Chapter 4: Validating and Documenting Data

Which of the following examples of documentation best exemplifies sound clinical documentation practices? -"Client is anxious during questioning regarding health history and family history." -"Abnormal chest sounds noted during posterior chest auscultation." -"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." -"Client reports sharp pain to chest on deep inspiration."

"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."

A nurse works at a dermatologist's office and is assessing a client for skin conditions. Which of the following forms should the nurse use? -Focused -Nursing minimum data set -Assessment flow chart -Progress notes

Focused

The nurse caring for six clients enters the room of a client who underwent gastrointestinal surgery and assesses vital signs, the abdominal wound, and auscultates bowel sounds before seeing the next client. Which type of assessment did this nurse perform on the client? -Shift -Head to toe -Focused -Comprehensive

Focused

During the chest auscultation portion of a general survey, a 31-year-old client suddenly stands up and leaves the room quickly, stating, "I'm sorry, I just can't do this." How should the clinician best document this event? -"Client visibly agitated during assessment and unwilling to continue." -"Client became upset and terminated assessment." -"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." -"During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."

The nurse has assessed the breath sounds of an adult client. The best way for the nurse to document these findings on a client is to write -"after listening to client's lung sounds, both lungs appeared clear." -"the client's lung sounds were clear on both sides." -"bilateral lung sounds clear." -"client's lung sounds were auscultated with stethoscope and were clear on both sides."

"bilateral lung sounds clear."

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? Select all that apply. -A 24-hour recall of what the client has eaten -The client's weight -The presence of a lump in the client's breast discovered on palpation -A description of gall bladder surgery the client had 10 years ago -A description of a large bruise on the client's thigh

-A description of a large bruise on the client's thigh -The client's weight -The presence of a lump in the client's breast discovered on palpation

A nurse is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply. -Description of a lesion that the nurse observes on the client's arm -The client's weight-lifting routine -The client's family history of cancer -The client's occupation -The client's blood pressure

-The client's weight-lifting routine -The client's family history of cancer -The client's occupation

The nurse manager intervenes when which of the following is observed? -A nurse reviews discharge instructions with a client and the client's caretaker. -A nurse shows a client their laboratory results as requested. -A nurse instructs a friend of a client who is asking about the client's care to speak directly with the client. -A nurse provides the spouse of a client access to the client's medical record.

A nurse provides the spouse of a client access to the client's medical record.

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call? -Have the other nurse speak with the attending physician to clear up any misunderstandings -Communicate face to face with good eye contact -Provide documentation of the data you are sharing -Ask the other nurse to read back what first nurse reported

Ask the other nurse to read back what first nurse reported

The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC? -Client and family requests -Medical diagnosis -Standards of nursing care -Assessment data in the medical record

Assessment data in the medical record

The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems? -Safety among client populations decreases -Pharmacy orders are electronically verified -Client safety increases -Physician notes are more secure

Client safety increases

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain? -Bowel sounds are present in all four quadrants, all organ within normal limits -Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 -Abdominal pain x 2 weeks, no medications taken, denies diarrhea or constipation -Abdominal pain most likely due to client's unhealthy lifestyle and poor eating habits

Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

What is the primary purpose of the client record? -Advocacy -Communication -Education -Research

Communication

A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use? -Cued or checklist forms -Integrated cued checklist -Nursing minimum data set -Open-ended forms

Cued or checklist forms

During the admission assessment, the nurse notes the client has cuts to her face and bruises on her chest and back. Which of the following demonstrates the most appropriate documentation of these findings? -Bruises and cuts to face and torso. Client appears to have been severely beaten by her husband. -Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye. -Bruises on chest and back with multiple cuts on her face. -Multiple bruises and cuts on client's body. Client states she fell down a flight of stairs.

Dark purple-blue area on the right side of chest and on right lower back. Open areas on the left side of the lower lip and above right eye.

