207 CH 4 Documentation and Interprofessional Communication
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? - APIE - SOAPIE - OASIS - CAMEL
OASIS
When performing an assessment, which of the following would be most helpful in validating a client's chief complaint? - Objective data - Past health history - Family history data - A genogram
Objective data
A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym? - Patient's chief complaint - Patient symptoms - Patient interventions - Patient complains of pain
Patient complains of pain
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 a legal requirement to document the care that you receive." - "It's so that we don't forget to do something." - "It's a way to check off all of the care that you require throughout the day." - "It helps the health care providers to read what care you have received."
"It's a legal requirement to document the care that you receive."
While assisting an older adult with morning hygiene, the nurse notes a lesion on the client's coccyx region. How should the nurse best document this objective assessment finding? - "Possible pressure ulcer observed over client's coccyx region." - "Reddened area noted on skin surface superficial to client's coccyx." - "Impaired skin integrity related to decreased mobility." - "Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."
"Area of non-blanching erythema noted over client's coccyx, 2 cm × 2 cm."
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? - "Client visibly agitated during assessment and unwilling to continue." - "Client became upset and terminated assessment." - "During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of examination room." - "During chest auscultation, client decided that she could no longer participate in assessment and removed herself from the room."
"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? - "Patient is overwhelmed by the diagnosis of pancreatic cancer." - "Patient kidneys are producing sufficient amount of measured urine." - "Patient complained about the quality of the nursing care provided on previous shift." - "Following oxygen administration, vital signs returned to baseline."
"Following oxygen administration, vital signs returned to baseline." "The nurse should record client 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."
A nurse is providing a verbal update to a client's primary care provider because of the client's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which statement? - "I think this client would benefit from an antiemetic." - "This client rates his nausea as seven out of ten." - "This client has no recent history of any nausea or vomiting." - "What would you like to do to address this client's nausea?"
"I think this client would benefit from an antiemetic."
A nurse is documenting the intensity of a client's pain. What would be the most accurate entry? - "Patient states pain is a 9 on a scale of 1 to 10." - "Patient states has pain; walking in the hall with ease." - "Patient complaining of severe pain." - "Patient appears to be in a lot of pain and is crying.
"Patient states pain is a 9 on a scale of 1 to 10."
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? - "I can use a paper chart if you prefer." - "We back up all of our files so that your health information is always secure." - "Computers do make errors from time to time, that is why we are extra careful." - "The electronic medical record is one of the tools we use to keep you safe."
"The electronic medical record is one of the tools we use to keep you safe."
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? - A client has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. - A client who resides in Indiana has required hospitalization during a vacation in Hawaii - A client has ask a nurse if he can read the documentation that his physician wrote in his chart. - A client wishes to appeal her insurance company's refusal to reimburse for a diagnostic test.
A client has ask a nurse if he can read the documentation that his physician wrote in his chart.
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 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 - A record supplied by a physician in which diagnoses and prescribed treatments are recorded
A record supplied by a physician in which diagnoses and prescribed treatments are recorded
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 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 - Bowel sounds normoactive - No tenderness on palpation - Liver palpation normal
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 - It is not a breach, because both parties involved are nurses - It is not a breach, because it is acceptable for a nurse to discuss client information with nurses who are not involved in that client's care - Other people besides the other nurse may have heard
All client information is private and confidential
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use? - An assessment flow chart - A screening tool that assesses specific risks - An abbreviated admission data sheet - An integrated cued checklist
An assessment flow chart "Flow charts help staff record and retrieve data for frequent reassessments. Flow charts help streamline documentation and prevent needless repetition of data."
A nurse has completed a client's initial assessment and is now interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process? - Planning - Evaluation - Analysis - Implementation
Analysis "Interpretation and inference are performed during the analysis phase of the nursing process. Evaluation determines achievement of expected outcomes. Implementation involves carrying out the plan. Planning involves determining outcomes and developing a plan."
The nurse is about to leave the floor for her lunch break. Before leaving she must report using the SBAR model to the nurse who is to care for the client during her absence. She tells the nurse, "The client was admitted 8 hours ago after spending the night in the ER with abdominal and back pain. He has had numerous tests; results indicate that he has gallstones. He is scheduled for surgery tomorrow." What part of the SBAR model does this information represent? - Background - Situation - Assessment - Recommendation
Background
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. - Determine ways to validate the data. - Identify areas where data are missing. - Decide whether the data require validation. - Verify every piece of data that was assessed. - Repeat all objective assessments.
