Ch. 20 Documenting and Reporting
The nurse manager of a home health care office wishes to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which documentation format is most likely to promote this goal?
a. SOAP notes b. narrative notes
c. FOCUS charting d. charting by exception
b. narrative notes
Upon assessment, a client reports drinking 5 to 6 bottles of beer every evening after work. Based upon this information, the nurse is aware that the client may require?
a. larger doses of anesthetic agents and lower doses of postoperative analgesics
b. larger doses of anesthetic agents and larger doses of postoperative analgesics
c. lower doses of anesthetic agents and lower doses of postoperative analgesics
d. lower doses of anesthetic agents and larger doses of postoperative analgesics
b. larger doses of anesthetic agents and larger doses of postoperative analgesics
Pet therapy is commonly used in long-term facilities for distraction. If a client is experiencing pain and the pain is temporarily decreased while petting a visiting dog or cat, this is an example of which type of distraction technique?
a. visual distraction
b. tactile kinesthetic distraction
c. auditory distraction
d. project distraction
b. tactile kinesthetic distraction
What is the term for the change that takes place in response to a stressor?
a. rehabilitation b. positive movement
c. negative movement d. adaptation
d. adaptation
A cleansing enema is prescribed for a client who is scheduled to have colon surgery. What is the rationale for this procedure?
a. surgical clients routinely are given a cleansing enema
b. cleansing enemas are given before surgery at the client's request
c. there will be less flatus and discomfort postoperatively
d. peristalsis does not return for 24 to 48 hours after surgery
d. peristalsis does not return for 24 to 48 hours after surgery
A hospital utilizes the SOAP method of charting. Within this model, which of the nurses' statements would appear at the beginning of a charting entry?
a. "Client is reporting abdominal pain and is rated at 8/10"
b. " Client has a history of recent abdominal pain"
c. " 2mg hydromorphone hydrochloride PO was administered with good effect"
d. " Client is guarding the abdomen and occasionally moaning"
a. "Client is reporting abdominal pain and is rated at 8/10 "
The nurse is providing education to a client regarding pain control after surgery. What time does the nurse inform the client is the best time to request pain medication?
a. when the client experiences a pain rating of "10" on a 0 to 10 pain scale
b. when there is no pain, but it is time for the medication to be administered
c. before the pain becomes severe
d. after the pain becomes severe and relaxation techniques have failed
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c. before the pain becomes severe
A client in an emergency department is diagnosed with a myocardial infarction (MI) (heart attack). The client describes pain in the left arm and shoulder. What name is given to this type of pain?
a. cutaneous b. allodynia c. referred d. nociceptive
c. referred
A client responds to bad news regarding test results by crying uncontrollably. What is the term for this response to a stressor?
a. adaptation b. homeostasis
c. coping mechanism d. defense mechanism
c. coping mechanism
A nurse is providing education for a postoperative client regarding pain management. Which teaching point should the nurse include?
a. " Be sure to ask for your PRN medication when the pain becomes severe"
b. " If your pain is not relieved, ask your nurse to order a different medication"
c. "You will receive pain medication by injection as long as you are NPO"
d. " All postoperative pain control methods will be given by injection"
c. " You will receive pain medication by injection as long as you are NPO"
What is the primary purpose of the client record?
a. communication b. advocacy
c. research d. education
a. communication
A nurse is educating a preoperative client on how to cough effectively after abdominal surgery. What can the nurse tell the client to do to facilitate coughing?
a. " Get up and walk before you try to cough"
b. " It would be best if you do not cough until you feel better"
c. " When you cough, cover your nose and mouth with a tissue"
d. " Hold a pillow or folded bath blanket over the incision"
d. " Hold a pillow or folded bath blanket over the incision."
Why is acute pain said to be protective in nature?
a. it enables the person to increase personal strength
b. as a subjective experience, it serves no purpose
c. as an objective experience, it aids diagnosis
d. it warns an individual of tissue damage or disease
d. it warns an individual of tissue damage or disease
A client with an inflamed appendix is feeling pain in the stomach area. What is the term for this body response to stress?
a. local adaptation syndrome
b. general adaptation syndrome
c. physiologic homeostasis
d. fight-or-flight response
a. local adaptation syndrome
A nurse is working with a group of clients in the preoperative area. Which client task would be the highest priority?
a. Inserting a Foley catheter in a client in a client before major surgery
b. Raising the stretcher side rails when administering a sedative
c. Obtaining a list of home medications from a client
d. Measuring a diabetic client's blood glucose
b. Raising the stretcher side rails when administering a sedative
Which part of the client's record is commonly used to document specific client variables, such as vital signs?
a. progress notes b. nursing notes
c. critical paths d. flow sheets
d. flow sheets
A client scheduled for major surgery will receive general anesthesia. Why is inhalation anesthesia often used to provide the desired actions?
a. rapid excretion and reversal of effects
b. safe administration in the client's own room
c. involves only the respiratory system and skin
d. slow onset of action maintains reflexes
a. rapid excretion and reversal of effects
Eight hours after spinal surgery a client has not voided. The client is restless and reports abdominal pain. What action would the nurse perform before administering pain medication?
a. palpate abdomen for distended bladder
b. assess dressing for drainage
c. auscultate abdomen for bowel sounds
d. check database for last bowel movement
a. palpate abdomen for distended bladder
An individual steps into a tub of very hot water and immediately jumps out again. What mechanism caused this response?
a. inflammatory response
b. reflex pain response
c. general adaptation syndrome
d. figh-or-flight response
b. reflex pain response
Which method of pain control is based on the gate control theory?
a. biofeedback b. distraction
c. hypnosis d. acupuncture
d. acupuncture
A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called?
a. nursing care conferences b. staff visits
c. nursing care rounds d. interdisciplinary rounds
c. nursing care rounds
The nurse is caring for a client who returned from the post anesthesia care unit (PACU) 3 hours ago. The surgical dressing was dry and intact upon arrival to the postoperative unit, but now it is saturated with fresh blood. Which actions should the nurse take first?
a. remove the dressing and inspect the wound
b. reinforce the dressing with more bandages until the bleeding stops
c. measure vital signs
d. draw a circle around the drainage and note the time
b. reinforce the dressing with more bandages until the bleeding stops
The nurse has provided a hot pack to a client who has been experiencing neck pain. According to the gate control theory of pain transmission, why is this intervention likely to be effective?
a. heat stimulates the large diameter fibers that inhibit pain transmission
b. heat and pressure open the gates that conduct pain relieving endorphins to the brain
c. heat overwhelms the small-diameter pain fibers and they stop transmitting pain signals
d. heat opens nerve gates so that they can transmit pain inhibiting encephalins
a. heat stimulates the large diameter fibers that inhibit pain transmission
The spouse of a client reports daily migraine headaches since the client's diagnosis of colon cancer. Which action by the nurse is helpful in addressing the spouse's issue?
a. Reassuring the spouse the migraines are a physiologic response to stress
b. Telling the spouse he or she probably is not eating enough and has low blood sugar
c. suggesting a massage for muscle tension related to fight-or flight response
d. providing the contact for a neurologist for a migraine medication prescription
c. suggesting a massage for muscle tension related to fight-or flight response
A client responds to an approaching diagnostic test with a rapidly beating heart and hands that are shaking. This is the result of what type of response?
a. stress adaptation b. defense mechanism
c. coping response d. withdrawal behavior
c. coping response