Chapter 4: Health assessment Prep U

Which of the following examples of documentation best exemplifies sound clinical documentation practices?

"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."

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.

Which of the following data entries follows the recommended guidelines for documenting data?

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

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?

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

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."

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?

"The electronic medical record is one of the tools we use to keep you safe."

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."

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 supplied by a physician in which diagnoses and prescribed treatments are recorded

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.

One of the goals of nursing is to provide care that is safe to clients. What is the best way for nurses to realize this goal?

By continual communication with all members of the health care team

A client with hemiplegia has been admitted to the health agency. The nurse who cares for the client has a fixed routine of cleaning, feeding, and administering medicines to the client. Which of the following should the nurse use to record these details?

Checklists

The nurse understands that information documented in the client's medical record provides a foundation for care providers to do what? Select all that apply.

Coordinate care Develop a plan of care Communicate care

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?

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?

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 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?

Details are often missing

When documenting the care of a patient, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes:

Limiting abbreviations to those approved for use by the institution.

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?

Meaningful use of electronic health records

The nurse managers of a home healthcare office wish to maximize nurses' freedom to characterize and record patient conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal?

Narrative notes

Which assessment form provides a nurse with the ability to compare nursing data across clinical populations, settings, geographical areas, & time?

Nursing minimum data set

A nurse who has been working at the health clinic for 20 years has just taken a client's blood pressure and found it to be 110/70. When consulting the client's record, the nurse sees that he has had persistent hypertension for the past 5 years and has been on antihypertensive medication the whole time. His blood pressure has never been below 150/90 and was 180/95 at his last visit, 1 year ago. The patient's weight has remained the same. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case?

Repeating the measurement with a different sphygmomanometer and stethoscope

A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered?

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 communicate effectively with other health care team members

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 have up-to-date information on which to base clinical decisions

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 investigate the quality of care in the agency

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.

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 complete

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.

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.

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

Which strategy reduces documentation errors? Select all that apply.

Document patient information immediately. Designate a person to document during emergencies. Organize patient data logically, using a timed sequence.

How does the client's medical record affect financial reimbursement? (select all that apply.)

Insurance companies audit client records to ensure that billing is accurate

A nurse admits a client to the health care facility. The nurse gathers data about the client's social history and wants to make this information available to the social worker. Which initial assessment documentation form is best for the nurse to use?

Integrated Cued Checklist

A nurse is caring for a patient 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

What are the purposes of them medical record? Select all that apply.

1.Communication between health care members. 2.Research. 3.Quality assurance. 4.Research

A nurse has just finished taking a client's vital signs and is comparing the results with those from his previous visit 3 months ago. Which of the following situations would require the nurse to validate the data?

Client's weight was 200 lb (91 kg) 3 months ago but 125 lb (57 kg) today.

During an accrediting agency visit, it is found that some patient care standards are not being met. Where should problem solving occur in this instance?

Facility level

A nurse receives lab results on a client that show that the client is pregnant. The client says that this is impossible, however, because she is still breastfeeding her 1-year-old son. Which of the following would be appropriate ways for the nurse to validate the positive finding for pregnancy? Select all that apply.

Have the client take a different pregnancy test

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?

Verify the data by having another nurse come in to perform the percussion

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?

Vulnerability to legal liability since the nurse's safe, routine care is not recorded.

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 palpated What the nurse observed