Chapter 4
Reassess blood pressure
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?
An x in a circle
Which sign in a genogram indicates a deceased female client ?
A vertical dotted line
Which sign in a genogram indicates adoption?
An x in a square
Which sign indicates in a genogram a deceased male client?
Document patient information immediately. Designate a person to document during emergencies. Organize patient data logically, using a timed sequence.
Which strategy reduces documentation errors? Select all that apply.
Identify the patient's problems
You are the office nurse admitting a new patient to the clinic. You have gained your patient's trust, gathered a detailed history, and finished your portion of the physical examination. What is your next step in caring for this patient?
A horizontal dotted line
which sign in a genogram indicates a spouse?
Data analysis is also referred to as the diagnostic phase because the end result is the identification of the nursing diagnosis."
The student nurse asks the instructor, "What is the difference between the data analysis and the diagnostic phase?" What is the best response by the instructor?
Identifying the standards and norms for the institution
When charting by exception is used in a health care agency, the most important aspect of this method is what?
"It was done to validate the reading."
A client asks why a nurse measured the blood pressure after the nursing assistant completed the measurement a few minutes ago. What should the nurse respond to the client?
Itchy feeling
A client presents to the clinic with reports of an itchy rash all over the body. The nurse observes lesions on the client's arms and legs as well as the presence of a dry, hacky cough and sneezing. Which data collected from the client can be classified as a subjective abnormal finding?
Unable to feel his leg
A client presents to the emergency department following an accident at a construction site. The client is bleeding profusely from a deep wound on his head and states he cannot feel his leg. The nurse notes that the client is lethargic and mildly confused. What subjective data should the nurse document on this client?
"Can you tell me about your sleep problem from when it started until now?"
A client reports difficulty sleeping. Which question would be the most effective way for the nurse to open the interview?
Anxious appearance
A client reports sudden hair loss and a continuous itching sensation all over the body. The client appears anxious and seems to be worried about her appearance. Which abnormal finding should the nurse classify as objective data?
wellness diagnostic
A client who is overweight tells the nurse that he wants to lose weight but he doesn't know the best way to begin. The client states that he participates in routine exercise, but wants to increase the intensity of his workout. Which type of nursing diagnosis should the nurse choose for this client based on this information?
Medication reconciliation
A client with an elevated blood pressure asks the nurse why he is not taking his blood pressure medication from home while he is hospitalized. The nurse reviews the orders and discovers that indeed the client is not taking his usual blood pressure medication. Which preventive measure was most likely omitted on admission?
true
A client's feelings and perceptions may be recorded as subjective data.
quickly make a diagnosis without hypothesizing several diagnoses.
A common error for beginning nurses who are formulating nursing diagnoses during data analysis is to
A referral
A community health nurse provides information to a patient with newly diagnosed multiple sclerosis for a support group at the local hospital for patients diagnosed with multiple sclerosis and their families. Providing this information is an example of which of the following?
To provide a record of the actual events
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance?
Determining eligibility for reimbursement Legal document of care A method to gather research data Promoting effective communication between caregivers
A legal nurse consultant explains to a group of nursing students that the medial record serves what purpose? Select all that apply.
Place on cardiac monitor.
A male client presents to the emergency department complaining of new onset chest pain. What is the priority action of the nurse?
Specialty area assessment form
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?
The quality of the data may be low.
A nurse assesses an older adult client with confusion. When collecting clinical information from the client, which factor is the most important for the nurse to consider?
Narrative charting
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?
Details are often missing
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?
Use phrases instead of sentences to record data.
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?
charting by exception
A nurse is caring for a patient 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.
The client's family history of cancer The client's weight-lifting routine The client's occupation
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.
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?
Three lesions, 5 mm in diameter, producing purulent yellow drainage on the client's right
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?
Progressive Notes
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?
Intuition
A nurse is working with a patient who has a history of chronic obstructive pulmonary disease (COPD). While bathing the patient, the nurse senses that something is not quite right and takes the patient's vital signs and obtains an oxygen saturation reading. The nurse is acting on which of the following?
