Chapter 4 Nursing Final

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? a) client reports headache b) Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. c)Client has dull, aching pain in the back of his head that began 2 weeks ago. The pain is constant and seems to be worse in the mornings. d) Client has severe headache, probably related to alcoholism

Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.

A nurse works at a dermatologist office and is assessing a client skin for conditions. Which of the following forms should the nurse use? a) Focused b) Progress notes c) Assessment flow chart d) Nursing minimum data set

Focused

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? a) Have you been experiencing increased stress at work lately? b) Has your diet or exercise changed significantly in the past year? c) Have you experienced unusually high thirst or frequency in vomiting d) Have you experienced any chest pain recently?

Has your diet or exercise changed significantly in the past year?

What statement by adolescent female client admitted for excessive weight loss and dehydration requires validation by the nurse? a) I am very happy with my life right now b) I have been having a lot of nausea lately c) I exercise at least two hours everyday d) My mouth and lips feel very dry

*a) I am very happy with my life right now

Why should the nurse document assessment findings? a)Eliminate the possibility of diagnosing new problems b)Determine the educational needs of the client c)Ensure that only nurse is aware of the assessments d)Avoid delays in carrying out the plan of care

*b)Determine the educational needs of the client

Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas and time? a) Integrated cued checklist b) Nursing minimum data set c) Cued or checklist forms d) Open-ended forms

*b)Nursing minimum data set

A nurse is explaining to a new client that the office uses electronic health records (EHRs) fro all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR. a) A record designed to reach out beyond the health organization that originally obtains the data b)A record that is intended for sharing data with many different types of health care providers c) A record that covers the more comprehensive health status of the client d) A record supplied by a physician in which diagnoses and prescribed treatments are recorded

A record supplied by a physician in which diagnoses and prescribed treatments are recorded

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

Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

A nurse has just finished taking a client's vital signs and comparing the results with those from previous visit 3 months ago. Which of the following situations would require the nurse to validate the data? a) client's temperature was 98.6 F months ago but is 99.2 F today b) Resting heart rate was 65 bpm 3 months ago but 70 bpm today c) Client's weight was 200lb 3 months ago but 125lb today d) Blood pressure was 130/85 3 months ago but 120/80 today

Client's weight was 200lb 3 months ago but 125lb today

A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that the client has gained 6 pounds over a week. How should the nurse validate this data? a) avoid questioning the client on the sudden weight gain b) have the client weighed again on the same equipment c) verify the previously documented data d) Compare objective findings with subjective findings

Compare objective findings with subjective findings

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? a) Cued or checklist forms b)Nursing minimum data set c) Open-ended forms d) integrated cued checklists

Cued or checklist forms

A nurse makes an incorrect entry onto a client's paper record during documentation of the assessment data. What is the correct way for the nurse to fix this error?

Draw a line through the error, write "error" and initial the entry

A nurse who is new to the health clinic and who recently graduated from a nursing program tells 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? a) It means I need to have the physician come in and look over your chart to make sure i didn't miss anything b) It means I need to take all of your vital signs one more time c) it means that i need you to sign a statement in which you confirm that everything you have shared with me today is true d) It means i need to make sure that al the information gathered today is reliable and accurate

It means i need to make sure that al the information gathered today is reliable and accurate

A nurse is conducting clients assessments in a long-term care facility. The manger of the facilty 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? a) Cued or checklist forms b) Nursing minimum data set c) Open-ended forms d) integrated cued checklists

Nursing minimum data set

A nurse is performing an initial assessment of a client. Which assessment form should the nurse use? a) Assessment flow chart b) Frequent vital signs sheet c) Nursing minimum data set d) Cardiovascular assessment sheet

Nursing minimum data set

A nurse who has been working 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

Repeat the measurement with a different sphygmomanometer and stethoscope

A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the health insurance portability and accountability act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately described what HIPAA covers?

The confidentiality of electronic and printed health information

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

Use phrases instead of sentences to record data

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 needs to be validated. Which method of validation would be most appropriate in this case? a)Repeat the percussion using the nondomiant hand b) Confirm that the client has truly never been a smoker by asking him c)Verify the data by having another nurse come in to perform the percussion d) Clarify the data by asking whether the client has experienced any trouble breathing lately

Verify the data by having another nurse come in to perform the percussion

A nurse admits a client to the health care facility The nurse gathers data about the client's social history and wants to make this information available to the social worker. Which initial assessment documentation form is best for the nurse to use? a) checklist b) Nursing minimum data set c) Open-ended d) integrated cued checklists

integrated cued checklists