Question 1

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

Accepted Answer

The answer of To limit liability, nursing documentation must clearly...

Question 2

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?

Accepted Answer

A) The patient's parents 
B) The patient's significant other only 
C) No one in the hospital until the patient says so 
D) The patient's physician, significant other, and laboratory personnel

Question 3

__________________ documentation should include your observations of patient behavior.

Accepted Answer

The answer of __________________ documentation should include your observations of...

Question 4

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

Accepted Answer

The answer of ________________ provide a quick, easy reference for...

Question 5

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?

Accepted Answer

A) Document the 1000 vital signs in the graphic record only. 
B) Not report the incident because it was a transient episode. 
C) Document the vital signs in the graphic and progress record. 
D) Document the vital signs as 12 o'clock signs.

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 _____________________.

__________________ documentation should include your observations of patient behavior.

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