114 Chapter 4
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 pain relief measures. client's occupation. client's caregiver. cause of the pain.
A
A new nurse is unfamiliar with the electronic charting system in use at the institution. What positive attribute of electronic charting could the nurse's preceptor emphasize to this new nurse? It allows several health team members to view the client record simultaneously. It disables the graphing of trends in vital signs or assessment data. It automatically corrects both spelling and grammar. It maximizes compliance with standards of documentation.
A
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. 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. Client has a severe headache, probably related to alcoholism. Client reports headache.
A
A physician has asked a nurse to use written forms of communication to share the client's health status with other medical personnel. Which of the following is an example of a written form of communication that the nurse should use? Checklists Notepad E-mail SMS
A
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." "the client's lung sounds were clear on both sides." "client's lung sounds were auscultated with stethoscope and were clear on both sides." "after listening to client's lung sounds, both lungs appeared clear."
A
The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should validate all data before documentation of the data. document the data after the entire examination process. record the nurse's understanding of the client's problem. use medical terms that are commonly used in health care settings
A
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 biased timely Concise
A, B, C, E, F
A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? Select all that apply. A description of a large bruise on the client's thigh A description of gall bladder surgery the client had 10 years ago The client's weight A 24-hour recall of what the client has eaten The presence of a lump in the client's breast discovered on palpation
A, C, E
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. Compare objective findings with subjective findings. Avoid questioning the client on the sudden weight gain.
C
A nurse assesses a series of clients throughout the day and obtains the findings listed below. Which finding would require validation? A blood pressure reading of 110/70 mm Hg in a competitive athlete 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 temperature of 97 degrees in an elderly woman
C
What is the primary purpose of the client record? Communication Advocacy Research Education
A
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 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 Asking the client whether his exercise habits have changed recently
A
A nursing instructor is teaching a student about the importance of documenting all interventions on the client record for reimbursement purposes. The instructor knows the student understands when she states which of the following: "Lack of appropriate charting can affect whether financial payment will be authorized." "Third-party insurance companies do not count on the client's record to show care has been given." "Medicaid and Medicare pay the same, even though the care may not be charted." "Diagnostic-related groups are not supported by documentation in the client's record."
A
An assessment form commonly used in long-term care facilities is the nursing minimum data set. One primary advantage to this type of assessment form is that it establishes comparability of nursing data across clinical populations. clusters all the nursing and medical diagnoses in one place. allows for individualization for each client in the health care setting. uses a flowchart format for easy documentation of objective data.
A
One advantage for an institution to use an integrated cued/checklist type of assessment data form is that it may be easily used by different levels of caregivers, which enhances communication. provides for easy and rapid documentation across clinical settings and populations. includes the 11 health care patterns in an easily readable format. allows a comprehensive and thorough picture of the client's symptoms.
A
The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form prevents missed questions during data collection. covers all the data that a client may provide. clusters the assessment data with nursing diagnoses. establishes comparability of data across populations.
A
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 SOAP notes Focus charting Charting by exception
A
What are the primary frameworks used in conducting a health assessment? Select all that apply. Head to toe Gordon's Analytical Body systems Functional systems
A, D, E
When documenting assessment information in the medical record, what does the nurse know that the assessment information must accurately reflect? Select all that apply. What the nurse heard What the nurse observed What the nurse palpated What the nurse overheard What the nurse assessed from the client's family
A,B,C
A client comments that the nursing staff spend a great deal of time writing things down. What should the nurse respond to this statement? "It's so that we don't forget to do something." "It's a legal requirement to document the care that you receive." "It helps the health care providers to read what care you have received." "It's a way to check off all of the care that you require throughout the day."
