Questions: Question 48 The nurse is preparing to document information after an interaction with a patient. Which information would the nurse classify as appropriate to include? Select all that apply. One, some, or all responses may be correct. - Patient crying throughout interaction - Bruises noted on right arm and lower back - Safety plan discussed if abuse occurs again - Restraining order filed with law enforcement - Patient states, "My spouse has hit me before"

The answer is:

• Patient crying throughout interaction
• Bruises noted on right arm and lower back
• Safety plan discussed if abuse occurs again
• Patient states, "My spouse has hit me before"

Explanation for each option:

1. Patient crying throughout interaction: This is correct. Documenting the patient's emotional state is important as it provides context for their condition and can be relevant for understanding their overall well-being and mental health.

2. Bruises noted on right arm and lower back: This is correct. Physical observations such as bruises are critical to document as they provide evidence of potential abuse or injury, which is essential for medical and legal purposes.

3. Safety plan discussed if abuse occurs again: This is correct. Documenting the discussion of a safety plan is important as it shows that the nurse has taken steps to ensure the patient's future safety and has provided necessary resources and support.

4. Restraining order filed with law enforcement: This is incorrect. While it is important to know if a restraining order has been filed, this specific action is typically documented by law enforcement or legal professionals, not by the nurse. The nurse should document that the patient has been advised to seek a restraining order if appropriate.

5. Patient states, "My spouse has hit me before": This is correct. Documenting the patient's statements verbatim is crucial as it provides direct evidence of the patient's experience and can be important for both medical treatment and legal proceedings.

In summary, the nurse should document observations, patient statements, and any discussions related to the patient's safety and well-being. However, actions taken by other entities, such as law enforcement, should be noted but not documented as actions taken by the nurse.