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Ans 3 do not write personal opinions document

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ANS: 3Do not write personal opinions. Document observable, measurable client-oriented data only. Theremaining options either make assumptions regarding observed client behavior or fail toobjectively describe the noted client behavior.DIF: C REF: 388-389 OBJ: AnalysisTOP: Nursing Process: PlanningMSC: NCLEX test plan designation: Safe, Effective Care Environment20.Which of the following nursing notations shows the greatest need for instruction regardingthe need to document only objective client assessment data?1Client was angry because breakfast was not to her liking.2Client is depressed; was observed crying while alone in room.3Client expressed pain as an 8 out of 10, was diaphoretic,guarding her abdomen and clenching her fists.4Client was verbally abusive to staff when approachedconcerning clients continued attempts to smoke in thebathroom.ANS: 2Do not write personal opinions. Document observable, measurable client-oriented data only.Recording that the client is depressed based on the observation of tears is not objective and so isnot acceptable. While one option does report only observable, measurable behavior, theremaining options, while noting observed client behavior, do fail to objectively describe thenoted client behavior.Downloaded by Theresa Vu ([email protected])lOMoARcPSD|13002207
Stuvia.com - The Marketplace to Buy and Sell your Study MaterialStuvia.com - The Marketplace to Buy and Sell your Study MaterialDIF: C REF: 388-389 OBJ: AnalysisTOP: Nursing Process: AssessmentMSC: NCLEX test plan designation: Safe, Effective Care Environment21.Which of the following statements made by a nurse most reflects a need for additionalinstruction on areas of client care requiring nursing documentation?1The fact that the client refused the prescribed antidepressantmedication was noted in his chart.2I provided a detailed description of the dressing change in theclients chart in order to show it was done as prescribed.3The clients wife told me he often develops a rash when hecomes into contact with scented soaps, so I noted that in hischart.4I had a long conversation with the client concerning his fearsabout his upcoming surgery and I mentioned his concerns inmy nursing note.ANS: 2Common charting mistakes that can result in malpractice include the following: (1) failing torecord pertinent health or drug information; (2) failing to record nursing actions; (3) failing torecord that medications have been given; (4) failing to record drug reactions or changes in clientscondition; (5) writing illegible or incomplete records; and (6) failing to document a discontinuedmedication. Detailed descriptions of procedures are not included in the nursing notes.

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Nursing, Theresa Vu

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