B
A client with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the client's chart. The nurse knows to look at what part of the client's medical record to check the current medical diagnosis? Demographic data sheet Progress notes Admission history Medication record
B
A clinical instructor is discussing with students the care provided to a client. The instructor asks the student why it is important to make timely entries into the medical record. What would be the student's best answer? To be able to update the plan of care To have up-to-date information on which to base clinical decisions To be able to verify what care has been given To communicate with other health care providers
B
A court trial is being conducted over an incident in the operating room. How would the medical record best be used in this instance? To provide a record of the nurse's activities To provide a record of the actual events To provide a record of how the client was harmed To provide a record of the physician's activities
B
A nurse charting the medical record for a client knows that which of the following forms of charting involves writing information about the client and client care in chronological order? SOAP charting Narrative charting Focus charting PIE charting
B
A nurse has been called to testify in a lawsuit brought by a client against his employer. This institution uses charting by exception (CBE). What type of legal problems does CBE pose? The charting format is not ethical Details are often missing Subjective information is often missing It reflects poor assessment skills on the part of the nurse
B
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: pie charting charting by exception narrative charting batch charting
B
A nurse is explaining to a new client that the office uses electronic health records (EHRs) for all clients. The client says that at his last office, they used electronic medical records (EMRs). He asks whether these are the same thing. The nurse explains that they are different. Which of the following is a characteristic that is true of an EMR? A record designed to reach out beyond the health organization that originally obtains the data A record supplied by a physician in which diagnoses and prescribed treatments are recorded A record that is intended for sharing data with many different types of health care providers A record that covers the more comprehensive health status of the client
B
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? Problem list Progress notes Plan of care Data base
B
A nurse will be assessing many clients and needs an assessment form that will promote easy and rapid documentation, while at the same time allowing the categorization of information. Which assessment form should the nurse use? Open-ended forms Cued or checklist forms Integrated cued checklist Nursing minimum data set
B
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? Bruises on chest and back with multiple cuts on her face. 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. Multiple bruises and cuts on client's body. Client states she fell down a flight of stairs. Bruises and cuts to face and torso. Client appears to have been severely beaten by her husband.
B
How does the client's medical record affect financial reimbursement? (select all that apply.) Financial reimbursement is not affected by documentation Insurance companies audit client records to ensure that billing is accurate Documentation does not support specific interventions that a care provider ordered Financial reimbursement is authorized without detailed charting of assessments and interventions
B
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? Have you been experiencing increased stress at work lately? Has your diet or exercise changed significantly in the past year? Have you experienced unusually high thirst or frequency in voiding? Have you experienced any chest pain recently?
B
The nurse is admitting a client to a medical unit. The client is concerned that all of his private health information is on the computer and an error may occur. What is the most appropriate response of the nurse? "We back up all of our files so that your health information is always secure." "The electronic medical record is one of the tools we use to keep you safe." "I can use a paper chart if you prefer." "Computers do make errors from time to time, that is why we are extra careful."
B
The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? Significant differences in charting between nurses due to lack of standardization. Vulnerability to legal liability since the nurse's safe, routine care is not recorded. Failure to identify an record client problems and associated interventions. Increased workload for nurses in order to complete necessary documentation.
B
The nursing instructor is demonstrating to the student how to perform a physical assessment on a client. 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: computerized documentation accurate documentation narrative charting shift report
B
When charting by exception is used in a health care agency, the most important aspect of this method is what? Organizing new forms for the nursing staff Identifying the standards and norms for the institution Training new nurses in writing charting by exception notes Pulling together a group of experts to teach agency staff
B
Why is accurate and effective documentation most important? It keeps clients informed about their care. Documentation constitutes a legal record. It ensures that data can be used for research purposes. It can be used to educate other nurses.
B
The hospital where a nurse works is converting from a paper-based documentation system to a computer-based one. The nurse recognizes that which of the following are advantages of computer-based over paper-based systems? Select all that apply. Freedom from having to satisfy legal standards Elimination of redundant data collection by other health care team members Increased likelihood that clients will receive life-saving treatment Potential lowered risk of hospital-acquired infections Ability to link the client's health record to other documents Greater security and privacy of client's health information
B, C, D, E
Which strategy reduces documentation errors? Select all that apply. Document client information after assessing all assigned clients. Document client information immediately. Designate a person to document during emergencies. Document ambiguous client information. Organize client data logically, using a timed sequence.
B, C, E
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. Description of a lesion that the nurse observes on the client's arm The client's occupation The client's blood pressure The client's family history of cancer The client's weight-lifting routine
B, D, E
The nurse manager reviews documentation completed by a graduate nurse. Which entry should the manager question? Select all that apply Reddened area 1 cm x 2 cm on left upper thigh Right foot swollen Appetite good Vital signs normal Rates pain as a 6 on a scale of 1 to 10
B,C,D
The nurse is reviewing the client's medical record. Which of the following does the nurse recognize as accurate documentation? (Select all that apply.) Patient reports pain is less intense and now tolerable Bowel sounds are hyperactive in all 4 quadrants. Coarse rhonchi noted throughout lung fields Left dorsalis pedis pulse weaker than right. Patient is confused and exhibits inappropriate behavior.
