Chapter 4: Validating and Documenting Data

A nurse works at a dermatologists's office is assessing a client for skin conditions. Which of the following forms should the nurse use?

Focused

On reviewing a client's database following a physical examination, a nurse realizes that the client's wright has been steadily increasing over her past three visits. What follow-up question would be best for the nurse to pose to the client based on this finding?

Has your diet or exercise changed significantly in the past year?

Which statement by an adolescent female client admitted for excessive weight loss and dehydration requires validation by the nurse?

"I am very happy with my life right now"

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 make sure that all the information I gathered today is reliable and accurate."

A nurse has completed assessing a client and now must validate the collected data. What are the steps that the nurse should follow?

- Decide whether the date requires validation - Determine ways to validate the data - Identify areas where data is missing

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?

- Elimination of redundant data collection by other health care team members - Increased likelihood that clients will receive life-saving treatments - Potential lowered risk of hospital-acquired infections -Ability to link the client's health record to other documents

A nurse is currently in the assessment phase of the nursing process with a client. Which pieces of information should the nurse document during this phase?

- Physical assessment data - Nursing history - Information provided by the client

A nurse is recording some vital signs in a 12-year-old girl's chart when the girl asks why the nurse is writing all that information down. Which of the following should the nurse mention to this client ass reasons for documenting assessment findings?

- To prevent delays in carrying out the plan of care - To determine the educational needs of the client

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

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 n back of head, began 2 weeks ago, is constant, is worst in a.m.

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain?

Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10

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 to 3 months ago but 125 lb today.

A nurse assesses a pregnant client in her second trimester. The nurse documents the weight of the client and notices that he client has gained 6 pounds over a week. How should the nurse validate this data?

Compare objective findings with subjective findings

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

Why should the nurse document assessment findings?

Determine the education needs of the client

A nurse makes an incorrect entry onto a client's paper record during documentation of the assessment data. What is the correct way for the nurse to fix this error?

Draw a line through the error, write "error", and initial the entry

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 conducting client assessments in a long-term care facility. The manager of the facility has requested that the clinical staff use assessment forms that allow them to compare nursing data across clinical populations, settings, geographic areas, and time, so that they can compare their results with other long-term care facilities in the nation. Which form should the nurse use?

Nursing minimum data set

A nurse is performing an initial assessment of a client. Which assessment form should the nurse use?

Nursing minimum data set

Which assessment form provides a nurse with the ability to compare nursing data across clinical populations. settings, geographical area, and 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 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 described what HIPAA covers?

The confidentiality of electronic and printed health information

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

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 realized that the data needs 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