During assessment, a patient says, “I feel dizzy,” while the nurse observes an unsteady gait. Which documentation is correct?
Correct answer: B. The patient reports dizziness and has an unsteady gait
- A. The patient is unstable and probably has vertigo
- B. The patient reports dizziness and has an unsteady gait
- C. The patient is confused and cannot walk safely
- D. The patient has a balance disorder caused by illness
Explanation
The patient's words are documented as subjective data, and the observed unsteady gait is documented as objective data. The other statements add unconfirmed interpretations or medical conclusions that require further assessment.
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About Nursing Process and Health Assessment
Assessment gathers subjective and objective data through health history, physical examination and observation. The nursing process then uses nursing diagnoses, planning, implementation and evaluation to provide individualised care, while distinguishing a nursing diagnosis from a medical diagnosis and identifying priorities such as airway, breathing, circulation and safety.
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