Health Asses Part 5

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? • It provides a chronologic source of patient assessment data. • It creates a database for care that was not rendered to the patient. • It replaces the patient acuity classification system. • It directly formulates the nursing diagnoses. • A nurse is comparing the subjective data and objective data obtained from an assessment of a patient who is thought to have hepatitis A. This nurse's comparison will achieve what benefit to this patient's care? • Formulation of nursing diagnoses • Identification of missing data • Determination of documentation form to use • 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. • Joint Commission • State nurse practice act • Medicare • Local or city government • Institutional agency • A nurse has completed an assessment of a patient with cholecystitis and is about to document the findings. Which statement best reflects accurate documentation? • patient appears upset about upcoming surgery. • patient was interviewed about previous history of hypertension. • Skin pale, warm, and dry without evidence of lesions. • patient's oral intake is satisfactory. • A nurse is using a nursing minimum data set to document findings following the assessment of a patient. This nurse is most likely providing care in which setting? • Acute care facility • Long-term care facility • Urgent care center • Health clinic • While performing the initial assessment of a patient, the patient tells the nurse that this is his first hospitalization and that he has no previous surgeries. The nurse should document which of the following? • patient denies prior hospitalizations and surgeries • patient has not been hospitalized before nor has he had any surgery • patient answered no to previous hospitalizations or surgery • Negative for past hospitalizations • 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? • Repeating the assessment • Asking additional questions • Having the patient repeat what was said • Checking findings with another health care professional • A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data? • Open-ended form • Focused assessment form • Frequent assessment form • Ongoing 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? • ìDocumentation helps support reimbursement but gives little epidemiologic data.î • ìDocumentation provides a permanent legal record of care given and not given.î • ìDocumentation is a viable means of communication but is repetitious.î • ìDocumentation helps determine patient education needs but not staff mix.î • A nurse is providing a verbal update to a patient's primary care provider because of the patient's worsening nausea. When using an SBAR format to provide a report, the nurse should complete the report with which of the following statements? • ìWhat would you like to do to address this patient's nausea?î • ìI think this patient would benefit from an antiemetic.î • ìThis patient has no recent history of any nausea or vomiting.î • ìThis patient rates his nausea as seven out of ten.î • A surgical patient'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? • Read the order back to the surgeon for confirmation. • Compare the order with the standard timing and dosage of the analgesic. • Compare the order to the patient's existing medication administration record (MAR). • Have another nurse read the order that the nurse has transcribed. • 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? • Delegate handoff reports to unlicensed care providers who have fewer demands on their time. • Use an intermediary to receive report from the first nurse and then provide the handoff report to the second nurse. • Involve as few people as possible in the verbal report. • Encourage nurses to perform handoff as quickly as possible. • A patient has illuminated his call light and tells the nurse that he is having ìten out of tenî pain. The nurse's initial inspection reveals that the patient is watching videos on his tablet computer and appears to be at ease physically and emotionally. How should the nurse validate the patient's subjective complaint of pain? • Ask the patient to repeat his rating of his pain. • Observe the patient for several seconds to see if his demeanor or his behavior changes. • Consult the patient's medication administration record (MAR) to check for recent analgesic use. • Perform further assessments addressing various aspects of the patient's pain. • A hospital nurse is admitting a patient with a documented history of acute pancreatitis, liver cirrhosis, malnutrition, and frequent traumatic injuries. What assessment finding would most clearly warrant validation? • The patient's blood pressure is 148/88 mm Hg. • The patient is oriented to person and place but not to time. • The patient states that she only drinks alcohol on a social basis. • The patient states, ìMy skin's kind of yellow because of my liver.î • 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? • Expand the use of the Nursing Minimum Data Set. • Eliminate the use of verbal handoffs between nurses. • Increase interdisciplinary collaboration in the hospital. • 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 patient who is a 79-year-old man. What assessment finding most clearly indicates a need for further data? • The man has male pattern baldness. • The man has a diffuse rash on his torso. • The man's heart rate is 63 beats per minute. • The man had an inguinal hernia repair in 2008. • 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? • Increased influence for the nursing profession • Elimination of documentation • Improved continuity of care • Reduced nursing workload • While assisting an older adult with morning hygiene, the nurse notes a lesion on the patient's coccyx region. How should the nurse best document this objective assessment finding? • ìPossible pressure ulcer observed over patient's coccyx region.î • ìReddened area noted on skin surface superficial to patient's coccyx.î • ìArea of nonblanching erythema noted over patient's coccyx, 2 cm ◊ 2 cm.î • ìImpaired Skin Integrity related to decreased mobility.î • A nurse is conscientious in adhering to the requirements of the Health Insurance Portability and Accountability Act (HIPAA) when providing care for patients. What action best meets these legal requirements for care? • Having a colleague audit the nurse's documentation to ensure objectivity • Maintaining the privacy and confidentiality of patients' medical records • Using electronic records whenever possible, rather than paper-based records • Collaborating with the patient and his or her family prior to documenting A nurse has completed a comprehensive assessment of a patient and has begun the process of data analysis. Data analysis should allow the nurse to produce which of the following direct results? • Outcomes evaluation • Nursing diagnoses • Holistic interventions • An interdisciplinary plan of care • A new nursing graduate recently made an oversight during the analysis of a patient's assessment data that resulted in a postoperative complication. What characteristic of data analysis makes it a challenging aspect of nursing practice? - The Marketplace to Buy and Sell your Study Material • Abnormal data must be identified. • It requires the prior identification of nursing diagnoses. • It requires sophisticated diagnostic reasoning skills. • Conclusions must be clearly and accurately documented. • A hospital nurse has identified a need to improve her critical thinking skills in an effort to improve patient care. The nurse should identify which of the following characteristics of critical thinking? • It is an innate skill that some individuals possess and which others do not. • It does not include past experiences. • It is based primarily on getting correct and timely information. • It involves reflections on thoughts before reaching conclusions. • The emergency department has collected extensive data from a patient who has presented with a new onset of severe abdominal pain. What nursing action should the nurse perform before proceeding with data analysis? • Validate the collected data. • Formulate a nursing diagnosis. • Make inferences about the data. • Identify the patient's strengths. • A nurse has completed a patient's initial assessment and is preparing to identify abnormal data and the patient's strengths. Successful completion of this phase of the nursing process most requires which of the following? • Knowledge of anatomy and physiology • Awareness of the patient's medical prognosis • Inferences about the patient • Knowledge about the referral process • A nurse is planning a patient's care following the completion of an initial assessment. When formulating a risk nursing diagnosis, which piece of data would be most useful? • The patient has an elevated white blood cell count. • The patient is 66 years of age. • The patient has pain in her joints, especially in the morning. • The patient is separated from her usual social supports. • During the assessment interview, the patient made numerous statements that suggested his life generally exists in a state of harmony and balance. This fact would most likely prompt the nurse to identify which of the following? • Actual nursing diagnosis • Risk nursing diagnosis • Collaborative problem • Health promotion diagnosis