jensen chapter 4
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? Open-ended form Focused assessment form Frequent assessment form Ongoing assessment form
Focused assessment form
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 cause of the pain. client's caregiver. client's occupation. pain relief measures.
pain relief measures.
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
The nurse responds to a call light for a client rating their pain "ten out of ten." The nurse's initial inspection reveals the client is watching videos and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain? -Ask the client to repeat his rating of his pain in five minutes. -Observe the client for several seconds to see if his demeanor or his behavior changes. -Consult the client's medication administration record to check for recent analgesic use. -Perform further assessments addressing various aspects of the client's pain.
Perform further assessments addressing various aspects of the client's pain.
The nurse documents data immediately after assessing the patient. This is an example of: Point-of-care documentation Batch charting Organized charting Accurate documentation
Point-of-care documentation
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." -"Area of nonblanching erythema noted over client's coccyx, 2 cm × 2 cm." -"Impaired skin integrity related to decreased mobility."
"Area of nonblanching erythema noted over client's coccyx, 2 cm × 2 cm."
During 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."
A nursing instructor is teaching a student about the importance of accurate reporting during a handoff. The student implies understanding when she states: "If they need to know anything, they can find me and ask me." "I will be right back from my break, so it's nothing to get too worried over." "Effective communication is the key to preventing errors." "I am not sure if that nurse really needs to know about my patient."
"Effective communication is the key to preventing errors."
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? "What would you like to do to address this client's nausea?" "I think this client would benefit from an antiemetic." "This client has no recent history of any nausea or vomiting." "This client rates his nausea as seven out of ten."
"I think this client would benefit from an antiemetic."
A patient asks to see his medical record (chart). How would the nurse respond? -"I can't let you do that without a doctor's order." -"Our hospital policy is that you can't do that." -"I will get your chart and provide you with privacy to read it.' -"Why would you want to do that? It will only make you worry."
"I will get your chart and provide you with privacy to read it.'
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."
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? -"Patient complaining of abdominal pain rated 8/10." -"Patient is guarding her abdomen and occasionally moaning." -"Patient has a history of recent abdominal pain." -"2 mg Dilaudid PO administration with good effect."
"Patient complaining of abdominal pain rated 8/10."
A nursing student has learned the importance of documenting only appropriate and accurate information. Which of the following is an appropriate notation in a patient's record? -"Patient is upset with her husband." -"Dr. Smith did not answer the patient's questions." -"Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10." -"Patient spoke to nurse in a sarcastic tone."
"Patient stated dull, aching pain in the lower abdomen-rates as a 5 on scale of 1-10."
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."
"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 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 that is intended for sharing data with many different types of health care providers 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
The nurse assesses all assigned patients and sits in the nursing station to document assessment data for all patients. This is an example of: -Batch charting -Point-of-care documentation -Organized charting -Accurate documentation
Batch charting
Abnormal assessment findings are clearly outlined in which documentation format? Charting by exception Narrative charting PIE charting Focus note
Charting by exception
While the nurse performs the initial assessment, the client states "This is my first hospitalization and I have had no previous surgeries." How would the nurse document this information? -Client has not been hospitalized before nor has he had any surgery -Client answered no to previous hospitalizations or surgery -Negative for past hospitalizations -Client denies prior hospitalizations and surgeries
Client denies prior hospitalizations and surgeries
A nurse is documenting a client's headache. Which of the following would be the best entry to include for this finding? -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 severe headache, probably related to alcoholism. -Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m. -Client reports headache.
Client reports dull, aching pain in back of head, began 2 weeks ago, is constant, is worse in a.m.
Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain? -Abdominal pain x 2 weeks, no medications taken, denies diarrhea or constipation -Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 -Abdominal pain most likely due to client's unhealthy lifestyle and poor eating habits -Bowel sounds are present in all four quadrants, all organ within normal limits
Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10
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
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? -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. -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.
The nurse completes documentation for a client. Which statement should be questioned? 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
Dressing on lower leg has some purulent drainage
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for quality assurance purposes? -Evaluate nursing care provided -Evidence in a situation of wrongdoing -Discharge planning for the patient -Reimbursement for care provided
Evaluate nursing care provided
The nurse recognizes the medical record serves multiple purposes. Which is an example of the medical record being used for legal purposes? -Evaluate nursing care provided -Discharge planning for the patient -Reimbursement for care provided -Evidence in a situation of wrongdoing
Evidence in a situation of wrongdoing
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? Patient level Shift level Department level Facility level
Facility level
The nursing instructor is teaching about the importance of good communication and accuracy when documenting on the patient chart. Some things that are high-risk errors in documentation are the following: (Check all that apply.) -Falsifying patient records -Failing to record changes in a patient's condition -Performing an inadequate admission assessment -Documenting the notification of the primary physician when the patient's condition changes -Charting in advance
Falsifying patient records Failing to record changes in a patient's condition Performing an inadequate admission assessment Charting in advance
The nurse is reviewing the patient's medical record. Which does the nurse recognize as accurate documentation? -Patient is overweight. -Patient is confused and combative. -Patient's pain is tolerable. -Hyperactive bowel sounds are heard in all four quadrants.
