Chapter #4 Validating and Documenting Data

One disadvantage of the open-ended assessment form is that it?

A. requires a lot of time to complete asks standardized questions. does not provide a total picture of the client. does not allow for individualization.

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?

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

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?

A. A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight A blood pressure reading of 110/70 mm Hg in a competitive athlete A pulse rate of 98 in a 10-year-old boy

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?

A. Ask the other nurse to read back what first nurse reported Provide documentation of the data you are sharing Have the other nurse speak with the attending physician to clear up any misunderstandings Communicate face to face with good eye contact

What is the primary purpose of the client record?

A. Communication Research Education Advocacy

A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings?

A. Use phrases instead of sentences to record data. Record how data findings were obtained. Use an eraser to remove any error in the document. Record "normal" for all normal findings if required.

The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?

A. client safety increases Physician notes are more secure Safety among client populations decreases Pharmacy orders are electronically verified

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?

A. client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 Abdominal pain most likely due to client's unhealthy lifestyle and poor eating habits Bowel sounds are present in all four quadrants, all organ within normal limits Abdominal pain x 2 weeks, no medications taken, denies diarrhea or constipation

What is the primary purpose of the client record?

A. communication education research advocacy

Which assessment is most likely performed when a client is admitted to the hospital?

A. comprehensive Shift Focused Abbreviated

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?

A. focused assessment flow chart progress notes nursing minimum data set

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?

A. focused compressive shift head to toe

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?

A. it provides quick access to abnormal findings it provides and refers to client's problem by a number. It documents assessments on separate forms. It records progress under problems, interventions, and evaluation.

A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order?

A. narrative charting PIE charting SOAP charting Focus charting

Symptom analysis is recorded in which of the following sections of the health history? Family History Adult Illnesses Personal and Social History Present Illness

A. personal and social history

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?

A. reassess the blood pressure Have the UAP retake the blood pressure Notify the physician Recheck blood pressure in 30 minutes

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?

A. to communicate more effectively with health care members To aid the nurse's recall of client information To avoid penalties imposed by the federal government To provide protection from liability in the case of a lawsu

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should

A. validate all data before documentation of the data record the nurse's understanding of the client's problem. document the data after the entire examination process. use medical terms that are commonly used in health care settings.

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?

A> to communicate more effectively with team members To aid the nurse's recall of client information To avoid penalties imposed by the federal government To provide protection from liability in the case of a lawsuit

A nurse is busy caring for several clients but understands the importance of taking the time to chart properly. Charting serves many purposes, which include: (Check all that apply.)

a. Allows for communication with other heath team members Provides proof for reimbursement Helps facilities to receive accreditation Serves as legal evidence shows the family what has been done for the client