Chapter 15 – Documenting and Reporting – Fundamentals of Nursing Exam 3- examples – Flashcards
Unlock all answers in this set
Unlock answersquestion
Which action by a nurse ensures confidentiality of a client's computer record? The nurse logs on to the client's file and leaves the computer to answer the client's call light. The nurse shares her computer password. The nurse closes a client's computer file and logs off. The nurse leaves client computer worksheets at the computer workstation.
answer
The nurse closes a client's computer file and logs off.
question
The case management model using critical pathways would be appropriate for a client with which diagnosis? Myocardial infarction (heart attack) Diabetes, hypertension Myocardial infarction, diabetes, hypertension Diabetes, hypertension, an infected foot ulcer, senile dementia
answer
Myocardial infarction (heart attack)
question
After making a documentation error which action should the nurse take? Use correcting liquid to cover the mistake and make a new entry. Draw a line through it and write error above the entry. Draw a line through it and write mistaken entry above it. Draw a line through the mistake and write mistaken entry with initials above it.
answer
Draw a line through the mistake and write mistaken entry with initials above it.
question
During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client's blood pressure (B/P) seems high. What is the next step? Ask the client about past blood pressure ranges. Review the graphic record on the client's record. Examine the medication record for antihypertensive medications. Review the progress notes included in the client's record.
answer
Review the graphic record on the client's record.
question
A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client's inner thighs. Which of the following is the most appropriate documentation? Six round skin lesions partially healed, on the inner thighs bilaterally. Several burned areas on both of the client's inner thighs. Multiple lesions on inner thighs possibly related to elder abuse. Several lesions on inner thighs similar to cigarette burns.
answer
Six round skin lesions partially healed, on the inner thighs bilaterally.
question
Source-Oriented Records
answer
Traditional client record Each discipline makes notations in a separate section Information about a particular problem distributed throughout the record Narrative charting used
question
When narrative charting is used
answer
Always chart head to toe
question
Focus Charting (Power Point)
answer
Focus on client concerns and strengths Progress notes organized into DAR format Data-assessment phase Action-planning and implementing phase Response-evaluation phase Holistic perspective of client and client's needs Nursing process framework for the progress notes
question
Documentation for the nursing process Assessment
answer
Initial assessment form, various flow sheets
question
Documentation for the nursing process Diagnosis
answer
Nursing care plan, critical pathway, progress notes, problem list
question
Documentation for the nursing process Planning
answer
Nursing care plan, critical pathway
question
Documentation for the nursing process Implementing
answer
Progress notes, flowsheets
question
Documentation for the nursing process Evaluating
answer
Progress notes
question
Guidelines for Change-of-Shift Report
answer
Be concise Incorporate a verification process SBAR
question
SBAR
answer
Used for organizing information to give quickly (Situation, Background, Assessment, Recommendation)
question
The source-oriented record
answer
Traditional client record. Each person or department makes notations in a separate section of the clients chart.
question
Narrative Charting
answer
Is a traditional part of the source oriented record. It consists of written notes that include routine care, normal finds, and client problems.
question
Focus Charting (Book)
answer
Is intended to make the client and client concerns and strengths the focus of care. Three columns for recording are usually used. Date and time, focus, and progress notes.
question
s - Situation
answer
State your name, unit, and client name Briefly state the problem
question
b - Background
answer
State client admission diagnosis and date of admission State pertinent medical history provide brief summary of treatment to date code status (If appropriate)
question
A - Assessment
answer
Vital sings Pain scale is there a change from prior assessment?
question
Recommendation
answer
State what you would like to see done or specify that the care provider needs to come and assess the client Ask if health care provider wants to order any tests or medications Ask health care provider if she or he wants to be notified for any reason as if no improvement when you should call again.