Decide whether the data require validation. Determine ways to validate the data. Identify areas where data are missing.
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? - Avoid questioning the client on the sudden weight gain. - Have the client weighed again on the same equipment. - Compare objective findings with subjective findings. - Verify the previously documented data.
Compare objective findings with subjective findings. "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."
A task force has been established at a hospital with the aim of overhauling the assessment forms that are used throughout the facility. Which of the following options is most likely to help standardize the process of data collection? - Nursing minimum data set - Integrated cued checklist form - Open-ended form - Cued or checklist form
Cued or checklist form "The cued or checklist form helps to standardize data collection because it lists or categorizes information that alerts the nurse to specific problems or symptoms assessed for each client. The open-ended form calls for a narrative description of the problem and listing of topics; it is time-consuming to complete. The integrated cued checklist form combines assessment data with nursing diagnoses. The nursing minimum data set has a cued format that prompts the nurse for specific criteria."
The nurse completes documentation for a client. Which statement should be questioned? - Dressing on lower leg has some purulent drainage - Apical heart rate 88 and regular - Bowel sounds present all 4 quadrants 24/minute - Client reports pain as a 4 on a scale from 1 to 10
Dressing on lower leg has some purulent drainage
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? - Shift level - Department level - Patient level - Facility level
Facility level
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? - Assessment flow chart - Focused - Progress notes - Nursing minimum data set
Focused
A nurse is working on a unit for clients with neurological conditions. Which assessment form would the nurse most likely use to document assessment data? - Frequent assessment form - Ongoing assessment form - Open-ended form - Focused assessment form
Focused assessment form
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 experienced unusually high thirst or frequency in voiding? - Have you been experiencing increased stress at work lately? - Has your diet or exercise changed significantly in the past year? - Have you experienced any chest pain recently?
Has your diet or exercise changed significantly in the past year?
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, clients: - Have the right to copy their health records. - Can be punished for violating guidelines. - Need to obtain legal representation to update their health records. - Are required to obtain health record information through their insurance company.
Have the right to copy their health records.
A client 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 client teaching and medications to the client. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes: - Help ensure that the client feels more comfortable about returning home. - Increase the nurse's level of competence. - Identify necessary resources and strategies for successful home management. - Make the chart look as complete and thorough as possible.
Identify necessary resources and strategies for successful home management.
How does the client's medical record affect financial reimbursement? - Documentation does not support specific interventions that a care provider ordered - Financial reimbursement is not affected by documentation - Financial reimbursement is authorized without detailed charting of assessments and interventions - Insurance companies audit client records to ensure that billing is accurate
Insurance companies audit client records to ensure that billing is accurate
A researcher in a health care facility is conducting a study without IRB approval. The researcher knows that this information is limited to what? - Financial reimbursement - Verification of laboratory testing - Pain management - Internal quality improvement
Internal quality improvement
What statement about batch charting is most accurate? - It provides clear documentation. - It makes the chart available to multiple users. - It contributes to many potential errors. - It facilitates completion in a timely manner.
It contributes to many potential errors. "Batch charting (waiting until the end of shift or until all clients have been assessed to document) contributes to many potential errors. If you wait to record, you may forget important information or chart assessment data on the wrong client."
The nurse manager is implementing walking client rounds for the change-of-shift reports. One benefit of this type of reporting over others is: - It allows for exercise. - It is quicker. - It frees up the report room. - It facilitates active participation of clients.
It facilitates active participation of clients.
A group of nursing students are reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes? - It creates a data base for care that was not rendered to the client. - It replaces the client acuity classification system. - It provides a chronologic source of client assessment data. - It directly formulates the nursing diagnoses.
It provides a chronologic source of client assessment data.
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 provides and refers to client's problem by a number. - It provides quick access to abnormal findings. - It records progress under problems, interventions, and evaluation. - It documents assessments on separate forms.
It provides quick access to abnormal findings.
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? - Data backup of all digital files - Use of a standard method of data communication - Evidence of validation of all vital sign measurements - Meaningful use of electronic health records
Meaningful use of electronic health records
A computerized risk assessment report correlates data and provides scores on various aspects of clients in the health care facility. Why would this be beneficial for client care? - Tells the physician when a change in client care is necessary - Notifies health care providers when clients show clinical signs of deterioration - Informs the laboratory when to recalibrate machines - Confirms pharmacy reception of client orders
Notifies health care providers when clients show clinical signs of deterioration "The risk assessment report provides risk scores on sepsis, pressure ulcers, falls, abnormal laboratory reports, and other criteria of interest. This permits early intervention and saves lives. Frequently, clients show clinical signs of deterioration, but health care providers fail to respond for 24 hours before a critical adverse event. The computerized risk assessment report does not tell the physician when a change in client care is necessary; it does not inform the laboratory when machines need to be recalibrated, nor does it confirm pharmacy reception of client orders."
