Prep U Ch. 4

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 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 nursing instructor is demonstrating to the student how to perform a physical assessement on a patient. The instructor stresses the importance of being precise when doing an assessment. Another necessary aspect of the assessment to render safe and effective care is which of the following:

accurate documentation

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

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

focused

A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?

focused assessment form

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

The nurse is reviewing a SOAPIE note in the patient's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note.

subjective

The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use?

verbal handoff

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."

A patient 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.'

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 of the following are examples of breaches of patient confidentiality? Select all that apply.

A nurse discusses a patient with a coworker in the elevator. A nurse shares her computer password with a relative of a patient. A nurse updates the employer of a patient regarding the patient's return to work. A head nurse accesses the medical records of a nurse on her shift to check her condition.

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 is in the elevator at the hospital. The nurse overhears another nurse laughing and making jokes about a client. Why is this situation a breach of confidentiality?

All client information is private and confidential

The nurse is reviewing the patient's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.)

Bowel sounds are hyperactive in all 4 quadrants. Coarse rhonchi noted throughout lung fields Left dorsalis pedis pulse weaker than right.

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.

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, patients:

Have the right to copy their health records.

The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation?

Hyperactive bowel sounds are heard in all four quadrants.

A patient is being discharged from the hospital after a below-the-knee amputation. The nurse has completed the discharge and gives a copy of the discharge summary with patient teaching and medications to the patient. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes:

Identify necessary resources and strategies for successful home management.

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 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.

When describing the importance of documenting initial assessment data to a group of new nurses, which of the following would the nurse emphasize as the primary reason?

It becomes the foundation for the entire nursing process.

A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three patients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting?

It contributes to many potential errors.

What statement about batch charting is most accurate?

It contributes to many potential errors.

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.

What is the name of the information program mandated by the federal government for the initial and ongoing assessment of Medicare and Medicaid clients in the homecare setting?

OASIS

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

Objective data

Which would the nurse recognize as an example of data found in the background section of the SBAR reporting format?

Patient was diagnosed with migraine headaches 2 years ago.

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

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'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. How would the nurse best validate the new order?

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

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

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

After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information 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 occupation The client's family history of cancer The client's weight-lifting routine

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.

Which example may illustrate a breach of confidentiality and security of patient information?

The nurse provides information over the phone to the patient's family member who lives in a neighboring state