Assessment _Ch 4

The nurse is documenting client care. Which nursing assessment note would be appropriate? "Client is a drug seeker." "Client voices concerns about being able to change abdominal dressings at home." "Client does not like her new baby." "Client sleeping."

"Client voices concerns about being able to change abdominal dressings at home." Documentation of data needs to be clear, concise and nonjudgmental. The documentation note "Client voices concerns about being able to change abdominal dressings at home." is clear and identifies the client's concerns. The other documentation notes are judgmental and not data based.

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

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

"I have pain across my entire forehead." The nurse should document only what the client says and what is observed. Documentation is not want the nurse interprets or infers from the data. The statement "I have pain across my entire forehead" is the correct statement of subjective data. The other statements are interpretations or inferences about the subjective 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 "bilateral lung sounds clear." "after listening to client's lung sounds, both lungs appeared 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."

"bilateral lung sounds clear." Use phrases instead of sentences to record data. For example, avoid recording: "The client's lung sounds were clear both in the right and left lungs." Instead record: "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? Communicate face to face with good eye contact Ask the other nurse to read back what first nurse reported Provide documentation of the data you are sharing Have the other nurse speak with the attending physician to clear up any misunderstandings

Ask the other nurse to read back what first nurse reported When reporting over a telephone, ask the receiver to read back what he or she heard you report and document the phone call with time, receiver, sender, and information shared. It would not be feasible to communicate face to face or provide documentation when speaking on the phone. Also, it would not be feasible or appropriate to have the attending physician speak with the other nurse, as the physician may not be available and would not likely be able to clarify the first nurse's assessment findings anyway.

A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? Client has severe headache, probably related to alcoholism. Client reports headache. 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 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? Pharmacy orders are electronically verified Physician notes are more secure Client safety increases Safety among client populations decreases

Client safety increases

After performing a comprehensive assessment on a new client, the nurse documents the following findings. Which documentation follows acceptable documentation guidelines? Client states, "I don't want to eat or do anything." Client stated they were depressed because they lost their job. Client seems depressed, tearful, not engaging in conversation. When asked, the client refused to eat or get out of bed.

Client states, "I don't want to eat or do anything." Entering what the client states using quotations is the most accurate way to document. Documentation must be objective, nonjudgmental, and clear; subjective information should be documented using quotations. Stating the client "seems" depressed is a judgment. Although the nurse documenting "When asked, the client refused to eat or get out of bed" is stating similar findings as documenting "Client states 'I don't want to eat or do anything,'" the latter is more concise. Instead of documenting "Client stated they were depressed because they lost their job," the nurse should have quoted the client directly, such as "I am depressed because I lost my job," to make the documentation clearer.

What is the primary purpose of the client record? Education Advocacy Communication Research

Communication

Which assessment is most likely performed when a client is admitted to the hospital? Comprehensive Focused Shift Abbreviated

Comprehensive A comprehensive assessment of the client is performed by a hospital nurse on admission. A shift assessment is performed at the beginning of each shift. A focused assessment is a very brief assessment of potential problems. An abbreviated assessment is a term not commonly used but is similar to a focused assessment.

A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation? Cross out the incorrect statement with a single line. Use correction fluid to obliterate what has been written. Erase the incorrect statement and write the correct one. Cross out the wrong statement in a way that is not readable.

Cross out the incorrect statement with a single line. When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, cross out the wrong statement in a way that means the statement is not readable, or use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

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? 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. 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.

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. Documentation needs to be clear and specific. Documentation should describe and provide a location of the areas. Documentation should not include any assumptions or judgements.

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 It reflects poor assessment skills on the part of the nurse Subjective information is often missing

Details are often missing CBE may pose legal problems, because details are often missing. CBE does not omit subjective assessment, CBE is an ethical form of charting, and the question does not indicate that the assessment skills of the nurse are lacking in any form.

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? Nursing minimum data set Assessment flow chart Progress notes Focused

Focused Some institutions may use assessment forms that are focused on one major area of the body for clients who have a particular problem. Examples include cardiovascular or neurologic assessment documentation forms. An assessment flow chart allows for rapid comparison of recorded assessment data from one time period to the next. Progress notes may be used to document unusual events, responses, significant observations, or interactions because the data are inappropriate for flow records. The nursing minimum data set form has a cued format that prompts the nurse for specific criteria; it is usually computerized and is commonly used in long-term care facilities.

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

Identifying the standards and norms for the institution Clearly identifying the standards and norms and educating all users takes time and significant commitment from the agency using charting by exception. Organizing new forms for the nursing staff, training new nurses, and acquiring teachers for agency staff may be important, but they are not the most important aspect of this method.