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? - Flow sheets - Progress notes - Plan of care - Clinical pathway
Progress notes
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 - Plan of care - Problem list - Progress notes
Progress notes "In a problem-oriented medical record, the progress notes describe the client's responses to what has been done and revisions to the initial plan. The data base contains initial health information about the client. The problem list consists of a numeric list of the client's health problems. The plan of care identifies methods for solving each identified health problem."
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? - Compare the order to the client's existing medication administration record (MAR). - Compare the order with the standard timing and dosage of the analgesic. - Read the order back to the health care provider for confirmation. - Have another nurse read the order that the nurse has transcribed.
Read the order back to the health care provider for confirmation.
When taking a telephone order from a physician, the nurse verifies that he or she understands the order by: - Asking the physician to summarize the orders given. - Confirming the order with the nurse manager. - Repeating the order back to the physician. - Faxing the written order to the physician's office.
Repeating the order back to the physician.
A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose? - A summary of the medical course of the client while in the hospital - Information that is only useful for an internal audit - Maintaining an accurate list of medications the client has taken - Resources and strategies for managing the client at home
Resources and strategies for managing the client at home
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 - Mismanagement - Side effects - Adverse reactions
Sentinel events "The Joint Commission refers to life-threatening errors in health care reported as "sentinel events." Adverse effects and side effects sometimes follow the administration of medications. Mismanagement is not how the Joint Commission labels such mistakes."
A nurse has completed an assessment of a client with cholecystitis and is about to document the findings. Which statement best reflects accurate documentation? - Client's oral intake and output are satisfactory. - Skin pale, warm, and dry without evidence of lesions. - Client appears upset about upcoming surgery. - Client was interviewed about previous history of hypertension.
Skin pale, warm, and dry without evidence of lesions.
A hospital nurse is admitting a client with a documented history of acute pancreatitis, liver cirrhosis, malnutrition, and frequent traumatic injuries. What assessment finding would warrant validation? - The client's blood pressure is 148/88 mm Hg. - The client states that she only drinks alcohol on a social basis. - The client states, "My skin's kind of yellow because of my liver." - The client is oriented to person and place but not to time.
The client states that she only drinks alcohol on a social basis. "There is a possible inconsistency between the client's stated alcohol use and her medical history. The client's BP and level of consciousness do not likely need to be validated, and her statement about her skin color is plausible."
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's heart rate is 63 beats per minute. - The man had an inguinal hernia repair in 2008. - The man has a diffuse rash on his torso. - The man has male pattern baldness.
The man has a diffuse rash on his torso.
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. - The man had an inguinal hernia repair in 2008. - The man has male pattern baldness. - The man's heart rate is 63 beats per minute.
The man has a diffuse rash on his torso. "The nurse should know the onset, precipitating factors, and course of the rash in order to plan appropriate interventions and referrals. The other data do not suggest an immediate need for more data."
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. - The presence of a lump in the client's breast discovered on palpation - The client's weight - A 24-hour recall of what the client has eaten - A description of a large bruise on the client's thigh - A description of gall bladder surgery the client had 10 years ago
The presence of a lump in the client's breast discovered on palpation The client's weight A description of a large bruise on the client's thigh
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 aid the nurse's recall of client information - To communicate effectively with other health care team members - To provide protection from liability in the case of a lawsuit - To avoid penalties imposed by the federal government
To communicate effectively with other health care team members
What is an appropriate guideline for the nurse to follow when documenting assessment findings on a client? - 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
A nurse is comparing the subjective data and objective data obtained from an assessment of a client who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this client's care? - Validation of data - Determination of documentation form to use - Formulation of nursing diagnoses - Identification of missing data
Validation of data
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? - If the client has a religious belief regarding illness - What support systems are in place to assist the client - If the client usually functions independently - If the client has transportation for follow-up appointments
What support systems are in place to assist the client
The nurse uses the SBAR model when reporting on clients at the change of shift. This type of report incorporates what part of the nursing process? - nursing diagnosis - evaluation - implementation - assessment
assessment
Nurses are aware that "handoff" can significantly increase the risk for errors. Common examples of "handoffs" are as follows (check all that apply): - upon admission to the ED - when a client is discharged - at change of shift - when a client is transferred from the PACU to the floor - when a nurse leaves for lunch
at change of shift when a nurse leaves for lunch when a client is transferred from the PACU to the floor
The nurse is preparing to document assessment findings in a client's record. The nurse should - avoid slang terms or labels unless they are direct quotes. - write in complete sentences with few abbreviations. - record how the data were collected. - use the term "normal" to describe nonpathological findings.
avoid slang terms or labels unless they are direct quotes.
