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?
C) Validating the data
A nurse is assessing a female client whose worsening sciatica has prompted her to seek care. Which of the client's following statements would the nurse most likely need to validate?
D) ìI don't generally have problems with pain.î
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?
C) What support systems are in place to assist the client
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?
C) It becomes the foundation for the entire nursing process.
A nurse has documented the nursing history and physical examination of a client. This health information is best described as which of the following?
C) Subjective data and objective data
The nurse is caring for a client with influenza symptoms and is documenting the initial and ongoing assessment database. Which of the following would the nurse emphasize as the major rationale for this action?
B) Promoting communication between disciplines
A nurse has completed a client's initial assessment and is now interpreting and making inferences from the data. The nurse is involved in which phase of the nursing process?
C) Analysis
A 54-year-old client is receiving a follow-up assessment in a clinic, following abnormal findings on her recent mammogram. Which of the following statements best reflects appropriate documentation by the nurse?
A) ìClient has unkempt appearance and avoids eye contactî
A nurse is working in a health care facility that uses charting by exception. Which of the following would the nurse expect to document?
A) Decreased range of motion in right shoulder
A task force has been established at a hospital with the aim of overhauling the assessment forms that are used throughout the facility. Which of the following options is most likely to help standardize the process of data collection?
C) Cued or checklist form
A nurse is providing in-service training to a group of nurses in a facility that has just begun to use an integrated cued checklist for documentation. Which of the following would the nurse identify as a major advantage of this type of documentation?
A) It helps nurses to cluster 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?
D) It provides a chronological source of client assessment data.
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?
B) Validation of data
A nurse is preparing an in-service education program for a group of staff nurses about documentation, including documentation of assessment data. The nurse demonstrates understanding of the significance of documentation by including a discussion of which
of the following as playing a role in this area? Select all that apply.
A) Joint Commission
B) State nurse practice act
C) Medicare
D) Local or city government
E) Institutional agency
A) Joint Commission
B) State nurse practice act
C) Medicare
E) Institutional agency
A nurse has completed an assessment of a client with cholecystitis and is about to document the findings. Which statement best reflects accurate documentation?
B) Skin pale, warm, and dry without evidence of lesions.
A nurse is using a nursing minimum data set to document findings following the assessment of a client. This nurse is most likely providing care in which setting?
A) Long-term care facility
While performing the initial assessment of a client, the client tells the nurse that this is his first hospitalization and that he has no previous surgeries. The nurse should document which of the following?
B) Client denies prior hospitalizations and surgeries
An instructor is describing various ways that a nurse can validate data to a group of nursing students. The instructor determines that additional teaching is necessary when the students identify which of the following as a reliable method?
D) Having the client repeat what was said
A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data?
D) Focused assessment form
A group of students is reviewing information from class about the purposes of assessment documentation. The students demonstrate understanding of the material when they state which of the following?
C) ìDocumentation provides a permanent legal record of care given and not given.î
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 of the following statements?
D) ìI think this client would benefit from an antiemetic.î
A surgical client's pain has become increasingly severe overnight, and she has received her maximum current doses of analgesics. The nurse has consequently phoned the surgeon to obtain a new order for analgesia. After the surgeon tells the nurse the new order, how should the nurse best validate this information?
B) Read the order back to the surgeon for confirmation.
An audit of a hospital unit's incident reports reveals that several errors have resulted from incomplete or inaccurate information during change-of-shift handoff. In order to prevent such errors, what practice should be encouraged on the unit?
A) Involve as few people as possible in the verbal report.
A client has illuminated his call light and tells the nurse that he is having ìten out of ten pain. The nurse's initial inspection reveals that the client is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the client's subjective complaint of pain?
C) Perform further assessments addressing various aspects of the client's pain.
A hospital nurse is admitting a client with a documented history of acute pancreatitis, liver cirrhosis, malnutrition, and frequent traumatic injuries. What assessment finding would most clearly warrant validation?
B) The client states that she only drinks alcohol on a social basis.
A small, rural hospital is revising the policies and procedures surrounding documentation in an effort to align practices with the Health Information Technology for Economic and Clinical Health (HITECH) Act. How can the requirements of this legislation best be met?
D) Increase the use of electronic health records (EHRs) in the hospital.
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?
B) The man has a diffuse rash on his torso.
There has been some resistance to the planned transition to electronic health records (EHRs) in a hospital system, with many caregivers questioning the rationale for this change in practice. What potential advantage of EHRs should administrators cite?
B) Improved continuity of care
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?
B) ìArea of nonblanching erythema noted over client's coccyx, 2 cm ◊ 2 cm.î
A nurse is conscientious in adhering to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) when providing care for clients. What action best meets these legal requirements for care?
B) Maintaining the privacy and confidentiality of clients' medical records