Hyperactive bowel sounds are heard in all four quadrants.
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 maximizes compliance with standards of documentation. It disables the graphing of trends in vital signs or assessment data. It allows several health team members to view the patient record simultaneously. It automatically corrects both spelling and grammar.
It allows several health team members to view the patient record simultaneously.
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.
The nurse manager is implementing walking patient rounds for the change-of-shift reports. One benefit of this type of reporting over others is: -It is quicker. -It facilitates active participation of patients. -It frees up the report room. -It allows for exercise.
It facilitates active participation of patients.
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 provides a chronologic source of client assessment data. -It creates a data base for care that was not rendered to the client. -It replaces the client acuity classification system. -It directly formulates the nursing diagnoses.
It provides a chronologic source of client assessment data.
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 provides a chronologic source of client assessment data. It creates a data base for care that was not rendered to the client. It replaces the client acuity classification system. It directly formulates the nursing diagnoses.
It provides a chronologic source of client assessment data.
A group of nursing students is 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 database for care that was not rendered to the client. -It replaces the client acuity classification system. -It directly formulates the nursing diagnoses. -It provides a chronologic source of client assessment data.
It provides a chronologic source of client assessment data.
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? Focus charting SOAP charting Narrative charting PIE charting
Narrative charting
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 reaosn for sharing client health details.
Not informing a client in writing of the purpose of sharing his or her personal details.
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 -Informs the laboratory when to recalibrate machines -Notifies health care providers when clients show clinical signs of deterioration -Confirms pharmacy reception of client orders
Notifies health care providers when clients show clinical signs of deterioration
A patient with abdominal pain is admitted from the emergency department. After having a gastrointestinal consultation and numerous tests, the results have been recorded on the patient's chart. The nurse knows to look at what part of the patient's medical record to check the current medical diagnosis? Demographic data sheet Progress notes Admission history Medication record
Progress notes
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 -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
A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose? Resources and strategies for managing the client at home Information that is only useful for an internal audit A summary of the medical course of the client while in the hospital Maintaining an accurate list of medications the client has taken
Resources and strategies for managing the client at home
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? -PIE -SBAR -DAR -SOAP
SBAR
When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? -Focus charting -SOAP charting -PIE charting -Narrative charting
SOAP charting
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
The client's occupation The client's family history of cancer The client's weight-lifting routine
A laboratory assistant who is trying to view the electronic record of a client's personal history gets an error message, "You are not authorized to view this information." What is the reason for this message? -The laboratory assistant does not have the correct password. -The laboratory assistant does not have the correct access number. -The laboratory assistant can only retrieve medical records but cannot view the details. -The laboratory assistant is trying to view archived data.
The laboratory assistant can only retrieve medical records but cannot view the details.
Which example may illustrate a breach of confidentiality and security of patient information? -The nurse provides information over the phone to the patient's family member who lives in a neighboring state -The nurse provides information to a professional caregiver involved in the care of the patient. -The nurse informs a colleague that she should not be discussing patient information in the hospital cafeteria. -The nurse accesses patient information on the computer at the nurse's station then logs off before answering a patient's phone.
The nurse provides information over the phone to the patient's family member who lives in a neighboring state
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 as reasons for documenting assessment findings? Select all that apply. -To eliminate the possibility of diagnosing new problems -To ensure that only the nurse is aware of the assessments -To prevent delays in carrying out the plan of care -To determine the educational needs of the client
To prevent delays in carrying out the plan of care To determine the educational needs of the client
What is an appropriate guideline for the nurse to follow when documenting assessment findings on a client? Use an eraser to remove any error in the document Use phrases instead of sentences to record data Record how data findings were obtained Record "normal" for all normal findings if required
Use phrases instead of sentences to record data
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 an eraser to remove any error in the document. Use phrases instead of sentences to record data. Record how data findings were obtained. Record "normal" for all normal findings if required.
Use phrases instead of sentences to record data.
The nurse is preparing to leave the unit for lunch. What type of communication method should the nurse use? -Written handoff -Verbal handoff -Focus note -Patient Assessment Instrument
Verbal handoff
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.
Verify the data by having another nurse come in to perform the percussion.
