Which of the following is an example of appropriate nursing documentation?

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The selection of the example that indicates appropriate nursing documentation focuses on the clarity and specificity of the provided information. In this case, stating that "the patient is a 40-year-old admitted with cholecystitis" provides clear and concise demographic information along with a specific medical condition, which are essential for understanding the patient's situation and needs.

Effective nursing documentation should include not just observations but also important clinical data to support comprehensive patient assessment and care planning. By including the patient's age and the diagnosis, this statement contributes to a more complete clinical picture, facilitating communication among healthcare providers and guiding further treatment.

In contrast, other options may lack necessary detail or specificity. For example, saying "the patient appears to be in discomfort" is an observation without concrete metrics, making it less effective for clinical use. Mentioning the administration of medication, such as "Patient was given 10 mg of Diazepam," is factual but does not provide context about why the medication was given or the patient's reaction. Additionally, although "Patient is moaning and guarding the abdominal area" describes observable behaviors indicative of pain, it lacks the formal attributes and clinical relevance that contribute to overall patient documentation. Thus, option B is the most fitting example of appropriate nursing documentation.

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