A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document? -Liver palpation normal -No tenderness on palpation -Bowel sounds normoactive -Decreased range of motion in right shoulder

Decreased range of motion in right shoulder

A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose? -Subjective information is often missing -It reflects poor assessment skills on the part of the nurse -The charting format is not ethical -Details are often missing

Details are often missing

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes? -Discharge planning for the client -Evaluate nursing care provided -Evidence in a situation of wrongdoing -Reimbursement for care provided

Evidence in a situation of wrongdoing

The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation? -Patient's pain is tolerable. -Hyperactive bowel sounds are heard in all four quadrants. -Patient is overweight. -Patient is confused and combative.

Hyperactive bowel sounds are heard in all four quadrants

Nurses at a health care facility maintain client records using a method of documentation known as charting by exception. Which of the following is a benefit of this method of documentation? -It records progress under problems, interventions, and evaluation. -It documents assessments on separate forms. -It provides and refers to client's problem by a number. -It provides quick access to abnormal findings.

It provides quick access to abnormal findings.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: -Using only those abbreviations that are defined in full at another location in the client's chart. -Using only abbreviations whose meaning is self-evident to an educated health professional. -Ensuring that abbreviations are understandable to clients who may seek access to their health records. -Limiting abbreviations to those approved for use by the institution.

Limiting abbreviations to those approved for use by the institution.

A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? -Minimum data set -PIE system -Charting by exception -OASIS

Minimum data set

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? -Focus charting -Charting by exception -SOAP notes -Narrative notes

Narrative notes

Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas, & time? -Nursing minimum data set -Cued or checklist forms -Integrated cued checklist -Open-ended forms

Nursing minimum data set

In order to help out the staff in completing admission tasks during a busy shift, the charge nurse is completing the admission database for a staff nurse. What is the charge nurse's best action? -Omit the fall risk assessment since the client is a young adult. -Place the completed assessment in the medical record. -File the admission database for nurse only access. -Document the highlights of the physical exam.

Place the completed assessment in the medical record.

A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis? -Demographic data sheet -Admission history -Progress notes -Medication record

Progress notes

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication? -SBAR -DAR -PIE -SOAP

SBAR

A novice nurse is preparing for a physical examination of a client with neurological issues. The nurse takes a copy of the practice's standard assessment form and heads to the examination room, where the client is already waiting. A senior nurse notes the novice nurse's actions and says, "Here, use this form instead; it's an assessment form specifically for the neurological system." This second form is an example of which type of form? -Specialty area assessment form -Initial assessment form -Ongoing assessment form -Frequent assessment form

Specialty area assessment form

When a nurse works in a health care agency that charts by exception (CBE), the nurse knows that the client assessment is structured by what? -Client needs -Medical diagnoses -Joint Commission standards -Standardized norms

Standardized norms

To make a legal entry into the medical record, the nurse must document what? -Nature of the assessment -Laboratory tests ordered -Attending physician -Time of the assessment

Time of the assessment

A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance? -To provide a record of the actual events -To provide a record of how the client was harmed -To provide a record of the nurse's activities -To provide a record of the physician's activities

To provide a record of the actual events

A new order for intravenous (IV) antibiotics has been prescribed for a female client who is hospitalized. The nurse reviews the client's chart, which indicates no known drug allergies and an admission diagnosis of a urinary tract infection (UTI). What is the first action of the nurse? -Check the medication for incompatibilities. -Verify whether the client has allergies. -Verify the client has been diagnosed with a UTI. -Administer medication as prescribed

Verify whether the client has allergies.

The nurse is preparing to document assessment findings in a client's record. The nurse should -write in complete sentences with few abbreviations. -avoid slang terms or labels unless they are direct quotes. -use the term "normal" to describe nonpathological findings. -record how the data were collected

avoid slang terms or labels unless they are direct quotes.

A nurse is caring for a client who has been admitted to the medical-surgical unit. After the original admission assessment is done and charted, the nurse documents only abnormalities found on subsequent assessments. This type of charting is called: -narrative charting -batch charting -pie charting -charting by exception

charting by exception

If the nurse makes an error while documenting findings on a client's record, the nurse should -erase the error and make the correction. -obliterate the error and make the correction. -draw a line through the error and have it witnessed. -draw a line through the error, writing "error" and initialing.

draw a line through the error, writing "error" and initialing.