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

It provides quick access to abnormal findings. Charting by exception provides quick access to abnormal findings as it does not describe normal and routine information. When using the PIE charting method, assessments are documented on separate forms. The PIE charting method, not charting by exception, records progress under problems, intervention, and evaluation. The client's problems are given a corresponding number in the PIE charting method, which is used in the progress notes when referring to interventions and the client's responses.

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 Charting by exception Focus charting Narrative notes

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 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? Plan of care Progress notes Data base Problem list

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.

The nurse is completing a comprehensive assessment on a new client. The nurse adheres to documentation guidelines by charting which of the following? Recent changes in hearing; client states, "I cannot hear high-pitched sounds"; Weber and Rinne tests confirmed sensory hearing loss. Client was interviewed for changes in hearing; tests were performed. Hearing tests confirmed hearing loss. Consultations were made. Interview was conducted on the client with new-onset hearing loss; tests were abnormal.

Recent changes in hearing; client states, "I cannot hear high-pitched sounds"; Weber and Rinne tests confirmed sensory hearing loss.

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? DAR SBAR PIE SOAP

SBAR PIE, DAR and SOAP are all types of progress notes.

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 weight-lifting routine The client's family history of cancer The client's occupation Description of a lesion that the nurse observes on the client's arm The client's blood pressure

The client's weight-lifting routine The client's family history of cancer The client's occupation

A nurse is having a new client complete a health history form and sign a form acknowledging his rights under the Health Insurance Portability and Accountability Act (HIPAA). The client asks the nurse what HIPAA covers. Which of the following most accurately describes what HIPAA covers? The confidentiality of electronic protected health information The confidentiality of the client's financial information The confidentiality of electronic and printed health information The confidentiality of printed protected health information

The confidentiality of electronic and printed health information All documented information in the client record, whether electronic or printed, should be kept confidential. Most agencies require nurses to complete the HIPAA training to ensure that the use, disclosure of, and requests for protected information are applied only to intended purposes and kept to a minimum, thus preserving confidentiality.

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

Use phrases instead of sentences to record data. The nurse should document assessments using phrases instead of sentences to avoid the use of too many redundant words and to focus only on the essential (information) terms. Errors in documentation should be corrected by drawing one line through the entry, writing "error," and initialing the entry; an eraser should not be used to remove any error in the document. A pencil or pen with erasable ink should never be used in documentation. The nurse needs to record only the data findings, not how the data findings were obtained, in precise terms. All findings should be recorded as per the values obtained during assessment in descriptive terms, even if the finding is normal.

A client has been prescribed a new medication. What action is most important for the nurse to take prior to administration? Clarify order with the health care provider. Assess client laboratory results. Assess client's vital signs prior to administration. Verify client allergies to medications.

Verify client allergies to medications.

A new order for intravenous (IV) antibiotics has been prescribed for a female client who is hospitalized. The nurse reviews the client's chart, which indicates no known drug allergies and an admission diagnosis of a urinary tract infection (UTI). What is the first action of the nurse? Verify whether the client has allergies. Administer medication as prescribed. Check the medication for incompatibilities. Verify the client has been diagnosed with a UTI.

Verify whether the client has allergies. The nurse should verify that the client does not have any allergies before administering any new medications; allergies may have been overlooked during the admission process. The nurse may verify the diagnosis and check for incompatibilities but to ensure client safety, the nurse must first verify the client is not allergic to the medication.

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 concise timely organized biased complete

accurate, concise, timely, organized, complete

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: charting by exception pie charting batch charting narrative charting

charting by exception Charting by exception uses predetermined standards and norms to record only significant assessment data, and only abnormal findings require additional documentation. Narrative charting is done using unstructured paragraphs to record assessments and other activities. Pie charting includes stating the problem, interventions, and evaluation. Batch charting is waiting until the end of shift or after all clients have been assessed to chart.

One disadvantage of the open-ended assessment form is that it asks standardized questions. does not provide a total picture of the client. requires a lot of time to complete. does not allow for individualization.

requires a lot of time to complete.

The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should document the data after the entire examination process. validate all data before documentation of the data. record the nurse's understanding of the client's problem. use medical terms that are commonly used in health care settings

validate all data before documentation of the data. Validation of data verifies the assessment data that you have gathered from the client. It consists of determining which data require validation, implementing techniques to validate, and identifying areas that require further assessment data.

An example of an objective finding in an adult client is vital signs. genetic disorders. a client's symptom of pain. family history data.

vital signs. Objective data are what the nurse observes through inspection, palpation, percussion, or auscultation.