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): - complete - timely - accurate - concise - organized - biased
complete timely accurate concise organized
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. - clusters the assessment data with nursing diagnoses. - establishes comparability of data across populations. - covers all the data that a client may provide.
prevents missed questions during data collection. "Cued or checklist forms prevents missed questions."
What information concerning a client's respirations should the nurse record after completing a general physical assessment? - rate, rhythm, and depth of respirations taken for a full minute - client's understanding of the assessment - client's understanding of the factors that can affect respirations - any existing chronic conditions that can affect respiration
rate, rhythm, and depth of respirations taken for a full minute
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? - If the client usually functions independently - If the client has a religious belief regarding illness - If the client has transportation for follow-up appointments - What support systems are in place to assist the client
What support systems are in place to assist the client
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 assessed from the client's family - What the nurse palpated - What the nurse overheard
What the nurse heard What the nurse palpated What the nurse observed
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations? - When providing a change-of-shift report to a colleague. - When reporting to a client's family member or significant other. - When communicating a client's change in condition to the client's physician. - When documenting the care that was provided to a client whose condition recently deteriorated.
When communicating a client's change in condition to the client's physician.
Which of the following data entries follows the recommended guidelines for documenting data? - "Following oxygen administration, vital signs returned to baseline." - "Patient is overwhelmed by the diagnosis of pancreatic cancer." - "Patient complained about the quality of the nursing care provided on previous shift." - "Patient kidneys are producing sufficient amount of measured urine."
"Following oxygen administration, vital signs returned to baseline."
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? - "It means I need to have the physician come in and look over your chart to make sure I didn't miss anything." - "It means I need to take all of your vital signs one more time." - "It means that I need you to sign a statement in which you confirm that everything you have shared with me today is true." - "It means I need to make sure that all the information I gathered today is reliable and accurate."
"It means I need to make sure that all the information I gathered today is reliable and accurate."
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 - "client's lung sounds were auscultated with stethoscope and were clear on both sides." - "the client's lung sounds were clear on both sides." - "after listening to client's lung sounds, both lungs appeared clear." - "bilateral lung sounds clear."
"bilateral lung sounds clear."
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? - Ask the other nurse to read back what first nurse reported - Communicate face to face with good eye contact - Have the other nurse speak with the attending physician to clear up any misunderstandings - Provide documentation of the data you are sharing
Ask the other nurse to read back what first nurse reported
What are the primary frameworks used in conducting a health assessment? Select all that apply. - Body systems - Analytical - Functional systems - Head to toe - Gordon's
Body systems Functional systems Head to toe
Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? - Focus charting - Problem-oriented medical record - PIE charting - Charting by exception
Charting by exception
Abnormal assessment findings are clearly outlined in which documentation format?
Charting by exception "Charting by exception clearly outlines abnormal assessment findings. A focus note is composed of three components: data (D), action (A), and response (R). PIE charting is composed of a specific problem (P), intervention (I), and evaluation (E). Narrative charting presents any and all information deemed by the writer."
The nursing instructor is teaching about the importance of good communication and accuracy when documenting on the client chart. Some things that are high-risk errors in documentation are the following: (Check all that apply.) - Charting in advance - Failing to record changes in a client's condition - Falsifying client records - Documenting the notification of the primary physician when the client's condition changes - Performing an inadequate admission assessment
Charting in advance Failing to record changes in a client's condition Falsifying client records Performing an inadequate admission assessment
A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? - Client reports headache. - Client has severe headache, probably related to alcoholism. - 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 reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
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? - Integrated cued checklist - Open-ended forms - Cued or checklist forms - Nursing minimum data set
Cued or checklist forms
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. - Bruises and cuts to face and torso. Client appears to have been severely beaten by her husband. - Multiple bruises and cuts on client's body. Client states she fell down a flight of stairs. - 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.
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.
