Question

Which represents correct documentation in the medical record of an initial nursing assessment of a client admitted with pneumonia

Answer 1

1. The client appears short of breath, with wheezing in all lung fields.
2. The client is admitted with pneumonia and the nurse will watch for respiratory symptoms.
3. Respiratory treatments are given as ordered every 4 hours.
4. The client reports improved breathing after breathing treatments given.
1. The client appears short of breath, with wheezing in all lung fields.

Rationale: Documentation of a nursing assessment includes signs and symptoms and an indication of any actual or perceived problems.