Texas Certified Nursing Assistant (CNA) Practice Exam

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Which piece of information is essential when documenting patient care?

The patient’s favorite activities

The details of the patient’s care plan and observations made

The details of the patient’s care plan and observations made are vital for accurate documentation in patient care. This information reflects the specific interventions provided, the patient's responses to those interventions, and any changes in their condition. Documenting these details ensures continuity of care among healthcare providers, allows for necessary adjustments to the care plan, and aids in the evaluation of the patient's progress. It also serves as a legal record in case of any disputes regarding the patient's treatment.

In contrast, while knowing the patient's favorite activities may enhance the therapeutic relationship, it is not essential for clinical documentation. Logging only the medications given neglects the broader scope of care and patient monitoring, which is fundamental to a comprehensive understanding of the patient's status. Additionally, general observations from nurses and doctors may not provide enough specific information required for a complete and effective care plan. Thus, focusing on the care plan and detailed observations is crucial for high-quality patient care.

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Only the medications given

General observations from nurses and doctors

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