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 assessed from the client's family -What the nurse overheard -What the nurse heard -What the nurse palpated -What the nurse observed
What the nurse heard What the nurse palpated What the nurse observed
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 assessed from the client's family What the nurse overheard What the nurse heard What the nurse palpated What the nurse observed
What the nurse heard What the nurse palpated What the nurse observed
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
accurate organized complete timely concise
The nursing instructor is demonstrating to the student how to perform a physical assessement on a patient. 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
accurate documentation
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? -Liver palpation normal -No tenderness on palpation -Bowel sounds normoactive -Aching, burning pain in lower back
aching, burning pain in lower back
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use? -A screening tool that assesses specific risks -An integrated cued checklist -An abbreviated admission data sheet -An assessment flow chart
an assessment flow chart
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: -pie charting -charting by exception -narrative charting -batch charting
charting by exception
Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse? -Problem-oriented medical record -Charting by exception -PIE charting -Focus charting
charting by exception
A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document? -Liver palpation normal -No tenderness on palpation -Bowel sounds normoactive -Decreased range of motion in right shoulder
decreased range of motion in right shoulder
A nurse is explaining to other nurses on the unit about diagnosis-related groups (DRGs). On what documentation do insurance companies base their payment approval/disapproval? -Medical diagnosis -Laboratory tests -Diagnosis codes -Narrative notes
diagnosis codes
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? -Checklist -Flow sheet -Narrative note -Specialty assessment form
flow sheet
According to the Health Insurance Portability and Accountability Act (HIPAA) passed in 1996, patients: -Have the right to copy their health records. -Need to obtain legal representation to update their health records. -Can be punished for violating guidelines. -Are required to obtain health record information through their insurance company.
have the right to copy their health records
A researcher in a health care facility is conducting a study without IRB approval. The researcher knows that this information is limited to what? Pain management Financial reimbursement Internal quality improvement Verification of laboratory testing
internal quality improvement
The nurse is recording admission data for an adult client using a cued or checklist type of assessment form. This type of assessment form -covers all the data that a client may provide. -clusters the assessment data with nursing diagnoses. -establishes comparability of data across populations. -prevents missed questions during data collection.
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? -Data base -Problem list -Plan of care -Progress notes
progress notes
The nurse is reviewing the patient'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 patient's status? Progress notes Plan of care Clinical pathway Flow sheets
progress notes
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 appears upset about upcoming surgery. -Client was interviewed about previous history of hypertension. -Skin pale, warm, and dry without evidence of lesions. -Client's oral intake and output are satisfactory.
skin pale, warm, and dry without evidence of lesions
The nurse is reviewing a SOAPIE note in the patient's medical record. The nurse recognizes that "States no longer nauseous and would like something to eat" is which part of the SOAP note. -Subjective -Objective -Analysis -Plan -Evaluation
subjective
A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following? -Subjective data and objective data -Interpretation and inference -Observation and inspection -Data and results
subjective data and objective data
After teaching a group of students about documenting the nursing history and physical examination, the instructor determines that the teaching was successful when the students refer to this information as which of the following? -Subjective data and objective data -Interpretation and inference -Observation and inspection -Data and results
subjective data and objective data
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."
"Non-blanching reddened area noted on medial aspect of left great toe, 1 cm in diameter."
A nurse has just finished assessing a client. Which of the following are objective data that the nurse would likely have gathered? A description of gall bladder surgery the client had 10 years ago A description of a large bruise on the client's thigh The client's weight The presence of a lump in the client's breast discovered on palpation A 24-hour recall of what the client has eaten
A description of a large bruise on the client's thigh The client's weight The presence of a lump in the client's breast discovered on palpation
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? -A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. -A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. -A patient who resides in Indiana has required hospitalization during a vacation in Hawaii -A patient has ask a nurse if he can read the documentation that his physician wrote in his chart.
A patient has ask a nurse if he can read the documentation that his physician wrote in his chart.
The plan of care (POC) identifies problems, intended outcomes, and necessary interventions to meet those intended outcomes. What provides the basis for the POC? Assessment data in the medical record Medical diagnosis Standards of nursing care Client and family requests
Assessment data in the medical record
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 patient during her absence. She tells the nurse, "The patient 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? Situation Background Assessment Recommendation
Background
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. Patient is confused and exhibits inappropriate behavior. 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.
Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse? Problem-oriented medical record Charting by exception PIE charting Focus charting
Charting by exception
Mistakes in charting can be costly to both the patient 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: Adverse reactions Side effects Sentinel events Mismanagement
Sentinel events
A nurse is completing the intake assessment of an older adult who has just relocated to a long-term care facility. Which of the following nursing actions would be most important to ensure accurate data when gathering the resident's information? Documenting the data Validating the data Identifying client support systems Determining client needs
Validating the 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 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.
