Chapter 4: Validating and Documenting Data

The medical record serves many purposes. What are they? (Select all that apply.) A. Means for financial reimbursement B. Information for the family C. Research D. Care planning E. Framework for medical information

A, C, D, E

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): A. Organized B. Biased C. Concise D. Timely E. Complete F. Accurate

A, C, D, E, F

Which assessment is most likely performed when a client is admitted to the hospital? A. Shift B. Abbreviated C. Focused D. Comprehensive

D. Comprehensive

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? A. Asking the client whether his exercise habits have changed recently B. Asking the client whether his diet has changed in the past year C. Asking the physician to come in and take the client's blood pressure D. Repeating the measurement with a different sphygmomanometer and stethoscope

D. Repeating the measurement with a different sphygmomanometer and stethoscope

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? A. PIE B. DAR C. SOAP D. SBAR

D. SBAR

When using the SBAR communication tool to inform the physician of a client's high blood pressure and anxiety, the nurse should make which statement first while on the phone with the physician? A. "I am a registered nurse caring for your client." B. "Your client has a high blood pressure and takes antihypertensives at home." C. "You need to come assess this client at the bedside." D. "The client's blood pressure is 180/85, pulse is 94 and client appears anxious."

A. "I am a registered nurse caring for your client."

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? A. "It means I need to make sure that all the information I gathered today is reliable and accurate." B. "It means that I need you to sign a statement in which you confirm that everything you have shared with me today is true." C. "It means I need to take all of your vital signs one more time." D. "It means I need to have the physician come in and look over your chart to make sure I didn't miss anything."

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

If the nurse makes an error while documenting findings on a client's record, the nurse should A. Draw a line through the error, writing "error" and initialing. B. Obliterate the error and make the correction. C. Erase the error and make the correction. D. Draw a line through the error and have it witnessed.

A. Draw a line through the error, writing "error" and initialing.

The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes? A. Evidence in a situation of wrongdoing B. Evaluate nursing care provided C. Reimbursement for care provided D. Discharge planning for the patient

A. Evidence in a situation of wrongdoing

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? A. Focused B. Assessment flow chart C. Progress notes D. Nursing minimum data set

A. 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? A. Focused B. Shift C. Head to toe D. Comprehensive

A. Focused

When charting by exception is used in a health care agency, the most important aspect of this method is what? A. Identifying the standards and norms for the institution B. Organizing new forms for the nursing staff C. Pulling together a group of experts to teach agency staff D. Training new nurses in writing charting by exception notes

A. Identifying the standards and norms for the institution

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? A. It provides quick access to abnormal findings. B. It documents assessments on separate forms. C. It records progress under problems, interventions, and evaluation. D. It provides and refers to client's problem by a number.

A. It provides quick access to abnormal findings.

What is the nurse's best defense if a patient alleges nursing negligence? A. Patient's record B. Patient's family C. Testimony of expert witnesses D. Testimony of other nurses

A. Patient's record

To make a legal entry into the medical record, the nurse must document what? A. Time of the assessment B. Laboratory tests ordered C. Attending physician D. Nature of the assessment

A. Time of the assessment

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

A. Validate all data before documentation of the data.

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? A. Communicate face to face with good eye contact B. Ask the other nurse to read back what first nurse reported C. Have the other nurse speak with the attending physician to clear up any misunderstandings D. Provide documentation of the data you are sharing

B. Ask the other nurse to read back what first nurse reported

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? A. Client has a dull, aching pain in the back of his head that began 2 weeks ago. The pain is constant and seems to be worse in the mornings. B. Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. C. Client reports headache. D. Client has severe headache, probably related to alcoholism.

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

The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems? A. Safety among client populations decreases B. Client safety increases C. Pharmacy orders are electronically verified D. Physician notes are more secure

B. Client safety increases

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain? A. Abdominal pain most likely due to client's unhealthy lifestyle and poor eating habits B. Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 C. Bowel sounds are present in all four quadrants, all organ within normal limits D. Abdominal pain x 2 weeks, no medications taken, denies diarrhea or constipation

B. Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: A. Ensuring that abbreviations are understandable to patients who may seek access to their health records. B. Limiting abbreviations to those approved for use by the institution. C. Using only abbreviations whose meaning is self-evident to an educated health professional. D. Using only those abbreviations that are defined in full at another location in the patient's chart.

B. Limiting abbreviations to those approved for use by the institution.

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? A. File the admission database for nurse only access. B. Place the completed assessment in the medical record. C. Omit the fall risk assessment since the client is a young adult. D. Document the highlights of the physical exam.

B. Place the completed assessment in the medical record.

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? A. Have the UAP retake the blood pressure B. Reassess blood pressure C. Recheck blood pressure in 30 minutes D. Notify the physician

B. Reassess blood pressure

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? A. "Client visibly agitated during assessment and unwilling to continue." B. "Client became upset and terminated assessment." C. "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." D. "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."

C. "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? A. "Patient kidneys are producing sufficient amount of measured urine." B. "Patient is overwhelmed by the diagnosis of pancreatic cancer." C. "Following oxygen administration, vital signs returned to baseline." D. "Patient complained about the quality of the nursing care provided on previous shift."

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

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

C. Focused

The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation? A. Patient is overweight. B. Patient is confused and combative. C. Hyperactive bowel sounds are heard in all four quadrants. D. Patient's pain is tolerable.

C. Hyperactive bowel sounds are heard in all four quadrants.

While recording the subjective data of an adult client 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. Client's occupation. C. Pain relief measures. D. Client's caregiver.

C. Pain relief measures.

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? A. Demographic data sheet B. Admission history C. Progress notes D. Medication record

C. Progress notes

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

C. Requires a lot of time to complete.