Ch 4 Assessment
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?
When communicating a patient's change in condition to the patient's physician.
A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.
• Determining eligibility for reimbursement • Legal document of care • A method to gather research data • Promoting effective communication between caregivers
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):
• accurate • organized • complete • timely • concise
Nurses are aware that "handoff" can significantly increase the risk for errors. Common examples of "handoffs" are as follows (check all that apply):
• when a patient is transferred from the PACU to the floor • when a nurse leaves for lunch • at change of shift
A client has illuminated his call light and tells the nurse that he is having "ten out of ten" pain. The nurse's initial inspection reveals that the client is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain?
Perform further assessments addressing various aspects of the client's pain.
The nurse documents data immediately after assessing the patient.
Point-of-care documentation
Why is accurate and effective documentation most important?
Documentation constitutes a legal record.
The nurse documents a blood pressure value for the patient without taking the patient's blood pressure. This is an example of:
Falsifying the patient record
A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data?
Focused assessment form
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
A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered?
• 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
How does the client's medical record affect financial reimbursement?
• Insurance companies audit client records to ensure that billing is accurate
The nurse is documenting client care. Which nursing assessment note would be most appropriate?
"Client voices concerns about being able to change abdominal dressings at home."
While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding?
"Area of nonblanching erythema noted over client's coccyx, 2 cm × 2 cm."
During 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?
"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which of the following statements?
"I think this client would benefit from an antiemetic."
Which of the following examples of documentation best exemplifies sound clinical documentation practices?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
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
"bilateral lung sounds clear."
A nurse is working in a health care facility that is using charting by exception. Which of the following would the nurse expect to document?
Aching, burning pain in lower back
A nurse is in the elevator at the hospital. The nurse overhears another nurse laughing and making jokes about a client. Why is this situation a breach of confidentiality?
All client information is private and confidential
A nurse has completed a client's initial assessment and is now interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process?
Analysis
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?
Ask the other nurse to read back what first nurse reported
What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the homecare setting?
OASIS
The nurse is about to leave the floor for her lunch break. Before leaving she must report using the SBAR model to the nurse who is to care for the patient during her absence. She tells the nurse, "The patient was admitted 8 hours ago after spending the night in the ER with abdominal and back pain. He has had numerous tests; results indicate that he has gallstones. He is scheduled for surgery tomorrow." What part of the SBAR model does this information represent?
Background
The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of:
Batch charting
Abnormal assessment findings are clearly outlined in which documentation format?
Charting by exception
While gathering a nursing history about a client's previous hospitalizations and surgeries, the nurse finds out that this is the client's first hospitalization and that he hasn't had any surgeries. The nurse would document which of the following?
Client denies prior hospitalizations and surgeries
A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?
Decreased range of motion in right shoulder
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
Evidence in a situation of wrongdoing
During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance?
Facility level
A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?
Focused assessment form
The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation?
Hyperactive bowel sounds are heard in all four quadrants.
There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many caregivers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite?
Improved continuity of care
An audit of a hospital unit's incident reports reveals that several errors have resulted from incomplete or inaccurate information during change-of-shift handoff. In order to prevent such errors, what practice should be encouraged on the unit?
Involve as few people as possible in the verbal report.
The nurse manager is implementing walking patient rounds for the change-of-shift reports. One benefit of this type of reporting over others is:
It facilitates active participation of patients.
A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?
It provides a chronologic source of client assessment data.
A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes?
It provides a chronologic source of client assessment data.
A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?
Repeating the measurement with a different sphygmomanometer and stethoscope.
Mistakes in charting can be costly to both the patient and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following:
Sentinel events
The nurse is reviewing the patient'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 patient's status?
Progress notes
After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following?
Subjective data and objective data
A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care?
Notifies health care providers when clients show clinical signs of deterioration.
A nurse is conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use?
Nursing minimum data set
When performing an assessment, which of the following would be most helpful in validating a client's chief complaint?
Objective data
The nurse is reviewing a SOAPIE note in the patient's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note.
Subjective
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?
The laboratory assistant can only retrieve medical records but cannot view the details.
Which example may illustrate a breach of confidentiality and security of patient information?
The nurse provides information over the phone to the patient's family member who lives in a neighboring state
A nurse is documenting a skin condition that she has observed while examining a client. Which of the following descriptions would be most appropriate to include in the client's chart?
Three lesions, 5 mm in diameter, producing purulent yellow drainage on the client's right anterior forearm
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
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?
Use phrases instead of sentences to record data.
