Exam 9: Nursing Processdocumentationinformatics

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

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

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?

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

Client documentation is important to medical researchers because it:

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

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?

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

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

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

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

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?

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

Which statement describes data that is from a primary source?

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?

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:

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

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