Registered Practical Nurse (RPN) Practice Test

What should a nurse document after observing a significant change in a client's physical condition?

1. Personal opinions about the client

2. Only the physical assessment

3. Verbatim communication with the client

4. A comprehensive observation report

The correct answer is: A comprehensive observation report

Documenting a comprehensive observation report is essential for several reasons. When a nurse observes a significant change in a client’s physical condition, thorough documentation provides a complete picture of the client’s current state. This report should include objective data such as vital signs, physical findings, and pertinent details about changes in the client’s condition, as well as any interventions that were taken in response. A comprehensive report ensures that all relevant information is captured and is critical for continuity of care, enabling other healthcare professionals to understand the situation and provide appropriate interventions. It’s also vital for legal and professional accountability, as comprehensive documentation serves as an official record of the care provided. The other options do not adequately address the need for comprehensive communication in the nursing process. Personal opinions can lead to bias and inaccuracies; documenting only the physical assessment would omit important contextual information; and while verbatim communication with the client may feel thorough, it does not encapsulate the full scope of changes observed and the overall clinical picture. Thus, a comprehensive observation report is the best choice for documenting significant changes in a client’s physical condition.