Deck 9: Nursing Processdocumentationinformatics

Question 1

A client exhibits signs of stress while awaiting results of lab work,and a nursing diagnosis of Anxiety secondary to knowledge deficit is made.Which type of nursing diagnosis does this represent?

A)actual
B)ongoing
C)risk
D)wellness

Answer 1

actual

Question 2

The nurse uses an assessment model that is derived from Maslow's theory.This model is based upon:

A)body systems model
B)functional health patterns
C)hierarchy of needs
D)human response patterns

Answer 2

hierarchy of needs

Question 3

Which of the following is a primary source of client data?

A)client
B)client's spouse,parent,or adult child
C)initial source of data,whoever that may be
D)health care provider

Answer 3

client

Question 4

The nurse is unable to obtain information from the client and knows the BEST secondary source of client information is which of the following?

A)client
B)client records
C)close friends
D)neighbors

Question 5

A facility's admission database divides client data by body systems and includes a section on psychosocial aspects of client status.This type of grouping similar data together into categories is called:

A)the medical model
B)an assessment model
C)data clustering
D)health management

Question 6

A client has been admitted with a history of dizzy spells and nausea.The client's blood pressure is highly variable with an elevated temperature on 3 successive days.The physician has ordered vital-sign monitoring,including temperature,heart rate,respirations,and blood pressure every 4 hours.What type of assessment is this type of monitoring called?

A)comprehensive
B)focused
C)ongoing
D)primary

Question 7

When client data are broken down into parts that can be examined,which step of the nursing process is involved?

A)diagnosis
B)assessment
C)evaluation
D)synthesis

Question 8

During an initial assessment,the nurse notes that the client reports being unable to walk more than a few steps without becoming short of breath.Which of these functional health patterns needs further investigation?

A)elimination
B)sleep/rest
C)coping/stress tolerance
D)activity/exercise

Question 9

A client has a nursing diagnosis of Readiness for enhanced spiritual well-being.Which type of nursing diagnosis does this represent?

A)wellness
B)risk
C)perceived
D)actual

Question 10

The nurse uses this type of assessment and organizes client data to determine if a client's current health patterns are working or not working:

A)body systems model
B)functional health patterns
C)hierarchy of needs
D)human response patterns

Question 11

A nurse is completing a client's initial admission database by asking the client questions about his past and current state of health,family history,and physical exam.These actions are part of which step of the nursing process?

A)assessment
B)diagnosis
C)evaluation
D)planning

Question 12

Which of the following would a nurse expect to include in the assessment phase of the nursing process?

A)determining the client's intellectual level
B)discussing any health care concerns or goals the client may have
C)identifying difficulties within the client's family
D)selecting appropriate nursing interventions to assist the client to recover

Question 13

A client has suffered a mild stroke.Which type of nursing diagnosis would reflect the client's health status?

A)wellness
B)risk
C)perceived
D)actual

Question 14

A client's hospital admission assessment includes a health history and current health assessment.This type of assessment is known as:

A)comprehensive
B)focused
C)ongoing
D)primary

Question 15

How does a nursing diagnosis differ from a medical diagnosis?

A)A nursing diagnosis is a clinical judgment about a family's,individual's,or community's responses to actual or potential health problems.
B)A nursing diagnosis is a clinical judgment that identifies a specific disease condition or pathological state.
C)Only a physician can make a medical diagnosis,but anyone can make a nursing diagnosis.
D)The physician specifically defines medical interventions to be performed by the medical staff for treatment only after a nursing diagnosis is made.

Question 16

Which of these provide the basis for selecting nursing interventions to achieve the goals for which the nurse is accountable?

A)medical diagnosis
B)nursing diagnosis
C)nursing process
D)specific orders

Question 17

When a nurse puts data together in a new way,the process is called:

A)analysis
B)assessment
C)evaluation
D)synthesis

Question 18

A client reports leg pain when walking or standing,and occasional pain during periods of rest.This type of data is known as:

A)a defining characteristic
B)inadequate
C)objective
D)subjective

Question 19

The nurse performs an initial assessment of a client's physiologic needs followed by assessment of higher-level needs.This is an example of:

A)the body systems model
B)functional health patterns
C)the hierarchy of needs
D)human response patterns

Question 20

The nurse is gathering data about the client through physical examination and observation.This is an example of:

A)comprehensive data
B)thorough data
C)objective data
D)subjective data

Question 21

For a client whose nursing diagnosis is Pain related to surgical incision,one nursing intervention states,"The nurse will administer pain medication as ordered,and will anticipate times when additional PRN medication might be required." What type of nursing intervention does this represent?

