chap 4: validating assesment

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

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

Verify the data by having another nurse come in to perform the percussion. The most appropriate method of validation in this case would be to have another nurse come in to perform the percussion. We know that the nurse is inexperienced, and with all of the other information supplied, it is much more likely that the discrepancy is due to improper percussion technique or faulty interpretation of the sound than it is to the client actually having emphysema. Repeating the procedure with the nondominant hand is not likely to change the results. If the client appears healthy and has not reported breathing difficulty, it is not likely that he has emphysema. If the client has already denied smoking, asking him again will likely only insult him.

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? Have the client weighed again on the same equipment. Verify the previously documented data. Avoid questioning the client on the sudden weight gain. Compare objective findings with subjective findings.

Verify the previously documented data. The nurse should compare the objective findings (i.e., the client's weight) with subjective findings (i.e., what the client says about her weight gain) to uncover any discrepancies. The nurse should have the client weighed again on a different scale, not the same one, to rule out equipment error. The nurse may not be able to verify the previously documented data; the nurse who conducted the assessment at that time must have ensured that it was right. The nurse should clarify data with the client by asking additional questions to support the objective data.

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 "the client's lung sounds were clear on both sides." "after listening to client's lung sounds, both lungs appeared clear." "client's lung sounds were auscultated with stethoscope and were clear on both sides." "bilateral lung sounds clear."

bilateral lung sounds clear."

alzheimers vs. dementia

onset of dementia is rapid and usually caused by CVA,

hich of the following data entries follows the recommended guidelines for documenting data? "Patient is overwhelmed by the diagnosis of pancreatic cancer." "Patient complained about the quality of the nursing care provided on previous shift." "Following oxygen administration, vital signs returned to baseline." "Patient kidneys are producing sufficient amount of measured urine."

"Following oxygen administration, vital signs returned to baseline." sufficient is opinion The nurse should record patient findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

The nurse prepares to document information collected during an assessment. Which statement correctly documents subjective data? The client doesn't want to bathe because of a headache The headache is upsetting the client The client has a headache "I have pain across my entire forehead."

"I have pain across my entire forehead."

what Glasgow score is considered a coma

<7

A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation? A pulse rate of 98 in a 10-year-old boy A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight A blood pressure reading of 110/70 mm Hg in a competitive athlete A temperature of 97 degrees in an elderly woman

A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and appears to be of normal weight A weight of 95 lbs in a woman who is 5 feet, 8 inches tall and who appears to be of normal weight, however, would be cause for validation, as there is a significant gap between the finding of the client's weight and the client's appearance.

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 Shift Head to toe Comprehensive

Focused

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 Asking the client whether his exercise habits have changed recently Asking the physician to come in and take the client's blood pressure Asking the client whether his diet has changed in the past year

Repeating the measurement with a different sphygmomanometer and stethoscope