Chapter 18. Documenting & Reporting

Chapter 18. Documenting & Reporting

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client’s condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first?

a)	Study the discharge plan.
b)	Check the graphic data for vital signs.
c)	Examine the history and physical examination.
d)	Look for an advance directive.

 

 

ANS:  D

The advance directive, which should be located in a special section of the patient’s medical record, should be examined first because the patient’s symptoms indicate that he may need to be resuscitated. The advance directive contains information about the patient’s wishes for intensity of care and actions that should be taken in the event of a life-threatening event. The discharge plan contains data from utilization review, case managers, or discharge planners on anticipated needs after discharge. Graphic data record assessment should be done frequently, such as vital signs. The history and physical examination provide a detailed summary of the patient’s current problem, past medical and social history, medications taken by the patient, review of systems, and physical examination data.

 

Difficulty: Easy

Nursing Process: Assessment

Client Need: Safe and Effective Care

Cognitive Level: Application

 

PTS:   1

 

2. A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system?

a)	It involves a cooperative effort among various disciplines.
b)	The system requires diligence in maintaining a current problem list.
c)	Data may be fragmented and scattered throughout the chart.
d)	It allows the nurse to provide information in an unorganized manner.

 

 

ANS:  C

A major disadvantage of a source-oriented medical record is that data may be fragmented and scattered throughout the chart. The problem-oriented medical record requires a cooperative effort among disciplines and diligence in maintaining a current problem list. Narrative charting allows the nurse to provide information in a disorganized manner.

 

Difficulty: Moderate

Nursing Process: Interventions

Client Need: Safe and Effective Care

Cognitive Level: Knowledge

 

PTS:   1

 

3. A student nurse makes the following comments to her preceptor: “I love getting information from the chart. Everything related to the patient’s problem is together and addressed by various members of the healthcare team.” The student nurse has been introduced to which type of charting system?

a)	Narrative
b)	Focus
c)	Source oriented
d)	Problem oriented

 

 

ANS:  D

Narrative charting is a free text description of the patient status and nursing care, not usually organized according to patient problems. Focus charting highlights the patient’s concerns, problems, and strengths in a three-column format. Source-oriented record systems require members of each discipline to record their findings in a separately labeled section of the chart. A problem-oriented record system is organized around the patient’s problems and each member of the healthcare team document in the area designated for that problem. This method makes it easier to view the patient’s progress and integrate the interdisciplinary perspective.

 

Difficulty: Easy

Nursing Process: Interventions

Client Need: Safe and Effective Care

Cognitive level: Application

 

PTS:   1

 

4. The department of nursing at a local hospital is considering changing to charting by exception (CBE). A major disadvantage of CBE is that it:

a)	Increases the time nurses spend on charting in narrative format
b)	Does not clearly identify deviations from normal expectations
c)	Requires all providers to document in the same sections of the chart
d)	Can increase the risk of omissions in patient care

 

 

ANS:  D

A major disadvantage of CBE is that it can result in omissions in documenting client care because of either varying views of what is abnormal or deviations. Another disadvantage is that is does not capture the application of critical thinking by the nurse in the provision of care. CBE reduces the amount of time spent in charting because if nurses document only deviations from the normal CBE, then it is assumed that unless a separate entry is made, all standards have been met with a normal response.

 

Difficulty: Moderate

Nursing Process: Interventions

Client Need: Safe and Effective Care

Cognitive Level: Application

 

PTS:   1