Verify the data by having another nurse come in to perform the percussion.
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? -Other people besides the other nurse may have heard -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 -All client information is private and confidential -It is not a breach, because both parties involved are nurses
all client information is private and confidential
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 -Progress notes -Focused -Nursing minimum data set
focused
In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed -progressive. -specific. -checklist. -focused.
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? -Open-ended form -Focused assessment form -Frequent assessment form -Ongoing assessment form
focused assessment form
The nurse prepares information to provide to the nurse scheduled to work the next shift. Which type of communication is the nurse preparing? -Verbal review -Handoff report -End-of-shift note -Discharge summary
handoff report
A patient 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 patient teaching and medications to the patient. The nurse understands the importance of doing a good assessment prior to discharge for which of the following purposes: -Identify necessary resources and strategies for successful home management. -Make the chart look as complete and thorough as possible. -Help ensure that the patient feels more comfortable about returning home. -Increase the nurse's level of competence.
identity necessary resources and strategies for successful home management
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? -Read the order back to the health care provider for confirmation. -Compare the order with the standard timing and dosage of the analgesic. -Compare the order to the client's existing medication administration record (MAR). -Have another nurse read the order that the nurse has transcribed.
read the order back to the health care provider for confirmation
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? -Have the UAP retake the blood pressure -Notify the physician -Recheck blood pressure in 30 minutes -Reassess blood pressure
reassess blood pressure
A client is being discharged home. The discharge note that the nurse writes for this client provides information for what purpose? -Information that is only useful for an internal audit -A summary of the medical course of the client while in the hospital -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 patient 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: -Adverse reactions -Side effects -Sentinel events -Mismanagement
sentinel events
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? -Formulation of nursing diagnoses -Identification of missing data -Determination of documentation form to use -Validation of data
validation of data
Which of the following clinical situations is addressed by the provisions of the Health Insurance Portability and Accountability Act (HIPAA)? A patient has ask a nurse if he can read the documentation that his physician wrote in his chart. A patient wishes to appeal her insurance company's refusal to reimburse for a diagnostic test. A patient has asked for a second opinion regarding treatment options for her diagnosis of ovarian cancer. A patient who resides in Indiana has required hospitalization during a vacation in Hawaii
A patient has ask a nurse if he can read the documentation that his physician wrote in his chart.
A nurse will be performing frequent assessment and reassessment of a client. Which form would be most appropriate for the nurse to use? A screening tool that assesses specific risks An integrated cued checklist An abbreviated admission data sheet An assessment flow chart
an assessment flow chart
The nurse uses the SBAR model when reporting on patients at the change of shift. This type of report incorporates what part of the nursing process? evaluation nursing diagnosis 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): at change of shift when a nurse leaves for lunch when a patient is transferred from the PACU to the floor upon admission to the ED when a patient is discharged
at change of shift when a nurse leaves for lunch when a patient is transferred from the PACU to the floor
The nurse is preparing to document assessment findings in a client's record. The nurse should -write in complete sentences with few abbreviations. -avoid slang terms or labels unless they are direct quotes. -record how the data were collected. -use the term "normal" to describe nonpathologic findings.
avoid slang terms or labels unless they are direct quotes
A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data? -Open-ended form -Focused assessment form -Frequent assessment form -Ongoing assessment form
focused assessment form
There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many health care providers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite? -Increased influence for the nursing profession -Elimination of documentation -Improved continuity of care -Reduced nursing workload
improved continuity of care
A nursing student is working a 7 a.m. to 3 p.m. shift with a preceptor and is caring for three patients independently. When the preceptor asks if the student has completed charting all her assessments, the student informs the preceptor that she is going to do batch charting. The preceptor informs the student of which of the following about batch charting? -It contributes to many potential errors. -It is a useful tool for prioritizing when busy. -It helps you remember important information. -It is fine unless you chart on the wrong patient.
ir contributes to many potential errors
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
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
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.
it provides quick access to abnormal findings
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? -SOAP notes -Focus charting -Charting by exception -Narrative notes
narrative notes
When performing an assessment, which of the following would be most helpful in validating a client's chief complaint? -A genogram -Past health history -Objective data -Family history data
objective data
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 male pattern baldness. -The man has a diffuse rash on his torso. -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
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 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 -To aid the nurse's recall of client information
to communicate effectively with other health care team members
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 transportation for follow-up appointments -If the client usually functions independently -What support systems are in place to assist the client -If the client has a religious belief regarding illness
what support systems are in place to assist the client