Repeating the measurement with a different sphygmomanometer and stethoscope
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?
"It means I need to make sure that all the information I gathered today is reliable and
A nurse who is new to the health clinic and who recently graduated from a nursing program tells a client at the end of an interview that data the nurse has just collected from the client needs to be validated. The client, an elderly gentleman, gives the nurse a strange look and says, "Validate my data? What does that mean?" How should the nurse respond to this client?
Focused
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?
"All patients have the same defining characteristics."
A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement?
All patients have the same defining characteristics."
A nursing instructor is teaching about diagnostic reasoning and the importance of culture. The student needs further explanation when making which statement?
organized concise timely accurate complete
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):
"Diagnostic reasoning is a form of critical thinking used to interpret data correctly."
A nursing student is explaining to a roommate the relationship between diagnostic reasoning and critical thinking. Which of the following is the correct statement for the nursing student to make?
It provides quick access to abnormal findings.
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?
Has your diet or exercise changed significantly in the past year?
On reviewing a client's database following a physical examination, a nurse realizes that the client's weight has been steadily increasing over her past three visits. What follow-up question would be best for the nurse to pose to the client based on this finding?
may be easily used by different levels of caregivers, which enhances communication.
One advantage for an institution to use an integrated cued/checklist type of assessment data form is that it
Client safety increases
The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?
Review the client's prescribed medication orders.
The nurse enters an unassigned client's room to investigate an alarm. The client's intravenous (IV) bag is empty and the IV bag on the pole, left by the client's assigned nurse to hang next, is a different solution. What is the nurse's best action?
Actual Nursing Diagnosis
The nurse formulates a nursing diagnosis of pain, acute, from assessment data collected from a patient who has complained of pain of a 7 (1 to 10 scale). What type of nursing diagnosis would this be considered?
"bilateral lung sounds clear."
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
discuss the plan with the patient
The nurse has completed an assessment on a new patient. After gathering the data, formulating a nursing diagnosis, and developing a plan of care, it is important for the nurse, before finalizing the plan, to
Analyze the data
The nurse has learned that after completing the assesment phase of the nursing process, the next step is the diagnostic phase. What does the diagnostic phase allow for the nurse to do?
"The electronic medical record is one of the tools we use to keep you safe."
The nurse is admitting a client to a medical unit. The client is concerned that all of his private health information is on the computer and an error may occur. What is the most appropriate response of the nurse?
Weight gain of 3 pounds (1.5 kilograms) over 1-2 days
The nurse is determining a priority problem that would be appropriate for a client with heart failure. Which problem would have the highest priority for the client?
Identified strengths
The nurse is formulating a wellness diagnosis for a patient ready for discharge from the hospital. In order to do this, what must the nurse identify?
validate all data before documentation of the data.
The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should
avoid slang terms or labels unless they are direct quotes.
The nurse is preparing to document assessment findings in a client's record. The nurse should
SBAR
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?
wellness diagnostic
The nurse is working with a 14-year-old girl who has told the nurse that she would like to try getting to bed a little sooner to get a full night's sleep and have more energy at school. The nurse diagnoses her with the following: Readiness for enhanced sleep related to client's expressed desire to go to bed earlier. Which type of nursing diagnosis is this?
Narrative Notes
The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record patient conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?
Evidence in a situation of wrongdoing
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes?
false
The nurse should use closed-ended questions to elicit the client's feelings and perceptions.
too many or too few data
The nursing instructor informs the students that there are pitfalls that decrease the reliability of cues and decrease diagnostic reasoning. The first set of pitfalls is related to the collection of data and includes which of the following?
seeing things as only right or wrong
The nursing instructor realizes that the nursing student understands all the criteria necessary for developing expertise when making clinical professional judgments by identifying the following as being a barrier to diagnostic reasoning.
Assessment data in the medical record
The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC?
