Quiz 4
A nurse is documenting care for patients in a hospital setting. Which documenting errors may potentially increase the nurse risk for legal problems? (SATA) The content reflects patient needs The content includes descriptions of situations that are out of the ordinary The content is not in accordance with professional standards There are lines between the entries The documentation is not countersigned. Dates and times of entries are omitted.
Dates and times of entries are omitted. The content is not in accordance with professional standards
When maintaining medical records for the client the nurse knows that the medical record also serves as a legal document of evidence. What should the nurse do to ensure legal defensible charting? Ensure that the clients name appears on all pages Leave spaces between entries and signature Use abbreviations wherever possible Record all facts an subjective interpretations
Ensure that the clients name appears on all pages
A 36 yr old patient who underwent a hysterectomy 4 days ago says to the nurse, "I wonder if I'll still feel like a woman". Which response would most likely encourage the patient to expand on this and express her concerns in more specific terms? When did you begin to wonder about this? Do you want more children? Feel like a woman...? Remaining silent
Feel like a woman...? *the nurse must clarify what the patient is specifically meaning by I wonder if I'll still feel like a woman. It is an attempt to understand the basic nature of the client statement. *technique used is seeking clarification.
A nurse is caring for a client with depression. The nurse finds that the client is withdrawn and does not communicate with others. Which of the following is most appropriate response by the nurse? Did you sleep well last night? Is that a new shirt you're wearing? Did you like the dinner yesterday? Do you feel like talking today?
Is that a new shirt you're wearing?
The nurse receives a verbal order from a physician during an emergency situation. What actions should be taken by the nurse?(SATA) Explain the nurse can't take VO with the physician present Mark the date and time of the order Include V.O. with the physician name on the order Record the order on the pharmacy discrepancy sheet Have the physician review and sign the order. Read back the order The nurse would report the situation to the charge nurse.
Mark the date and time of the order Include V.O. with the physician name on the order Have the physician review and sign the order. Read back the order
Nurses focus on the whole client. Statements that acknowledge the client as a human being are (SATA) Mr. Smith I will be taking you to x ray now I have your medications ready for you Mrs. Jackson I am going to cleanse your back turn over please for me sweetie Hi Tom please take your clothes off and put this gown on with the opeining in the back. Hey body how was last night
Mr. Smith I will be taking you to x ray now I have your medications ready for you Mrs. Jackson
The American Nurses Association identifies effective documentation using which of the characteristics (SATA) Readable Timely, contemporaneous, and sequential Clear concise and complete Readable Thoughtful Accurate, relevant and lengthy Retrievable on temporary basis
Readable Timely, contemporaneous, and sequential Clear concise and complete Readable Thoughtful
The nurse client relationship is dependent on communication. Effective communication between the nurse and the patient includes.(SATA) Spoken word Intuition Sight Telepathy Touch Observation
Spoken word Sight Touch Observation
Which actions help improve listening skills when conversing with patients (SATA) The nurse sits with the patient in a comfortable environment with arms and legs crossed in relaxed position The nurse always maintain eye contact with the patient in face to face pose The nurse uses appropriate facial expressions and body gestures to indicate that he or she is paying attention to what the patient is saying. The nurse thinks before responding to the patient even if this creates a lull in the conversation. The nurse listens for the themes in the patient's comments. If an action being performed does not allow for conversation the nurse pretends to listen to the patient rather than interrupting the patient.
The nurse uses appropriate facial expressions and body gestures to indicate that he or she is paying attention to what the patient is saying. The nurse thinks before responding to the patient even if this creates a lull in the conversation. The nurse listens for the themes in the patient's comments.