A client is having frequent blood pressure and blood glucose measurements to regulate an insulin infusion. Which type of documentation should the nurse use for this data? - Specialty assessment form - Checklist - Flow sheet - Narrative note
Flow sheet "Flow sheets streamline the documentation process and prevent needless repetition of data. A checklist would not be appropriate for this type of data. A narrative note would be too cumbersome. This type of data would not be appropriate for a specialty assessment form."
nsulin infusion. Which type of documentation should the nurse use for this data? - Flow sheet - Checklist - Specialty assessment form - Narrative note
Flow sheet "Flow sheets streamline the documentation process and prevent needless repetition of data.:
The nurse is reviewing the client's medical record. Which does the nurse recognize as accurate documentation? - Patient is confused and combative. - Hyperactive bowel sounds are heard in all four quadrants. - Patient's pain is tolerable. - Patient is overweight.
Hyperactive bowel sounds are heard in all four quadrants.
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? - Health care institutions have established policies regarding documentation. - Incorrect conclusions may be made without documentation of initial data. - It satisfies legal standards established by health care organizations and institutions. - It becomes the foundation for the entire nursing process.
It becomes the foundation for the entire nursing process.
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? - Eliminate the use of verbal handoffs between nurses. - Expand the use of the Nursing Minimum Data Set. - Increase the use of electronic health records (EHRs) in the hospital. - Increase interdisciplinary collaboration in the hospital.
Increase the use of electronic health records (EHRs) in the hospital.
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. - Eliminate the use of verbal handoffs between nurses. - Expand the use of the Nursing Minimum Data Set. - Increase interdisciplinary collaboration in the hospital.
Increase the use of electronic health records (EHRs) in the hospital.
Examples of objective data include all the following except: - Coughing - Foul-smelling discharge - Reddened skin - Itchy skin
Itchy skin
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 - Focus charting - PIE charting - Narrative charting
Narrative charting
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? - SOAP notes - Narrative notes - Charting by exception - Focus charting
Narrative notes "One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation."
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 health authorities before sharing client-specific information. - Not informing the auditors of the reason for sharing client health details. - Not informing a client in writing of the purpose of sharing his or her personal details. - Not informing the physician before sharing client-specific information.
Not informing a client in writing of the purpose of sharing his or her personal details.
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 the physician before sharing client-specific information. - Not informing health authorities before sharing client-specific information. - Not informing a client in writing of the purpose of sharing his or her personal details. - Not informing the auditors of the reason for sharing client health details.
Not informing a client in writing of the purpose of sharing his or her personal details.
A nurse is caring for a client at the local health care facility. Which of the following should the nurse do to ensure that the HIPAA legislation is implemented at the facility? - Put the client's health information up on a whiteboard to be seen by health care workers. - Ensure that the client's name is displayed on the first page of all faxed records. - Place light boxes for examining x-rays with the client's name in private areas. - Present end-of-shift reports to the nurse coming on duty in the client's room.
Place light boxes for examining x-rays with the client's name in private areas.
The nurse documents data immediately after assessing the client. This is an example of: - Point-of-care documentation - Batch charting - Accurate documentation - Organized charting
Point-of-care documentation "Point-of-care documentation occurs when nurses document assessment information as they gather it."
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? - Reassess blood pressure - Recheck blood pressure in 30 minutes - Notify the physician - Have the UAP retake the blood pressure
Reassess blood pressure
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? - 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 - Repeating the measurement with a different sphygmomanometer and stethoscope
Repeating the measurement with a different sphygmomanometer and stethoscope "The most appropriate method of validation in this case would be to simply retake the client's blood pressure with a different sphygmomanometer and stethoscope. Given the nurse's work experience, it is unlikely that the discrepancy is due to improper technique, thus having the physician take the client's blood pressure is not warranted. Given the client's long history of hypertension and that his weight has not changed, it seems unlikely that the discrepancy could be explained by improved diet or exercise."
The nurse is reviewing a SOAPIE note in the client's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note. - Evaluation - Plan - Analysis - Objective - Subjective
Subjective
Which example may illustrate a breach of confidentiality and security of client information? - The nurse provides information to a professional caregiver involved in the care of the client. - The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. - The nurse provides information over the phone to the client's family member who lives in a neighboring state - The nurse accesses client information on the computer at the nurse's station then logs off before answering a client's phone.
The nurse provides information over the phone to the client's family member who lives in a neighboring state "Providing information over the phone to a family member without knowing whether or not the client wants the family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach in confidentiality, while providing information to a professional not involved in the care of the client is a breach in confidentiality. Patient information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information."