Chapter 07 Documentation of Nursing Care

Chapter 07  Documentation of Nursing Care

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The nurse is with a patient who complains of severe pain, documents every 15 minutes about the steps taken to try to relieve the pain (without success). The nurse also documents the time and content of two calls made to the patient’s primary care provider requesting that the primary care provider examines the patient for unexpected complications. This documentation by the nurse is likely to:
a.
cause the primary care provider to come to the attention of the hospital administration.
b.
be questioned by the nurse’s supervisor for time inefficiency.
c.
be used against the nurse if a lawsuit results, because it proves the nurse was not able to relieve the pain.
d.
justify insurance reimbursement for an extended duration of hospitalization for the patient.

ANS: D
Documentation of complications or a patient’s changing condition is used by insurance companies to justify payments for hospitalization. Documentation also serves as evidence of standards of care in a court of law.

DIF: Cognitive Level: Application REF: p. 84 OBJ: Theory #4
TOP: Purposes of Documentation KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. A patient who is very angry and is leaving the hospital against medical advice (AMA) demands to have the medical record to take, because it is her personal property. An appropriate response would be:
a.
“Certainly. This hospital doesn’t need to keep it if you are leaving and will not be returning here.”
b.
“You are entitled to the information in your medical record, but the medical record is the property of the hospital. I will see about having a copy made for you.”
c.
“The information in your medical record is confidential, and you cannot leave this facility with it.”
d.
“Because you are leaving against the medical advice of your primary care provider, you may not have the medical record.”

ANS: B
The medical record is the property of the facility, but the patient has a legal right to the information in it even if she is leaving AMA.

DIF: Cognitive Level: Application REF: p. 86 OBJ: Theory #3
TOP: The Medical Record KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

3. A student nurse is assigned to a clinical unit on which one of the patients is a nationally known celebrity. The student reads the chart to find out why the celebrity is being treated. The student who is not the assigned caregiver is:
a.
motivated to learn about the health problem of this patient and is appropriately seeking knowledge during his clinical experience.
b.
doing appropriate research about nursing care as long as information is not divulged.
c.
violating the confidentiality of the patient’s record.
d.
neglecting the assigned patient load and should read the unassigned patient’s medical record only after his assigned work is completed.

ANS: C
A person reading a patient’s chart who is not involved in the patient’s care is in violation of confidentiality. Protecting the patient’s privacy is of prime importance.

DIF: Cognitive Level: Comprehension REF: p. 92 OBJ: Theory #3
TOP: The Medical Record KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A

4. A patient with a nursing diagnosis of Skin integrity, impaired, related to surgery as evidenced by disruption of skin surface has the following nursing documentation: “Incision clean, dry, intact. No pain or tenderness. Instructed to keep area dry, may wear light dressing to protect from clothing. Verbalizes understanding of wound care and ability to manage at home. Wound healing without complication.” This documentation is:
a.
an example of charting by exception.
b.
evidence of the use of the nursing process.
c.
using the problem-oriented medical record (POMR) format.
d.
usually entered on a flow sheet for treatments and vital signs.

ANS: B
The nursing process is evident in this documentation. Assessment, interventions, and evaluation are all noted.

DIF: Cognitive Level: Analysis REF: p. 92 OBJ: Theory #2
TOP: Methods of Charting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

5. Which nursing assessment is an example of brevity and clarity while meeting legal guidelines?
a.
“4 cm reddened area over sacrum. Skin intact, warm, and dry.”
b.
“Taking fluids poorly, but more than yesterday.”
c.
“Apparently comfortable all night. Offers no complaints of pain.”
d.
“Patient says she is still slightly nauseated, would like to try some toast and tea.”

ANS: A
Provision of specific objective data—size, location, and characteristics of the patient’s skin—is clear and brief and informative.

DIF: Cognitive Level: Comprehension REF: p. 95 OBJ: Clinical Practice #2
TOP: The Charting Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort