Documentation Chapter 6 4th Edition Test Bank - Health Assessment in Nursing 4e Test Bank by Cynthia Fenske. DOCX document preview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)
Chapter 6 Documentation
- The nurse is documenting a client's family medical history in a genogram. Which standardized symbol should the nurse use to identify the patient's biological mother?
1. Square.
2. Circle.
3. Diamond.
4. Rectangle.
Page Ref: 74
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting.
MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
- The nurse is using the acronym SOAP to record information obtained from a client assessment. Which should the nurse recognize should be recorded in the "S" category?
1. Blood pressure of 177/93 mmHg.
2. Inability to afford prescriptions.
3. Client states they lost their insurance.
4. Social service referral.
Page Ref: 76
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: VI.A.2. Identify essential information that must be available in a common database to support patient care. | AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Carefully maintain and use electronic and/or written health records. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The nurse is using the SBAR tool to notify a healthcare provider about a client that is physically declining. Which statement should the nurse include when communicating the situation?
1. "I think an increase in furosemide will help the patient."
2. "The patient was admitted yesterday with congestive heart failure."
3. "The patient's O2 saturation is 89%."
4. "The patient is experiencing dyspnea."
Page Ref: 66
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Tools for effective and open communication. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The nurse is preparing to create a pedigree for the client using the client's family history information. Which should the nurse recognize are benefits to using a genogram? Select all that apply.
1. Easy to fill in the family history.
2. Contains standardized symbols.
3. Allows for a visualization of disease incidence.
4. Provides a visual representation of a family's health patterns.
5. Can predict which generations are more susceptible to family illness.
Page Ref: 74
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.1: Describe the purpose of nursing documentation.
MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
- The nurse is constructing a pedigree for a client. Which symbol should the nurse use to represent the client's biological father?
1. Circle.
2. Square.
3. Diamond.
4. Rectangle.
Page Ref: 74
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting.
MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
- The nurse is using the SBAR communication tool to communicate with a healthcare provider. Which statement should the nurse use to communicate the background?
1. "I think that the client's medication has caused the confusion."
2. "The client's mental status is confused."
3. "I am calling about Mr. X's blood pressure."
4. "I would suggest decreasing the dosage of the medication."
Page Ref: 66
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families, and the healthcare team. | AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Tools for effective and open communication. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The preceptor is reviewing the use of the SBAR tool with a new nurse. Which statement made by the nurse indicates an understanding of the tool?
1. "The SBAR tool will help me organize my client's problems."
2. "The SBAR tool will help me organize the assessment on my client."
3. "The SBAR tool will help me organize my shift report."
4. "The SBAR tool will help me organize my documentation."
Page Ref: 66
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team. | AACN Essentials Competencies: I.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Tools for effective and open communication. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.1: Describe the purpose of nursing documentation.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The nurse is using the principles of documentation. Which principle should the nurse anticipate to incorporate?
1. Ethics.
2. Accountability.
3. Professionalism.
4. Communication.
Page Ref: 66
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.2: List the key principles of nursing documentation.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- The preceptor is discussing the principles of documentation with a new nurse. Which principles should the preceptor include? Select all that apply.
1. Completeness.
2. Professionalism.
3. Accuracy.
4. Timeliness.
5. Confidentiality.
Page Ref: 66
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.2: List the key principles of nursing documentation.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- The nurse has incorporated the principles of documentation into written communication. Which should the nurse recognize reflects the accuracy of the documentation?
1. Documentation that is limited to factualness.
2. Uniform language used throughout the documentation.
3. Limited sharing of the information.
4. Documentation that is completed promptly and is easily readable.
Page Ref: 66
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.2: List the key principles of nursing documentation.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- The nurse manager is discussing the principles of documentation with the nursing staff. Which statement made by a nurse indicates an understanding of the principle of professionalism?
1. "I will maintain the privacy of the information that I document."
2. "I will use uniform language so my documentation can be understood."
3. "I will use quotation marks when I record my subjective data."
4. "I will make sure I immediately document all of my assessments."
Page Ref: 68
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.2: List the key principles of nursing documentation.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- A client tells the nurse that they have pain in their lower abdomen. Which should the nurse record to reflect accuracy in the documentation of the information?
1. The client told me they have "pain" in their lower abdomen.
2. The client states, "I have pain in my lower abdomen."
3. The client complains they have pain in their lower abdomen.
4. The client states they are having pain in their abdomen.
Page Ref: 66
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
- The nurse is documenting an assessment. Which terms should the nurse be mindful of when recording information to ensure the documentation is accurate and complete? Select all that apply.
1. Precise.
2. Comprehensive.
3. Professional.
4. Succinct.
5. Concise.
Page Ref: 66
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- The nurse manager is reviewing tips for appropriate documentation with the nursing staff. Which statement made by the nursing staff indicates further education is required?
1. "I will document the exact time the events occurred."
2. "I will document why the client refused their medication."
3. "I will document for my colleague during an emergency."
4. "I will document client statements using quotations."
Page Ref: 68
Cognitive Level: Evaluation
Client Need & Sub: Management of Care; Ethical Practice
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.2: List the key principles of nursing documentation.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- A client tells the nurse that they are experiencing discomfort above their elbow. Which medical terminology should the nurse use to describe the location of discomfort?
1. Distal to the elbow.
2. Proximal to the elbow.
3. Anterior to the elbow.
4. Inferior to the elbow.
Page Ref: 68
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.3: Accurately document objective data from a physical assessment.
- The nurse is preparing to describe a location in the body in the documentation of an assessment. Which terminology should the nurse anticipate using?
1. Anatomic definition.
2. Anatomic plane.
3. Anatomic alignment.
4. Anatomic pathology.
Page Ref: 68
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.3: Accurately document objective data from a physical assessment.
- The nurse is avoiding the use of a client's personally identifiable information. Which information should the nurse recognize should not be used? Select all that apply.
1. Diagnosis.
2. Gender.
3. X-rays.
4. Age.
5. Religion.
Page Ref: 69
Cognitive Level: Applying
Client Need & Sub: Management of Care; Confidentiality/Information Security
Standards: QSEN Competencies: VI.B.1. Seek education about how information is managed in care settings before providing care. | AACN Essentials Competencies: IV.8. Uphold ethical standards related to data security, regulatory requirements, confidentiality, and clients' right to privacy. | NLN Competencies: Quality and Safety: Carefully maintain and use electronic and/or written health records. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.2: List the key principles of nursing documentation.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- A client tells the nurse that their pain is okay now. Which question should the nurse ask the patient to obtain more accurate information?
1. "Do you feel better?"
2. "Can you explain what okay means?"
3. "Are you pain free?"
4. "Is feeling okay a tolerable condition for you?"
Page Ref: 69
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Basic Care and Comfort
Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering. | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks and to identify current and future health problems. | NLN Competencies: Relationship Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
- The nurse is assessing the family history of a client that has children. Which should the nurse plan to do when creating a genogram?
1. Obtain information for at least two generations.
2. Depict members of each generation along a vertical line.
3. Begin the genogram with a proband.
4. At the top of the genogram indicate the gender of the patient.
Page Ref: 74
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting.
MNL Learning Outcome: 6.2: Accurately document subjective data from a health history.
- The nurse is preparing to document a narrative note. Which format should the nurse use?
1. Paragraph.
2. Acronyms.
3. Bullet points.
4. Short sentences.
Page Ref: 75
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- The nurse is reviewing the different types of documentation. Which should the nurse recognize is a benefit to charting by exception?
1. Allows for a focused documentation of symptoms.
2. The documentation is formatted for a specific purpose.
3. Focuses on problem-oriented documentation.
4. Repetition is eliminated from the documentation.
Page Ref: 77
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.1: Describe the purpose of nursing documentation.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- The nurse is reviewing the charting from the previous shift. Which should the nurse recognize is appropriate to chart?
1. "Encouraged the client to ask questions."
2. "Discussed the plan of care with the parents."
3. "The client is demanding and tired."
4. "The client is observed to be crying."
Page Ref: 79
Cognitive Level: Analyzing
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.2: List the key principles of nursing documentation.
MNL Learning Outcome: 6.3: Accurately document objective data from a physical assessment.
- A client asks the nurse why they are creating a genogram. Which information should the nurse provide the patient with?
1. Identify genetic risk factors.
2. Predict genetic illness.
3. Promote healthy behavior.
4. Prevent future illness.
Page Ref: 74
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.1: Describe the purpose of nursing documentation.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The nurse is creating a genogram for a client. Which standard symbol should the nurse use to identify a male carrier?
1. Square half shaded.
2. Diamond shaded.
3. Fully shaded square.
4. Fully shaded circle.
Page Ref: 74
Cognitive Level: Understanding
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The nurse is preparing to record a narrative health history. Which assessments should the nurse include in the health history? Select all that apply.
1. Spirituality.
2. Biographic data.
3. Family history.
4. Sexuality.
5. Medications.
Page Ref: 70
Cognitive Level: Applying
Client Need & Sub: Management of Care; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.1: Recognize the purpose and principles of nursing documentation.
- The nurse educator is presenting information about the APIE method of charting to the staff nurses. Which statements by the nurses should the preceptor recognize indicates an understanding of the information? Select all that apply.
1. "I will only need to chart by exception with this method."
2. "Only subjective data are included in the assessment portion."
3. "The 'P' refers to the chief problem of the client."
4. "The activities implemented to manage the client's needs will be documented in the 'I' section."
5. "The 'E' refers to the evaluation that occurs after an intervention is implemented."
Page Ref: 76
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6.2: List the key principles of nursing documentation.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The nurses have requested a documentation system that will reduce the time spent writing out routine tasks but will still allow for documentation of exceptions. Which type of documentation should the nurse manager consider implementing in the healthcare organization?
1. Focus documentation.
2. Flow sheets.
3. SOAP charting.
4. APIE charting.
Page Ref: 76
Cognitive Level: Applying
Client Need & Sub: Safe and Effective Care Environment; Management of Care
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6.4: Use the correct nursing documentation format for a given setting.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The nurse is preparing to document a client's position that is laying on their back facing the ceiling. Which terminology should the nurse use in the documentation?
1. Supine.
2. Anterior.
3. Prone.
4. Lateral.
Page Ref: 68
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- A client tells the nurse that her mother has type II diabetes. Which information about the patient's mother should the nurse include in genogram?
1. The current geographical residence.
2. The medications her mother takes.
3. The current age of her mother.
4. The age of onset of the type II diabetes.
Page Ref: 74
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology. | NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.
- The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation?
1. S: The client states, "I am so nauseated."
2. O: The client reports feeling fatigued.
3. A: Bowel sounds are high-pitched in all abdominal quadrants.
4. P: The client will remain NPO.
Page Ref: 76
Cognitive Level: Analyzing
Client Need & Sub: Health Promotion and Maintenance; Collaboration with Interdisciplinary Team
Standards: QSEN Competencies: II.B.13. Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care. | AACN Essentials Competencies: 1.4. Use written, verbal, non-verbal, and emerging technology methods to communicate effectively. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6.3: Correctly document the subjective and objective findings from a comprehensive health history and physical assessment.
MNL Learning Outcome: 6.4: Recognize the types of documentation systems and methods of documenting.