health assessment chapter 4

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 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?

narrative notes

Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015?

meaningful use of electronic health records

What is the primary purpose of the patient record?

communication

To make a legal entry into the medical record, the nurse must document what?

Time of the assessment

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

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 need to make sure that all the information I gathered today is reliable and accurate."

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call?

Ask the other nurse to read back what first nurse reported

A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse?

It allows several health team members to view the patient record simultaneously.

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.

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?

SBAR

One disadvantage of the open-ended assessment form is that it

takes a lot of time

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should

validate all data before documentation of the data.

When a client reports never having had surgery, yet physical examination reveals a 10-cm abdominal scar, the nurse needs to:

validate the data

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?

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

Which statement by an adolescent female client admitted for excessive weight loss and dehydration requires validation by the nurse?

"I am very happy with my life right now"

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 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."

Which assessment is most likely performed when a client is admitted to the hospital?

Comprehensive

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 has completed assessing a client and now must validate the collected data. What are the steps that the nurse should follow? Select all that apply.

Decide whether the data require validation. Determine ways to validate the data. Identify areas where data are missing.

Which strategy reduces documentation errors? Select all that apply.

Document patient information immediately. Designate a person to document during emergencies. Organize patient data logically, using a timed sequence.

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 nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding?

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

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?

details are often missing

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?

focused

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?

focused

n some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed

focused

The nurse manager reviews documentation completed by a graduate nurse. Which entry should the manager question? Select all that apply

Appetite good Right foot swollen Vital signs normal

The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems?

Client safety increases

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

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?

Place the completed assessment in the medical record.

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?

Repeating the measurement with a different sphygmomanometer and stethoscope

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):

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.

A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis?

progress notes

The nurse is reviewing the patient's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the patient's status?

progress notes

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?

reassess blood pressure

When a nurse works in a health care agency that charts by exception (CBE), the nurse knows that the client assessment is structured by what?

standardized norms