Documentation
What are the guidelines for quality documentation and reporting? (Select all that apply)
A) Detailed
B) Factual
C) Organized
D) Focused
E) Accurate
F) Complete
G) Current
H) Electronically recorded
Answer:B, C, E, F, G
A nurse states to a client, "Things will look better tomorrow after a good night's sleep." This is an example of which communication technique?
A. The therapeutic technique of "giving advice"
B. The therapeutic technique of "defending"
C. The nontherapeutic technique of "presenting reality"
D. The nontherapeutic technique of "giving false reassurance"
Answer: D
The nurse's statement, "Things will look better tomorrow after a good night's sleep." is an example of the nontherapeutic technique of giving false reassurance. Giving false reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.
Which factors should the nurse assess to determine a patient's ability to learn?
a. Developmental capabilities and physical capabilities
b. Sociocultural background and motivation
c. Psychosocial adaptation to illness and active participation
d. Stage of grieving and overall physical health
Answer: A
Developmental and physical capabilities reflect one's ability to learn. Sociocultural background and motivation are factors in readiness to learn. Psychosocial adaptation to illness and active participation are factors in readiness to learn. Readiness to learn is related to the stage of grieving. Overall physical health does reflect ability to learn; however, because it is paired here with stage of grieving (which is a readiness to learn factor), this is a wrong answer.
A nurse has provided care to a patient. Which entry should the nurse document in the patient's
record?
a. "Patient seems to be in pain and states, 'I feel uncomfortable.'"
b. Status unchanged, doing well
c. Left abdominal incision 1 inch in length without redness, drainage, or edema
d. Patient is hard to care for and refuses all treatments and medications. Family present
Answer: C
Use of exact measurements establishes accuracy. Charting that an abdominal wound is "5 cm in length without redness, drainage, or edema" is more descriptive than "large wound healing well." Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as "status unchanged" or "had a good day." It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. "Patient is hard to care for" is a personal opinion and should be avoided. It is also a
critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, "Refuses all treatments and medications."
When assessing a patient from a different culture, what is the most important area to consider?
1. Religious beliefs
2. Language spoken
3. Health practices
4. Social organizations
Answer: Language Spoken
Rationale:
is important to determine whether the nurse and patient can understand what the other is saying. It may be possible to find an interpreter in the event of a language barrier. Religious beliefs, health practices, and social organizations are an important area of cultural assessment, but not the most important.
A client diagnosed with post-traumatic stress disorder is admitted to an inpatient psychiatric unit for evaluation and medication stabilization. Which therapeutic communication technique used by the nurse is an example of a broad opening?
A. "What occurred prior to the rape, and when did you go to the emergency department?"
B. "What would you like to talk about?"
C. "I notice you seem uncomfortable discussing this."
D. "How can we help you feel safe during your stay here?
Answer: B
The nurse's statement, "What would you like to talk about?" is an example of the therapeutic communication technique of giving broad openings. Using a broad opening allows the client to take the initiative in introducing the topic and emphasizes the importance of the client's role in the interaction.
When the nurse describes a patient's perceived ability to successfully complete a task, which term should the nurse use?
a. Self-efficacy
b. Motivation
c. Attentional set
d. Active participation
Answer: A
Self-efficacy, a concept included in social learning theory, refers to a person's perceived ability to successfully complete a task. Motivation is a force that acts on or within a person (e.g., an idea, an emotion, a physical need) to cause the person to behave in a particular way. An attentional set is the mental state that allows the learner to focus on and comprehend a learning activity. Learning occurs when the patient is actively involved in the educational session.
Which phase of the nurse client relationship includes exploration of the clients feelings and participation in identifying his or her own problems?
A. Working
B. termination
C. Orientation
D. Beginning
Answer: A
1. A nurse is documenting patient data in the medical record of a patient admitted to the hospital with a diagnosis of appendicitis. The physician has ordered 10 mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follows recommended guidelines? Select all that apply.
a. 6/12/15 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN
b. 6/12/15 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN
c. 6/12/15 0945 30 minutes following administration of morphine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN
d. 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN
e. 6/12/15 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN
f. 6/12/15 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration.
Answer:
c. 6/12/15 0945 30 minutes following administration of morphine 10 mg IV patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN
d. 6/12/15 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN
f. 6/12/15 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration.
The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to describe the concept of acculturation. The nurse educator should make which most appropriate response?
1. "It is a process of learning a different culture to adapt a new or changing environment."
2. "It is a subjective perspective of the person's heritage and a sense of belonging to a group."
3. "It is a group of individuals in a society who are culturally distinct and have a unique identity."
4. "It is a group that shares some of the characteristics of the larger population group of which it is a part."
Answer: 1
Rationale: Acculturation is a process of learning a different culture to adapt to a new or changing environment. Option 2 describes ethnic identity. Option 3 describes an ethnic group. Option 4 describes a subculture.
A client who frequently exhibits angry outbursts is diagnosed with antisocial personality disorder. Which appropriate feedback should a nurse provide when this client experiences an angry outburst?
