Chapter 18 Documenting & Reporting

Chapter 18  Documenting & Reporting

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client’s condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first?
1)
Study the discharge plan.
2)
Check the graphic data for vital signs.
3)
Examine the history and physical.
4)
Look for an advance directive.

ANS: 4
The advance directive, which should be located in a special section of the patient’s medical record, should be examined first because the patient’s symptoms indicate that he may need to be resuscitated. The advanced directive contains information about the patient’s wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data are to record assessment done frequently, such as vital signs. The history and physical provide a detailed summary of the patient’s current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

PTS: 1 DIF: Easy REF: p. 386
KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application

____ 2. A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?
1)
It involves a cooperative effort among various disciplines.

2)
The system requires diligence in maintaining a current problem list. 3)
Data may be fragmented and scattered throughout the chart.
4)
It allows the nurse to provide information in an unorganized manner.

ANS: 3

Treas Fundamentals TB18-2 Test Bank, Chapter 18

A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.

PTS: 1 DIF: Moderate REF: p. 387
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Recall

____ 3. The patient’s medical record contains the following documentation: 06/05/05 0200 Received patient from the E.D. BP 80/52, HR 118, RR 24, temp 104°F. Arouses to verbal stimuli but drifts off to sleep. Normal saline infusing in left arm via18 gauge IV catheter at 250 mL/hr. Urinary catheter draining scant dark amber urine. Pt receiving O2 at 6 L/min via nasal cannula. Lungs with coarse crackles at the left base. Loose cough present. Pt unable to expectorate secretions.—Ann. Davids, RN

Which type of charting has the nurse used? 1)
Narrative
2)

Focus 3) SOAP 4) PIE

ANS: 1
The nurse used narrative charting when documenting the condition of this newly admitted patient. This format is free text description of the patient status and nursing care. Focus charting highlights the patient’s concerns, problems, and strengths in a three-column format. SOAP is an acronym for subjective data, objective data, assessment, and plan. This charting format is used to address single problems or to write summative notes. PIE is an acronym for problem, interventions, and evaluation. This charting method also addresses problems.

PTS: 1 DIF: Easy REF: p. 392
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

____ 4. The department of nursing at a local hospital is considering changing to charting by exception (CBE). Which statement provides a rationale to support making this change? CBE
1)

Reduces the time nurses spend charting 2)

Treas Fundamentals Test Bank, Chapter 18

Addresses the patient’s concerns holistically
3)
Establishes an ongoing care plan from admission 4)

Is most useful when constructing a timeline of events

TB18-3

ANS: 1
An advantage of CBE is that it reduces the amount of time that nurses must spend documenting. CBE assumes that unless a separate entry is made, all standards have been met with a normal response. Focus charting addresses the patient’s concerns holistically. PIE charting establishes an ongoing care plan from admission. Narrative charting is especially useful when attempting to construct timelines of events.

PTS: 1 DIF: Moderate REF: p. 387
KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application