Chapter 4 prep u

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.

What statement about batch charting is most accurate?

It contributes to many potential errors.

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.

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.

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 non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."

Examples of objective data include all the following except:

itchy skin

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 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

Which of the following data entries follows the recommended guidelines for documenting data?

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

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."

The nursing instructor is teaching about the importance of good communication and accuracy when documenting on the client chart. Some things that are high-risk errors in documentation are the following:

-Falsifying client records -Failing to record changes in a client's condition -Performing an inadequate admission assessment -Charting in advance

The nurse manager intervenes when which of the following is observed?

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

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 will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use?

An assessment flow chart

The nurse performs a focused respiratory assessment on a client. The nurse documents the following findings. Which documentation adheres to documentation guidelines?

Anterior, posterior lung sounds are clear bilaterally, 12 respirations per minute, unlabored.

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?

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.

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

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?

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?

Decreased range of motion in right shoulder

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?

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

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 nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?

Focused assessment form

A nurse receives lab results on a client that show that the client is pregnant. The client says that this is impossible, however, because she is still breastfeeding her 1-year-old son. Which of the following would be appropriate ways for the nurse to validate the positive finding for pregnancy? Select all that apply.

Have the client take a different pregnancy test

A client is being discharged from the hospital after a below-the-knee amputation. The nurse has completed the discharge and gives a copy of the discharge summary with client teaching and medications to the client. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes:

Identify necessary resources and strategies for successful home management.

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 responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos 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.

A nurse has completed an assessment of a client with cholecystitis and is about to document the findings. Which statement best reflects accurate documentation?

Skin pale, warm, and dry without evidence of lesions.

The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data?

The man has a diffuse rash on his torso.

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

What is an appropriate guideline for the nurse to follow when documenting assessment findings on a client?

Use phrases instead of sentences to record data.

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 SBAR model

The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use?

Verbal handoff

A client has been prescribed a new medication. What action is most important for the nurse to take prior to administration?

Verify client allergies to medications.

A client who had a mastectomy is being discharged home on postoperative day 1. Knowing that the client lives alone, which data would be most important for the nurse to validate for this client?

What support systems are in place to assist the client

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

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:

charting by exception

The nurse prepares information to provide to the nurse scheduled to work the next shift. Which type of communication is the nurse preparing?

handoff report

According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients:

have the right to copy their health records.

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?

progress 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?

progress notes

The nurse thinks that a client with pitting edema would benefit from wearing antiembolism stockings. Which part of the SBAR communication model is the nurse completing?

recommendation

The nursing instructor is demonstrating to the student how to perform a physical assessment on a client. 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:

accurate documentation

If the nurse makes an error while documenting findings on a client's record, the nurse should

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

When performing an assessment, which of the following would be most helpful in validating a client's chief complaint?

objective data

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

There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many health care providers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite?

Improved continuity of care

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 provides quick access to abnormal findings.

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

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

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?

"It means I nee

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 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

A hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?

Increase the use of electronic health records (EHRs) in the hospital.

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 client'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