Chapter 4 - Documentation and Interprofessional Communication

When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?

It becomes the foundation for the entire nursing process.

While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information?

Client denies prior hospitalizations and surgeries

After performing a comprehensive assessment on a new client, the nurse documents the following findings. Which documentation follows acceptable documentation guidelines?

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

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

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

The nurse is caring for a client with influenza symptoms and is documenting the initial and ongoing assessment database. What would the nurse emphasize as the major rationale for this action?

Promoting communication between disciplines

The nurse is completing a comprehensive assessment on a new client. The nurse adheres to documentation guidelines by charting which of the following?

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

A nurse is instructing the nursing student on strategies for reducing high-risk errors in documentation. Which examples should the nurse include when teaching the nursing student?

The nurse takes and records the client's heart rate before administering digoxin. The nurse notes the return of bowel sounds following the client's surgery. The nurse administers pain medication when the client reports a pain rating of 7.

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also

accurate organized complete timely concise

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.