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed -checklist. -focused. -progressive. -specific.

focused.

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed -focused. -specific. -progressive. -checklist.

focused.

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form -prevents missed questions during data collection. -establishes comparability of data across populations. -covers all the data that a client may provide. -clusters the assessment data with nursing diagnoses.

prevents missed questions during data collection.

What information concerning a client's respirations should the nurse record after completing a general physical assessment? -client's understanding of the assessment -any existing chronic conditions that can affect respiration -rate, rhythm, and depth of respirations taken for a full minute -client's understanding of the factors that can affect respirations

rate, rhythm, and depth of respirations taken for a full minute

One disadvantage of the open-ended assessment form is that it -requires a lot of time to complete. -does not provide a total picture of the client. -does not allow for individualization. -asks standardized questions.

requires a lot of time to complete.

The nurse completes a focused assessment of a wound. Which of the following demonstrates adherence to documentation guidelines? -deep wound, edges are well approximated, yellow slough covers ⅓ of wound bed -right lower leg wound, 1.2 in. wide x 1.6 in. length (3 cm wide x 4 cm length), deep with yellow slough distal end -right malleolus wound 1.2 in. wide x 1.6 in. length (3 cm wide x 4 cm length), .4 in. (10 mm) depth, quarter size yellow slough distal end of the wound -wound on right malleolus approximately 1.2 x 1.6 in. (3 x 4 cm), about .4 in. (1 cm) deep, quarter size yellow slough distal end of the wound

right malleolus wound 1.2 in. wide x 1.6 in. length (3 cm wide x 4 cm length), .4 in. (10 mm) depth, quarter size yellow slough distal end of the wound

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should -document the data after the entire examination process. -record the nurse's understanding of the client's problem. -Use medical terms that are commonly used in health care settings. -validate all data before documentation of the data.

validate all data before documentation of the data.

Which of the following data entries follows the recommended guidelines for documenting data? -"Patient complained about the quality of the nursing care provided on previous shift." -"Patient kidneys are producing sufficient amount of measured urine." -"Patient is overwhelmed by the diagnosis of pancreatic cancer." -"Following oxygen administration, vital signs returned to baseline."

"Following oxygen administration, vital signs returned to baseline."

Why is accurate and effective documentation most important? -It can be used to educate other nurses. -Documentation constitutes a legal record. -It ensures that data can be used for research purposes. -It keeps clients informed about their care.

Documentation constitutes a legal record.

A nursing instructor is showing the nursing student how to correct an error when documenting on the chart. The instructor directs the student to do the following: -Black out the incorrect information with a marker and write the correct entry above. -Draw a line through the error and place initials above the correction. -Use whiteout to make the chart appear neat and rewrite the entry. -Erase thoroughly and then rewrite the entry.

Draw a line through the error and place initials above the correction.

Which strategy reduces documentation errors? Select all that apply. -Document client information after assessing all assigned clients. -Document ambiguous client information. -Document client information immediately. -Organize client data logically, using a timed sequence. -Designate a person to document during emergencies.

-Document client information immediately. -Organize client data logically, using a timed sequence. -Designate a person to document during emergencies.

The nurse knows that computerized medical record systems are expensive and can be complicated, but understands that they can significantly increase client safety. Some things that an electronic medical record can do are as follows: (Select all that apply.) -Provide off-site viewing so personnel can note changes in the client's condition -Ensure that all entries are legible -Allow for several health team members to view a single chart simultaneously -Enable the graphing of trends in vital signs and assessments -Alert a physician when a change in a client's record is entered

-Provide off-site viewing so personnel can note changes in the client's condition -Ensure that all entries are legible -Allow for several health team members to view a single chart simultaneously -Enable the graphing of trends in vital signs and assessments

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply): -concise -biased -complete -timely -organized -accurate

-complete -timely -organized -accurate -concise

After performing a comprehensive assessment on a new client, the nurse documents the following findings. Which documentation follows acceptable documentation guidelines? -Client stated they were depressed because they lost their job. -When asked, the client refused to eat or get out of bed. -Client seems depressed, tearful, not engaging in conversation. -Client states, "I don't want to eat or do anything."