A)actual
B)dependent
C)independent
D)interdependent

Question 22

A goal for a client who has the nursing diagnosis Anxiety related to hospitalization is "The client will verbalize end or alleviation of periods of anxiety within 2 days of hospitalization." What type of goal does this statement represent?

A)focused
B)long-term
C)ongoing
D)short-term

Question 23

Which of these statements about the relationship between nursing process and critical thinking is TRUE?

A)Critical thinking is important to the nurse primarily during the assessment phase.
B)Critical thinking is important to the nurse primarily during the evaluation phase.
C)The nurse must use critical thinking in every component of the nursing process.
D)The nursing process is primarily linear.

Question 24

A postoperative client is being encouraged to increase physical activity each day.After assisting the client to ambulate down the hall and back to his room,on which part of the medical record should the nurse document this information?

A)nursing progress notes
B)flow sheet
C)nursing care plan
D)client education record

Question 25

Which of the following purposes for client documentation,an essential communication tool,is MOST important?

A)It forms the basis for health care students learning about disease processes,medical and nursing diagnoses,and interventions.
B)It confirms the care provided to the client and outlines crucial information about the client.
C)It directs the need for research.
D)It notifies the health care provider and other health care team members about significant data obtained during nurse-client interaction.

Question 26

The legal aspects of documentation require which of the following?

A)factual and time-sequenced descriptive entries
B)legible printing
C)proof or evidence of any form of malpractice or negligence that occurs during a client's stay
D)lack of abbreviations

Question 27

Using Maslow's hierarchy of needs to prioritize nursing diagnoses,which of these nursing diagnoses should the nurse focus on LAST?

A)Airway clearance,ineffective,related to excessive secretions
B)Anxiety related to unknown outcome of illness
C)Coping,individual,ineffective,related to loss of independence
D)Self-care deficit,feeding,related to decreased strength and endurance

Question 28

When a nursing care plan is implemented,the nurse in charge may ask specific staff members or assistive personnel to perform selected nursing tasks.This process is known as:

A)delegation
B)implementation
C)interdisciplinary action
D)process

Question 29

A client has a nursing diagnosis of Knowledge deficit (insulin injection technique)related to misinterpretation of information as evidenced by inaccurate return demonstration of self-injection.After several teaching sessions the client can self-inject insulin correctly and confidently.This nursing diagnosis is removed from the plan of care and others are addressed.What type of planning is this called?

A)discharge
B)goal
C)initial
D)ongoing

Question 30

Which step of the nursing process involves the execution of the nursing implementations derived from the nursing care plan?

A)assessment
B)evaluation
C)implementation
D)planning

Question 31

After completing a client's admission database,the nurse develops a plan of care to address each of the client's problems.This is known as what type of planning?

A)discharge
B)goal
C)initial
D)ongoing

Question 32

A client's morning glucose level is 46%.The facility has an order approved by a health care provider that states,"The nurse will administer 6 ounces of orange juice and repeat the glucose level in 30 minutes if below 60." This type of standardized intervention is known as what type of order?

A)emergency
B)health care provider
C)specific
D)standing

Question 33

Client documentation can be used as an educational tool by which of these persons or groups?

A)health care students
B)sociologists
C)the client and family
D)medical anthropologists

Question 34

Which step of the nursing process involves determination of how successfully the client goals have been met?

A)assessment
B)evaluation
C)implementation
D)planning

Question 35

For a client whose nursing diagnosis is Pain related to surgical incision,one nursing intervention states,"Teach client to support or splint abdominal incision with pillow when coughing or moving." What type of nursing intervention does this represent?

