Deck 5: Nursing Process and Documentation

Question 1

The patient tells the nurse that everything "tastes funny" since starting a new medication, making eating unpleasant. The nurse has given this medication to other patients and has not heard this complaint from any of them. The nurse checks the drug reference again to learn whether this is a known side effect of the medication and reads that it is. This information may be helpful in making a nursing diagnosis and determining how best to address this problem. Which data from this scenario is considered subjective?

A) The nurse rechecks the drug reference about known side effects of the medication.
B) The patient tells the nurse that everything "tastes funny."
C) The nurse reads that this medication can cause a metallic taste in some patients.
D) Other patients who have taken this medication have never reported this side effect to the nurse.

Answer 1

The patient tells the nurse that everything "tastes funny."

Question 2

A hospital is considering changing its documentation system to reduce the number of medication errors. Which system should the hospital investigate?

A) Problem, intervention, evaluation (PIE) system
B) Electronic medical record
C) Problem-oriented medical record
D) Narrative system

Answer 2

Electronic medical record

Question 3

Which aspect of critical thinking would the nurse use when making a nursing diagnosis?

A) Making decisions about an action
B) Identifying potential and actual problems
C) Increasing the likelihood of obtaining good results
D) Getting a better understanding of someone else

Answer 3

Identifying potential and actual problems

Question 4

When asking a patient if a pain medication provided a few hours ago has been effective, the nurse is performing which step of the nursing process?

A) Planning
B) Implementation
C) Evaluation
D) Assessment

Question 5

Which statement represents a nursing diagnosis?

A) High risk for delayed maternal-infant bonding due to maternal-infant separation
B) Crohn's disease
C) Hypertension
D) Appendicitis

Question 6

Critical thinking empowers the nurse to recognize important situational cues and respond quickly to adapt interventions, optimizing their effectiveness and the likelihood of a good outcome. What is true about this aspect of critical thinking?

A) This method of thinking is similar to the way that a skilled nurse uses continued assessment and evaluation to adapt the patient's care plan.
B) Using this method of critical thinking produces only one correct solution to a problem.
C) The need to change the plan of care indicates that critical thinking and the nursing process are not compatible.
D) The statement proves that critical thinking is another term for the nursing process.

Question 7

The nurse is using the Kardex to plan a patient's care. What information would the nurse expect to find in this document?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Nursing notes from the previous shift
B) Schedule of diagnostic tests
C) Level of activity
D) Diet
E) IV therapy

Question 8

A nurse manager is discussing documentation standards that reflect Joint Commission safety goals. Which information should the manager share with staff nurses?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) "The documentation of assessment of infants and children should reflect standardization of assessment techniques."
B) "Documentation should reveal that patients are reassessed according to hospital policy."
C) "Education about pain and pain management should be documented on all appropriate patients."
D) "Assessment documentation should make it clear that the assessment was conducted by a registered nurse."
E) "Traditional care plans should be documented for each patient."

Question 9

The nurse is using critical thinking to better understand a patient. The nurse is working in which part of the nursing process?

A) Implementation
B) Nursing diagnosis and outcome identification
C) Assessment
D) Planning

Question 10

While assessing a female patient from the Middle East, the nurse observes that the patient makes no eye contact and answers questions by nodding or with only a few words. The nurse's entry in the patient's record states that the patient "appears to be frightened." This is an example of which factor associated with assessment?

A) Personal interpretation
B) Subjective data
C) Nursing diagnosis
D) Objective data

Question 11

A 16-year-old patient has been admitted for treatment of presumptive pelvic inflammatory disease. The patient's hygiene is poor and she reports living "on the street" for a year. She is febrile and tachycardic and reports pain as 10 on the 1-to-10 scale. The nurse identifies Acute Pain as the priority nursing diagnosis. Which outcome statement is appropriate?

A) The patient's comfort will be achieved and maintained.
B) The patient will be discharged to a safe living environment.
C) The patient will be reunited with her parents.
D) The patient's infection will be eradicated.

Question 12

A nursing unit has changed its documentation system to documenting by exception. How will this system save time?

A) It eliminates lengthy or repetitive documentation.
B) It allows flexibility and description in the documentation.
C) It allows the reader to easily locate information about a specific problem.
D) It allows for quick and easy retrieval of information.

Question 13

The nurse is caring for a 70-year-old patient who was just admitted to an inpatient rehabilitation center. The patient had required total parenteral nutrition for several days, but recently resumed and is tolerating a regular diet. She has another 4 days left in a course of intravenous antibiotics to complete treatment of a positive central line culture. Which nursing action, required in the care of this patient, is considered a dependent role function?

A) Requesting that the health care provider order a consult because the patient states that her dentures no longer fit properly and she has trouble chewing
B) Asking the nursing assistant to demonstrate to the patient how to operate the call system
C) Interviewing the patient to assess whether she needs assistance with getting out of bed
D) Administering the antibiotics prescribed by the health care provider

Question 14

The nursing instructor knows that further education is needed when a student makes which statement?

A) "Assessment precedes nursing diagnosis and outcome identification."
B) "Planning follows nursing diagnosis and outcome identification and precedes implementation."
C) "Evaluation follows implementation and precedes planning."
D) "Planning follows assessment and precedes evaluation."

Question 15

Which nursing activities are examples of independent functions of the nursing role?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Teaching a soon-to-be-discharged patient about the medication regimen that the health care provider has prescribed
B) Talking with the patient about his or her abilities to manage personal hygiene activities while in the usual state of health at home
C) Incorporating adaptive techniques into nursing care as recommended by occupational therapy
D) Administering analgesic medication ordered by the health care provider
E) Introducing oneself to, and interviewing, the patient to collect data about physical health status

Question 16

Which statements reflect collaborative problems?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Knowledge deficit related to infant safety as evidenced by mother leaving crib rail down
B) Sleep apnea
C) Neonatal abstinence syndrome
D) Gestational diabetes
E) Sleep pattern disturbance related to hospital environment and routines

Question 17

The nurse is providing care for a patient who is unhappy with the health care provider's care. The patient signs the Against Medical Advice (AMA) form and leaves the hospital against medical advice. What should the nurse include in the documentation of this event in the patient's medical record or on the AMA form?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Documentation that the patient was informed that he or she cannot come back to the hospital
B) Documentation that the patient was informed that he or she was leaving against medical advice
C) Documentation that the risks of leaving against medical advice were explained to the patient
D) Documentation of any discharge instructions given to the patient
E) Documentation indicating an incident report has been completed

Question 18

According to the Health Insurance Portability and Accountability Act (HIPAA), which persons have legal access to the patient's health record?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) The patient
B) Any nurses working on the unit where the patient is hospitalized
C) Any physician who has credentials to admit patients to the hospital
D) The respiratory therapist who is providing inhalation therapy for the patient
E) The nuclear medicine technician who provided care during the patient's last hospitalization