B,C,D,
A nurse has completed assessing a client and now must validate the collected data. What are the steps that the nurse should follow? Select all that apply. Repeat all objective assessments. Determine ways to validate the data. Identify areas where data are missing. Verify every piece of data that was assessed. Decide whether the data require validation.
B,C,E
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.
C
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? Repeat the percussion using the nondominant hand. Clarify the data by asking whether the client has experienced any trouble breathing lately. Verify the data by having another nurse come in to perform the percussion. Confirm that the client has truly never been a smoker by asking him.
C
Based on her knowledge of the Health Information Technology for Economic and Clinical Health Act of 2009, a nurse understands that the health care clinic that she works in could face penalties if it does not demonstrate which of the following by 2015? Use of a standard method of data communication Evidence of validation of all vital sign measurements Meaningful use of electronic health records Data backup of all digital files
C
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? Head to toe Comprehensive Focused Shift
C
The nurse is reviewing the client's medical record. Which component of the medical record would provide the nurse the broadest overview of the health care team members' perspective of the client's status? Clinical pathway Flow sheets Progress notes Plan of care
C
The nursing manager explains to the nurses that it is important for the clients to be able to access their own medical records and the new electronic health record system will provide that opportunity. The nurse would identify which of the reasons this is so important? The clients will be able to order their own diagnostic studies The clients will be able to verify procedures were done correctly Health care providers can receive significant incentive payments Health care providers will not have to explain the care in as much detail to the client.
C
When a client reports never having had surgery, yet physical examination reveals a 10-cm abdominal scar, the nurse needs to: Confront the client Consider the client unreliable Validate the data Find a family member to give the health history
C
When a nurse works in a health care agency that charts by exception (CBE), the nurse knows that the client assessment is structured by what? Medical diagnoses Client needs Standardized norms Joint Commission standards
C
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? "Your client has a high blood pressure and takes antihypertensives at home." "You need to come assess this client at the bedside." "I am a registered nurse caring for your client." "The client's blood pressure is 180/85, pulse is 94 and client appears anxious."
C
Which of the following examples of documentation best exemplifies sound clinical documentation practices? "Client is anxious during questioning regarding health history and family history." "Abnormal chest sounds noted during posterior chest auscultation." "Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter." "Client reports sharp pain to chest on deep inspiration."
C
Which statement by an adolescent female client admitted for excessive weight loss and dehydration requires validation by the nurse? "I exercise at least two hours every day" "My mouth and lips feel very dry" "I am very happy with my life right now" "I have been having a lot of nausea lately"
C
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? Initial assessment form Frequent assessment form Ongoing assessment form Specialty area assessment form
D
A nurse caring for a client at a health care facility has to maintain a medical record for the client. Which of the following is a use of the medical record? To inform family and others concerned about the client's care To transmit health records between insurance companies To release the entire health record for research To investigate the quality of care in the agency
D
A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? PIE system Charting by exception OASIS Minimum data set
D
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? Data base Problem list Plan of care Progress notes
D
During an accrediting agency visit, it is found that some client care standards are not being met. Where should problem solving occur in this instance? Department level Patient level Shift level Facility level
D
Examples of objective data include all the following except: Coughing Foul-smelling discharge Reddened skin Itchy skin
D
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? It documents assessments on separate forms. It records progress under problems, interventions, and evaluation. It provides and refers to client's problem by a number. It provides quick access to abnormal findings.
D
The implementation of computerized charting systems is a nationwide event. What has research shown about the use of computerized systems? Safety among client populations decreases Pharmacy orders are electronically verified Physician notes are more secure Client safety increases
D
The nurse enters a client's room to administer scheduled medications through a barcode system. The client is not wearing an armband. What is the nurse's best action? Confirm the client's identity with visitors who are present. Ask the client for name and birth date, then administer the medications. Scan the barcode on the client's chart, then administer the medications. Leave the room to obtain another armband for the client.
D
The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC? Client and family requests Medical diagnosis Standards of nursing care Assessment data in the medical record
D
When an agency has policies that require nurses to write focus notes, the nursing documentation can include what? Areas of personal accomplishments Areas of personal weakness Social networks Family concerns
D
Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas, & time? Open-ended forms Cued or checklist forms Integrated cued checklist Nursing minimum data set
D