A)actual
B)dependent
C)independent
D)interdependent

Question 36

Client documentation is important to medical researchers because it:

A)confirms the care provided to the client
B)determines whether clients meet criteria for a study
C)satisfies legal and practice standards
D)verifies the administration of tests,procedures,and treatments and confirms results

Question 37

A client who had hip replacement surgery yesterday has a nursing diagnosis Pain related to hip replacement surgery.Which of these would represent a long-term goal for this client?

A)"Client will verbalize relief of pain by the third postoperative day."
B)"Client will be pain-free by discharge."
C)"Client will request pain medication less frequently by the second postoperative day."
D)"Client will express desire to use alternative methods of pain relief as soon as possible."

Question 38

The multidisciplinary and standard plans of care for specific case situations have the overall goal of to improve the quality and efficiency of client care.This is an example of:

A)critical pathways
B)goal-oriented care plans
C)linear care directories
D)multidisciplinary action diagrams

Question 39

Using the Alfaro-LeFevre approach to prioritizing nursing diagnoses,which of these nursing diagnoses should the nurse focus on first?

A)Airway clearance,ineffective,related to excessive secretions
B)Anxiety related to unknown outcome of illness
C)Coping,individual,ineffective,related to loss of independence
D)Self-care deficit,feeding,related to decreased strength and endurance

Question 40

A nurse receives a report from the microbiology department that a client's blood culture is positive for gram-negative rods.The client is not on antibiotics.Which of these steps should the nurse take FIRST?

A)Document the result in the appropriate area of the chart.
B)Inform the client that the cause of illness has been identified.
C)Notify the health care provider,and document the results and the time the health care provider was notified.
D)Place the laboratory report on the client's chart as soon as possible.

Question 41

Which of these nursing documentation methods take an unstructured approach to documenting on the client record and often present disorganized client information?

A)charting by exception and critical pathways
B)computerized documentation and point-of-care charting
C)narrative and source-oriented charting
D)SOAP (-IE,-IER)and PIE charting

Question 42

What is the relationship between nursing practice acts and documentation?

A)Nursing practice acts establish guidelines for practice and standards of care that are evidenced by documentation.
B)Documentation ensures safe practice.
C)Documentation and nursing practice requirements differ from state to state.
D)Nursing practice acts are independent of documentation requirements.

Question 43

Which statement BEST describes how the assessment and the diagnosis steps of the nursing process are related?

A)If insufficient data is collected,then the problem may not be accurately identified.
B)After the problem is decided,the nurse should do an assessment to validate the data.
C)Once the nurse knows about the client,actions can be planned to fit the client's lifestyle.
D)Assessments need to be done repeatedly to determine if the goals have been met.

Question 44

Advance directives differ from informed consent in that advance directives:

A)are guidelines to be used only if a client cannot make medical decisions for him- or herself
B)are only used for specific procedures and expire after the procedure is performed
C)can be obtained from a client who is sedated,while informed consent cannot
D)only apply to medical treatments and interventions and cannot be used to direct future nursing care

Question 45

Which term describes a method of evaluating the quality of care provided to clients that addresses both quality of individual care and overall care in a health facility?

A)nursing process
B)critical thinking
C)discharge summary
D)nursing audit

Question 46

Which of the following is a key factor in many malpractice cases?

A)incomplete incident reports
B)inadequate documentation
C)absence of signed informed-consent forms
D)lack of nursing diagnoses for clients

Question 47

Which forms of nursing documentation use the nursing process through problem-oriented charting?

A)charting by exception and critical pathways
B)computerized documentation and point-of-care charting
C)narrative and source-oriented charting
D)SOAP (-IE,-IER)and PIE charting

Question 48

In addition to recording,which of these communication tools is based on the nursing process,standards of care,and legal and ethical principles?

A)nursing diagnosis
B)reporting
C)nursing history
D)flow sheets

Question 49

The Joint Commission now requires which of the following to be documented in the client record?

A)evidence of informed consent to participate in the plan of care
B)the process by which the plan of care is developed
C)an individualized plan of care for the client
D)the number of health care professionals who participated in development of the care plan

Question 50

Subjective data differs from objective data in that subjective data is usually:

A)concretely measurable
B)obtained from the client
C)observable
D)totally unreliable

Question 51

A nurse mistakenly gives a client an additional dose of medication.Which of these actions should the nurse take?