Client states, "I don't want to eat or do anything."

The nurse is performing a focused assessment on a client who reports several episodes of dizziness on standing. How should the nurse document the findings? -vital signs within normal limits, heart rate regular, skin turgor good, voiding regularly throughout the day -vital signs normal, no changes in renal function, skin turgor good (right arm, returned to normal in 2 seconds) -Client states, "I have frequently felt dizzy when standing the past 2 weeks," heart rate 94, BP 105/70mm Hg, skin turgor elastic, voiding 3 liters/day. -heart rate 94, regular rhythm, BP 105/70 mm Hg, skin turgor elastic (right arm, returned to normal 2 seconds), client denies changes in urine output

Client states, "I have frequently felt dizzy when standing the past 2 weeks," heart rate 94, BP 105/70mm Hg, skin turgor elastic, voiding 3 liters/day.

When an agency has policies that require nurses to write notes using the DAR (Data, Action, Response) system, the nursing documentation can include what? -Social networks -Areas of personal weakness -Family concerns -Areas of personal accomplishments

Family concerns

When charting by exception is used in a health care agency, the most important aspect of this method is what? -Identifying the standards and norms for the institution -Training new nurses in writing charting by exception notes -Pulling together a group of experts to teach agency staff -Organizing new forms for the nursing staff

Identifying the standards and norms for the institution

A nurse is maintaining a problem-oriented medical record for a client. Which of the following components of the record describes the client's responses to what has been done and revisions to the initial plan? -Problem list -Data base -Plan of care -Progress notes

Progress notes

The nurse is reviewing the client's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the client's status? -Progress notes -Flow sheets -Clinical pathway -Plan of care

Progress notes

The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse recognizes this blood pressure is abnormally low for this client. What is best response of the nurse? -Recheck blood pressure in 30 minutes -Notify the physician -Reassess blood pressure -Have the UAP retake the blood pressure

Reassess blood pressure

The nurse is completing a comprehensive assessment on a new client. The nurse adheres to documentation guidelines by charting which of the following? -Hearing tests confirmed hearing loss. Consultations were made. -Interview was conducted on the client with new-onset hearing loss; tests were abnormal. -Recent changes in hearing; client states, "I cannot hear high-pitched sounds"; Weber and Rinne tests confirmed sensory hearing loss. -Client was interviewed for changes in hearing; tests were performed.

Recent changes in hearing; client states, "I cannot hear high-pitched sounds"; Weber and Rinne tests confirmed sensory hearing loss.

After assessing a client, the nurse thoroughly documents all of her findings. She understands that which of the following is the primary reason for documentation of assessment data? -To communicate effectively with other health care team members -To avoid penalties imposed by the federal government -To provide protection from liability in the case of a lawsuit -To aid the nurse's recall of client information

To communicate effectively with other health care team members

The nurse is providing care to a client who has had a significant change in their vital signs and worsening symptoms. How should the nurse communicate these new findings to the health care provider? -Use the COLDSPA model. -Use the SBAR model. -Complete an ongoing assessment form. -Write a narrative progress note.

Use the SBAR model.

When a client reports never having had surgery, yet physical examination reveals a 10-cm abdominal scar, the nurse needs to: -Validate the data -Find a family member to give the health history -Consider the client unreliable -Confront the client

Validate the data

A client has been prescribed a new medication. What action is most important for the nurse to take prior to administration? -Clarify order with the health care provider. -Verify client allergies to medications. -Assess client laboratory results. -Assess client's vital signs prior to administration.

Verify client allergies to medications.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? -Clarify the data by asking whether the client has experienced any trouble breathing lately. -Verify the data by having another nurse come in to perform the percussion. -Confirm that the client has truly never been a smoker by asking him. -Repeat the percussion using the nondominant hand.

Verify the data by having another nurse come in to perform the percussion.