Chapter 4: Validating and Documenting Data

Guidelines for documentation include? (select all that apply) A. Legible B. Permanent blue of black ink C. Uses nondescript terms D. Uses the word "normal"

A. Legible B. Permanent blue of black ink C. Uses nondescript terms

The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form: A. Prevents missed questions from data collection B. Covers all the data that a client may provide C. Clusters the assessment data with nursing diagnoses D. Establishes comparability of data across populations

A. Prevents missed questions from data collection

A nurse is nurse what a patient has stated, what should the nurse do? A. Recheck data B. Move on to the next part C. Compare objective and subjective data D. Clarify data with patient

D. Clarify data with patient

Which of the following information would need to be validated? (select all that apply) A. Discrepancies between subjective and objective data B. Discrepancies in history from one time to another C. Findings that are inconsistent D. Findings that are within defined limits

A. Discrepancies between subjective and objective data B. Discrepancies in history from one time to another C. Findings that are inconsistent

What is helpful for recording family history? A. Genogram B. Histogram C. Instagram D. Spectoheliograph

A. Genogram

Which of the following are words/phrases to avoid while documenting? (select all that apply) A. Good B. Normal C. Poor D. Nickel sized

A. Good B. Normal C. Poor

How would you validate data? (select all that apply) A. Clarify data with patient B. Compare subjective findings with objective findings C. Look in the patient's family member's chart D. Look in your pathophysiology book

A. Clarify data with patient B. Compare subjective findings with objective findings

What act requires confidentiality with patient information?A A. HIPPA B. NRA C. ANA

A. HIPPA

The nurse is planning to assess a newly admitted patient. While gathering data from the patient, the nurse should: A. Validate all data before documentation of the data B. Document the data after the entire examination C. Record the nurse's understanding of the client's problem D. Use medical terms that are commonly used in healthcare settings

A. Validate all data before documentation of the data

Which of the following are methods of validating? A. Verifying data B. Rechecking you own data through a repeat assessment C. Going off what seems right D. Comparing your objective findings with your subjective findings to uncover discrepancies

A. Verifying data B. Rechecking you own data through a repeat assessment D. Comparing your objective findings with your subjective findings to uncover discrepancies

What is an example of a discrepancy between subjective and objective data? A. A female client claims to have the chills, temperature is 101. B. A male client tells you that he is very happy even though learning that he has terminal cancer C. A male client claims to have pain in his left arm, his arm has a fracture D. A female client feels tired, has stayed up every night in the hospital from stress

B. A male client tells you that he is very happy even though learning that he has terminal cancer

The nurse is preparing to document assessment finding in a patient's record. The nurse should: A. Write in complete sentences B. Avoid slang terms or labels unless they are direct quotes C. Record how the data was collected D. Use the term "normal" to describe nonpathologic findings

B. Avoid slang terms or labels unless they are direct quotes

An example of subjective data findings in a patient is: A. Apical pulse B. Pain C. Height D. Blood pressure

B. Pain

One disadvantage of the open-ended assessment form is that it: A. Does not allow for individualization B. Ask standardized questions C. Requires a lot of time to complete D. Does not provide a total picture of the client

C. Requires a lot of time to complete

What is the primary reason for documentation of assessment data? A. To promote safety B. To promote efficiency C. To promote effective communication D. To keep information organized

C. To promote effective communication

The advent of what technology made it possible to link other documents and healthcare departments? A. Walkman B. Telegraph C. SEGA Genesis D. Computer

D. Computer

If the nurse makes an error while documenting findings on the client's record, the nurse should: A. Erase the error and make the correction B. Obliterate the error and make the correction C. Draw a line through the error and have it witnessed D. Draw a line through the error and write "error" with initials, credentials, date, and time

D. Draw a line through the error and write "error" with initials, credentials, date, and time

In some healthcare settings, the institution uses an assessment form that assesses only one part of a patient. These types of forms are termed: A. Progressive B. Specific C. Checklist D. Focused

D. Focused

While recording the subjective data of a patient who complains of pain in his lower back, the nurse should include the location of the pain and the: A. Cause of the pain B. Patient's caregiver C. Patient' occupation D. Pain relief measures

D. Pain relief measures

What is the primary purpose of documentation? A. To have legal record B. So healthcare providers don't have to assess patients the next time they come to the hospital C. To communicate with other healthcare providers D. Provides a database which serves as the foundation of the nursing process

D. Provides a database which serves as the foundation of the nursing process

What is an example of an objective finding in a patient? A. A client's symptom of pain B. Family History data C. Genetic disorders D. Vital signs

D. Vital signs

True/False Every piece of data the nurse collects must be verified.

False