A)Notify the pharmacy and the client's health care provider.
B)Complete an incident report,and place a copy in the client's chart.
C)Document in the nurse's notes the name and dosage of the medication,time given,client's response,and the name of the health care provider and the time this person was notified.
D)Report the incident to the immediate supervisor.

Question 52

When a nurse completes a client's discharge summary,which of these data should be included?

A)intervention and education outcomes
B)problems encountered with the client's family
C)number of incident reports involving the client
D)results of specialized treatments and diagnostic tests

Question 53

While giving an end-of-shift report at 1915,a nurse realizes that a client's physical therapy session that occurred at 1030 was not documented.Which of the following is the correct method for adding this information to the client record?

A)Ask the oncoming nurse to make the notation for you.
B)Date and time the entry for 1915;then write "Late Entry (date-1030)" before making the addition.
C)Do not add the information to the chart,but complete an incident report.
D)Do nothing,since the physical therapist documented the session in the multidisciplinary progress notes.

Question 54

Which of the following statements about the client Kardex is true?

A)Only nursing orders are recorded on it.
B)Personal data such as sex,age,marital status,and religious preference are noted on it.
C)It is part of the medical record.
D)It is sent home with the client upon discharge.

Question 55

If a nurse makes a mistake while charting,which of these actions is correct?

A)Black out the entry so that it cannot be read;then date,time,and initial the entry.
B)Cross out the entry with a single line;then write "mistaken entry" with date,time,and initials.
C)Erase the entry if possible.
D)Use correction fluid to obliterate the incorrect entry;then enter the correct notation over the previous one.

Question 56

Which of these terms is used when goals are not met or interventions are not performed within the established time frame while using a critical pathway?

A)critical events
B)exception charting
C)incident reports
D)variances

Question 57

Which of these statements about informed consent and documentation is TRUE?

A)Clients who have been sedated must have the consent form witnessed by a family member.
B)Clients who decline to have any specific treatment performed are not required to sign an informed consent form.
C)There is no legal requirement for informed consent to be written.
D)Informed consent must be obtained by a health care professional.

Question 58

Reimbursement from insurance companies can be denied or reduced when a nurse fails to document which of the following?

A)client phone calls
B)nursing diagnoses
C)equipment used or procedures performed
D)physician rounds

Question 59

Which statement BEST explains how a framework can be helpful for collecting assessment data?

A)The framework lists every question to ask the client so that the nurse will not forget.
B)The framework allows the nurse to organize the data and helps determine the priority focus.
C)Each nurse creates his or her own framework so that all of the assessments are the same.
D)The framework will provide the nurse with the appropriate interventions to implement.

Question 60

Which of these categories are included in a nursing minimum data set?

A)a client's major complaint and a listing of any known allergies
B)nursing interventions classification
C)demographics,service,and nursing care
D)nursing diagnoses

Question 61

Which statement describes data that is from a primary source?

A)The client's wife said that he had these symptoms for months.
B)The old chart has a note that the client denies any previous heart attacks.
C)The admitting nurse stated that the client was in severe pain when admitted yesterday.
D)The client says he came to the hospital because he is too short of breath to sleep.

Question 62

Which functional health pattern would be MOST appropriate to use to categorize this data: client is awake,alert,and oriented.

A)sleep and rest pattern
B)health management pattern
C)cognitive and perceptual pattern
D)activity and exercise pattern.

Question 63

The nurse is planning to initiate a phone call to the client's physician regarding a change in status.Which of the following should the nurse ensure would be done prior to making the call? (Select all that apply. )

A)Ensure that all lab reports are back.
B)Ask another nurse their opinion prior to calling.
C)Ask the charge nurse to complete the call for you.
D)Wait until the end of the shift and consult with the next nurse.
E)Have the client's assessment data available.
F)Minimize the chance of interruptions during the call.

Question 64

Which of the following statements could be included in a definition of nursing diagnosis?

A)directly derived from pathological changes
B)directly derived from client responses
C)highly dependent on diagnostic test results
D)purpose is to remove or modify the cause of the disease