PrepU Chapter 4: Documentation and Interprofessional Communication

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

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

A client asks to see his medical record (chart). How would the nurse respond?

"I will get your chart and provide you with privacy to read it.'

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 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

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

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.

Why is accurate and effective documentation most important?

Documentation constitutes a legal record.

The nurse documents a blood pressure value for the client without taking the client's blood pressure. This is an example of:

Falsifying the client record

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

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?

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

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

Have the right to copy their health records.

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.

Examples of objective data include all the following except:

Itchy skin

A health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation?

Not informing a client in writing of the purpose of sharing his or her personal details.

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 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

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing?

SOAP charting

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.

Which of the following should be included in the documentation of subjective data in the nurse's findings from the physical examination of the head and neck in the client with acute neck pain?

The client reports worsening pain in the neck when she looks down.

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

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 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

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

Objective data

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."

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 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

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

The nurse manager is implementing walking client rounds for the change-of-shift reports. One benefit of this type of reporting over others is:

It facilitates active participation of clients.

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.

A nurse is conscientious in adhering to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) when providing care for clients. What action best meets these legal requirements for care?

Maintaining the privacy and confidentiality of clients' medical records.

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 client's pain has become increasingly severe, but the client has received the maximum doses of analgesics. The nurse is receiving a new analgesic order from the health care provider via telephone. How would the nurse best validate the new order?

Read the order back to the health care provider for confirmation.

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 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 is collecting data from a client during an interview. Which of the following are subjective data that the nurse would collect? Select all that apply.

The client's occupation The client's family history of cancer The client's weight-lifting routine

A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message?

The laboratory assistant can only retrieve medical records but cannot view the details.