A. "Why do you continue to alienate your peers by your angry outbursts?"
B. "You accomplish nothing when you lose your temper like that."
C. "Showing your anger in that manner is very childish and insensitive."
D. "During group, you raised your voice, yelled at a peer, left, and slammed the door."
Answer: D
The nurse is providing appropriate feedback when stating, "During group, you raised your voice, yelled at a peer, left, and slammed the door." Giving appropriate feedback involves helping the client consider a modification of behavior. Feedback should give information to the client about how he or she is perceived by others. Feedback should not be evaluative in nature or be used to give advice.
The nurse is educating a patient with newly diagnosed type 1 diabetes mellitus. When the nurse has the patient demonstrate self-injection of insulin, which domain of learning is the nurse assessing?
a. Physical domain
b. Affective domain
c. Cognitive domain
d. Psychomotor domain
d. Psychomotor domain
A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisors most appropriate response?
1. These clients don't know life any other way, and change is not an option until they have improved insight.
2. These clients have limited cognitive skills and few vocational abilities to be able to make it on their own.
3. These clients often have a lack of financial independence to support themselves and their children, and most have religious beliefs prohibiting divorce and separation.
4. These clients are paralyzed into inaction by a combination of physical threats and a sense of powerlessness.
Answer: 4
The nursing supervisor is accurate when stating that clients who are in abuse relationships are paralyzed into inaction by a combination of physical threats and a sense of powerlessness. Women often choose to stay with an abusive partner: for the children, for financial reasons, for fear of retaliation, for lack of a support network, for religious reasons, or because of hopefulness.
A nurse obtained a telephone order from a primary care provider for a patient in pain. Which
chart entry should the nurse document?
a. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back.
b. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN, read back.
c. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back.
d. 12/16/20XX 0915 Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO J. Winds, RN.
Answer: C
The nurse receiving a TO writes down the complete order or enters it into the computer as it is being given. Then he or she reads the order back to the health care provider, called read back, and receives confirmation from the person who gave the order that it is correct. An example
follows: "10/16/2011: 0815, Tylenol 3, 2 tablets, every 6 hours for incisional pain. TO Dr. Knight/J. Woods, RN, read back." VO stands for verbal order, not telephone order. The doctor's name and read back must be included in the chart entry
What are common characteristics seen among different cultures? (Select all that apply.)
1. Culture is learned from birth through language and socialization.
2. Culture is dynamic and ever changing, but it remains stable.
3. Members of the same cultural group have different patterns of socialization than other cultural groups.
4. Culture is an adaptation to specific conditions in a specific location.
5. Child-rearing practices are approximately the same in all cultures.
Answer: 1, 2
Rationale:
Culture is learned, dynamic, and adapted to specific conditions in a specific location. All members of the same cultural group share the patterns that are present in every culture. Though all cultures appear to value children, child-rearing practices are very different. REF: Page 95
A woman comes to an emergency department with a broken nose and multiple bruises after being beaten by her husband. She states, "The beatings have been getting worse, and I'm afraid, next time, he will kill me." Which is the appropriate nursing response?
1. Leopards don't change their spots, and neither will he.
2. There are things you can do to prevent him from losing control.
3. Lets talk about your options so that you don't have to go home.
4. Why don't we call the police so that they can confront your husband with his behavior?
Answer: 3
The most appropriate response by the nurse is to talk with the client about options so that the client does not have to return to the abusive environment. It is essential that clients make decisions on their own without the nurse being the rescuer. Imposing judgments and giving advice is non-therapeutic.
A nurse wants the patient to begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning?
a. Lecture
b. Demonstration
c. Role play
d. Question and answer session
Answer: C
Affective learning deals with expression of feelings and acceptance of attitudes, opinions, or values. Role play and discussion (one-on-one and group) are effective teaching methods for the affective domain. Lecture and question and answer sessions are effective teaching methods for the cognitive domain. Demonstration is an effective teaching method for the psychomotor domain.
Which entry will require follow-up by the nurse manager?
0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Call bell within reach. Bed monitor on.
-------------------Jane More, RN
0810 Notified primary care provider of patient's status. New orders received.
-------------------Jane More, RN
0815 Portable x-ray of L hip taken in room. States, "I feel fine."
-------------------Jane More, RN
0830 Incident report completed and placed on chart.
-------------------Jane More, RN
a. 0800
b. 0810
c. 0815
d. 0830
Answer:D
Note that you do not include mention of the incident report in the patient's medical record. Instead you document in the patient's medical record an objective description of what happened, what you observed, and follow-up actions taken. It is important to evaluate and
document the patient's response to the error or incident. Always contact the patient's health care provider whenever an incident happens
A client tells the nurse, "I feel bad because my mother does not want me to return home after I leave the hospital." Which nursing response is therapeutic?
A. "It's quite common for clients to feel that way after a lengthy hospitalization."
B. "Why don't you talk to your mother? You may find out she doesn't feel that way."
C. "Your mother seems like an understanding person. I'll help you approach her."
D. "You feel that your mother does not want you to come back home?"
Answer: D
This is an example of the therapeutic communication technique of restatement. Restatement is the repeating of the main idea that the client has verbalized. This lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue, or clarify if necessary.
A student nurse learns that a normal adult heartbeat is 60 to 100 beats/minute. In which domain did learning take place?
a. Kinesthetic
b. Cognitive
c. Affective
d. Psychomotor
Answer: B