?

Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026pathophysiology

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

Answer and explanation

Correct answer

C. 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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