Exam 4: Documentation and Informatics

To limit liability, nursing documentation must clearly indicate that the nurse provided individualized, goal-directed nursing care to a patient based on the _____________________.

The patient is a 24-year-old man who is diagnosed with possible HIV infection while being treated for active pneumonia.He has stated that the nurse may share test result information with his significant other but nothing else at this time.With whom may the nurse communicate regarding this information?

__________________ documentation should include your observations of patient behavior.

________________ provide a quick, easy reference for health care team members in assessing the patient's status.

Patients on the unit have their vital signs taken routinely at 0800, 1200, 1600, and 2000.At 1000, a patient complains of feeling "light-headed." The nurse takes the patient's vital signs and finds blood pressure to be lower than usual.Within 15 minutes, the patient says that he feels better.The nurse rechecks the blood pressure and finds that it is now back to normal.How should the nurse handle documentation for this episode?