PA Study Guide Ch. 4

2. The nurse is preparing to document assessment findings in a client's record. The nurse should

Ans: Avoid slang terms or labels unless they are direct quotes

1. If the nurse makes an error while documenting findings on a client's record, the nurse should

Ans: Draw a line through the error, writing error and initiating

9. An assessment form commonly used in long term care facilities is the nursing minimum data set. One primary advantage of this type of assessment form is that it

Ans: Establishes comparability of nursing data across clinical populations

10. In some health care settings, the institutions uses an assessment form that assesses only one part of a client. These types of forms are termed

Ans: Focused

8. One advantage for an institution to use an integrated cued/checklist type of assessment data form is that it

Ans: May be easily used by different levels of caregivers which enhances communication

5. 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

Ans: Pain relief measures

7. The nurse is recording admission fate for an adult client using a cued or checklist type of assessment form. This type of assessment form

Ans: Prevents missed questions during data collection

6. One disadvantage of the open-ended assessment form is that it

Ans: Requires a lot of time to complete

11. The nurse is planning to assess a newly admitted adult client. While gathering data from the client, the nurse should

Ans: Validate all data before documentation of the data

4. An example of an objective finding in an adult client is

And: Vital signs

3. 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

Ans: "Bilateral lung sounds clear"