Itchy Skin
Examples of objective data include all the following except:
requires a lot of time to complete.
One disadvantage of the open-ended assessment form is that it
Limiting abbreviations to those approved for use by the institution.
When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:
False
Is the following statement true or false? Good overhead lighting is an effective substitute for sunlight during an assessment.
True
Is the following statement true or false? Sitting upright on the side of the examination table is a useful position while examining the client as it allows full expansion of the lungs.
True
Is the following statement true or false? There are times when gloves must be changed between procedures on the same patient.
Moderate palpation
Depressing the skin surface with the dominant hand and using a circular motion to palpate falls under which palpation type?
Blunt
Percussion that is used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface is known as direct percussion.
Time of the assessment
To make a legal entry into the medical record, the nurse must document what?
accurate documentation
20s The nursing instructor is demonstrating to the student how to perform a physical assessement on a patient. The instructor stresses the importance of being precise when doing an assessment. Another necessary aspect of the assessment to render safe and effective care is which of the following:
Capillary blood glucose
22s A hospitalized client is prescribed a short course of corticosteroids. The client is placed on sliding scale regular insulin. The nurse should routinely assess which laboratory value while the client is hospitalized?
Make a referral to the dietician.
28s A client has been diagnosed with diabetes mellitus, and the nurse knows that the client requires education on the dietary restrictions. What would be an appropriate intervention by the nurse?
Nursing minimum data set
29s 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?
Checklists
33s A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication that the nurse should use?
Place the completed assessment in the medical record.
35s 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?
Elimination of redundant data collection by other health care team members Increased likelihood that clients will receive life-saving treatment Potential lowered risk of hospital-acquired infections Ability to link the client's health record to other documents
37s The hospital where a nurse works is converting from a paper-based documentation system to a computer-based one. The nurse recognizes that which of the following are advantages of computer-based over paper-based systems? Select all that apply.
t's acceptable for a client to admitted for observation."
47s A client is admitted for observation after complaining of chest pain. A 12-lead electrocardiogram (ECG) reveals a normal sinus rhythm. The staff nurse questions the charge about whether the client can be observed or should be sent home because the ECG is normal. What is the charge nurse's best response?
Focused
50s 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?
Cued or checklist forms
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?
To communicate effectively with other health care team members
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?
Validate the client's identified problems.
After collecting subjective and objective data for the admission database, what is the nurse's next action?
Verify the data by having another nurse come in to perform the percussion.
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?
During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room."
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?
draw a line through the error, writing "error" and initialing.
If the nurse makes an error while documenting findings on a client's record, the nurse should
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
False
Is the following statement true or false? A partial assessment is done when the client first enters a health care facility.
False
Is the following statement true or false? Physical medical assessment collects holistic subjective and objective data to determine a client's overall level of functioning in order to make a professional clinical judgment.
True
Is the following statement true or false? Subjective data are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client.
validate information and judgments.
One characteristic of a nurse who is a critical thinker is the ability to
Ambulation assistance
The RN may delegate which care component to a nursing assistant?
Verify positioning of the catheter.
The nurse observes no urine output in a client's indwelling urinary catheter drainage bag. What is the nurse's first action?
Diagnostic reasoning skills are required to interpret data accurately.
The nurse recognizes that the second step or phase of the nursing process is difficult. Why is data analysis a difficult step?
clinical experience
What can the nurse use to learn new information and add to their knowledge base?
Clinical reasoning process
What is pivotal to determining how to move from each client problem to its goals?
Collecting subjective and objective data
What occurs during the assessment phase of the nursing process?
Validate the data
When a client reports never having had surgery, yet physical examination reveals a 10-cm abdominal scar, the nurse needs to:
Comprehensive
Which assessment is most likely performed when a client is admitted to the hospital?
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10
Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?
"Following oxygen administration, vital signs returned to baseline."
Which of the following data entries follows the recommended guidelines for documenting data?
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
Which of the following examples of documentation best exemplifies sound clinical documentation practices?
