Question

the nurse is caring for a client admitted following a total abdominal hysterectomy. which data entered in the medical record is most accurate?

nausea observed in the client following meals
states, \my blood pressure is elevated.\
denies pain or discomfort
angry because i dropped their pills on the floor

Explanation:

Analyze the principles of clinical documentation

Using the Nursing Documentation Standards knowledge point, medical record entries must be objective, factual, accurate, and free of personal bias, judgment, or speculation. Subjective statements made by the client should be documented as direct quotes to maintain accuracy.

Evaluate the first option

"Nausea observed in the client following meals" is problematic because nausea is a subjective symptom that cannot be directly observed by the nurse. The nurse can observe objective signs like emesis (vomiting), but not the sensation of nausea itself.

Evaluate the second option

"States, 'My blood pressure is elevated.'" is a subjective statement. While it uses quotation marks, documenting a client's self-report of a physiological parameter like blood pressure is less accurate and useful than documenting the actual measured objective value (e.g., "BP 150/90 mmHg").

Evaluate the third option

"Denies pain or discomfort" is a clear, objective, and standard factual description of a client's reported status. It accurately reflects the client's direct communication regarding their pain level without adding subjective interpretation or bias.

Evaluate the fourth option

"Angry because I dropped their pills on the floor" contains subjective interpretation ("Angry") and unprofessional personal narrative ("I dropped their pills"). Documentation should describe observable behaviors (e.g., "Client raised voice") rather than labeling emotions, and must remain professional.

Answer:

• Nausea observed in the client following meals
• States, "My blood pressure is elevated."
• Denies pain or discomfort (Correct answer)
• Angry because I dropped their pills on the floor