Chapter 4.2

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 assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation?

A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight

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."

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

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

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

The nurse assesses all assigned clients and sits in the nursing station to document assessment data for all clients. This is an example of:

Batch charting

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

A researcher in a health care facility is conducting a study without IRB approval. The researcher knows that this information is limited to what?

Internal quality improvement

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?

Narrative notes

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.

A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose?

Resources and strategies for managing the client at home

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

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

Mistakes in charting can be costly to both the client and nurse. The Joint Commission has listed a primary cause for these mistakes as a failure in communication. Life-threatening errors in health care have been labeled as which of the following:

Sentinel events

A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?

Subjective data and objective data

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

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.

A nurse is instructing the nursing student on strategies for reducing high-risk errors in documentation. Which examples should the nurse include when teaching the nursing student? Select all that apply.

The nurse notes the return of bowel sounds following the client's surgery. The nurse takes and records the client's heart rate before administering digoxin. The nurse administers pain medication when the client reports a pain rating of 7.

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 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