NUR 155 Exam 1 (Units 1 & 2) QUESTIONS AND ANSWERS

Which action by a nurse ensures confidentiality of a client's computer record? 1. The nurse logs on to the client's file and leaves the computer to answer the client's call light. 2. The nurse shares her computer password. 3. The nurse closes a client's computer file and logs off. 4. The nurse leaves client computer worksheets at the computer workstation. Answer: 3 Rationale: All of the other answers endanger the client's confidentiality. The case management model using critical pathways would be appropriate for a client with which diagnosis? 1. Myocardial infarction (heart attack) 2. Diabetes, hypertension 3. Myocardial infarction, diabetes, hypertension 4. Diabetes, hypertension, an infected foot ulcer, senile dementia Answer: 1 Rationale: Critical pathways work best for clients with one diagnosis. After making a documentation error, which action should the nurse take? 1. Use correcting liquid to cover the mistake and make a new entry. 2. Draw a line through it and write error above the entry. 3. Draw a line through it and write mistaken entry above it. 4. Draw a line through the mistake and write mistaken entry with initials above it Answer: 4 Rationale: It is the most complete answer. The client's record is a legal record and should not be altered with correcting liquid. You may see "error" written above a mistake even though many authors suggest not writing it. It is important to also put your name or initials next to the words of the mistaken entry. During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client's blood pressure (BP) seems high. What is the next step? 1. Ask the client about past blood pressure ranges. 2. Review the graphic record on the client's record. 3. Examine the medication record for antihypertensive medications. 4. Review the progress notes included in the client's record. Answer: 2 Rationale: The graphic record provides the trend of the vital signs. Option 1, verbal information, is not appropriate for validation assessment that is measurable. This is more appropriate for pain or dizziness. The medication record would not include documentation of blood pressure ranges (option 3). The progress notes (option 4) provide information about how the client is progressing. It may have information about the client's BP if it was a problem. The best answer is option 2. A student nurse observes the change-of-shift report. Which behavior(s) by the reporting nurse represents effective nursing practice? Select all that apply. 1. Provides the medical diagnosis or reason for admission. 2. States the time the client last received pain medication. 3. Speaks loudly when giving report. 4. States priorities of care that are due shortly after the report. 5. Reports on number of visitors for each client. Answer: 1, 2, and 4 Rationale: Option 3 is incorrect because it could be a HIPAA violation if others hear protected health information. Option 5 is not needed unless it is a concern and it would not be done for every client. Which charting entries are written correctly? Select all that apply. 1. MS 5 gr given IV for c/o abdominal pain 2. Lanoxin 0.25 mg given orally per Dr. Smith's stat order 3. KCl 15 mL given orally for K+ level of 2.9 4. Regular insulin 10.0 u given SQ for capillary blood glucose of 180 5. Ambien 5 mg given orally at bedtime per request Answer: 2, 3, and 5 Rationale: Option 1: "MS" is on the "Do Not Use" list—the nurse needs to write out morphine sulfate. Option 4 has three errors—should not have a trailing zero after the decimal point; "u" and "SQ" are on the "Do Not Use" list. A 74-year-old female is brought to the emergency department c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client's inner thighs. Which of the following is the most appropriate documentation? 1. Six round skin lesions partially healed, on the inner thighs bilaterally 2. Several burned areas on both of the client's inner thighs 3. Multiple lesions on inner thighs possibly related to elder abuse 4. Several lesions on inner thighs similar to cigarette burns Answer: 1 Rationale: Option 1 is the most specific, non-assuming, and nonjudgmental charting. Option 2 could be more specific by describing the lesions and not calling them "burns." Option 3 is making a judgment of elder abuse, and option 4 is also making an assumption that the lesions are from cigarette burns Which charting rule(s) will keep the nurse legally safe? Select all that apply. 1. Use military time. 2. Document worries or concerns expressed by the client. 3. Perform most of the charting at the end of the shift. 4. Record only information that pertains to the client's health problems. Answer: 1, 2, and 4 Rationale: Military time is commonly used; documenting worries or concerns provides clues to other nurses; gossip, unprofessional comments or thoughts, or personnel issues should not be recorded in the client's chart. Option 3 is incorrect because charting should be done as events occur. Waiting until the end of the shift increases the chance of forgetting something. Which charting entry would be the most defensible in court? 1. Client fell out of bed 2. Client drunk on admission 3. Large bruise on left thigh 4. Notified Dr. Jones of BP of 90/40 Answer: 4 Rationale: Option 4 is the "best" answer although it could be more complete by adding the response of the primary care provider. Option 1 is too vague because it is not clear if the nurse found the client or was present when the client fell. Also, there is no need to write the word client because it is the client's chart. Option 2 is judgmental, revealing a negative attitude toward the person. It would be better to describe specific signs and symptoms such as staggering, slurred speech, and smell of alcohol on breath. Option 3 is too general and can be more specific by charting "2 cm × 3 cm purplish bruise on mid-inner thigh along with color." A nurse and a primary care provider inform a client that chemotherapy is recommended for a diagnosis of cancer. Which nursing action is most representative of the concept of holism? 1. Offer to come to the client's home to provide needed physical care. 2. Contact the client's spiritual adviser. 3. Inquire how this will affect other aspects of the client's life. 4. Provide the client with information about how to join a support group. Answer: 3 Rationale: Holism implies consideration of all aspects of the client's life. Although arranging for home care (option 1), facilitating spirituality (option 2), and offering coping resources (option 4) may be appropriate, the nurse begins a holistic approach to care by examining, with the client, in what ways the illness influences the various segments of her life. The client is the best source of information regarding personal needs. Assessment should always precede intervention. A nurse is planning a workshop on health promotion for older adults. Which topic will be included? 1. Prevention of falls 2. Cardiovascular risk factors 3. Adequate sleep 4. How to stop smoking Answer: 3 Rationale: Learning about sleep will increase the older adult's well-being, which is the focus of health promotion. Prevention of falls (option 1) is health protection because the focus is avoiding injury. Learning about cardiovascular risk factors (option 2) relates to health protection/disease prevention. How to stop smoking (option 4) focuses on health protection and avoiding illness. While hospitalized, a client is very worried about business activities. The client spends a great deal of time on the phone and with colleagues instead of resting. Which principle of need therapy applies to this client? 1. His higher level need cannot be met unless the lower level physiological need is met. 2. His lower level physiological needs are being deferred while higher needs are addressed. 3. The higher need takes precedence and the lower need no longer must be met. 4. It is necessary for someone else to meet his higher level needs so he can focus on the lower level needs. Answer: 2 Rationale: Choices are often related to learned experiences, lifestyle, and values. The client obviously values the business more than physical health. When a person feels strongly enough, a lower level need (rest) can be postponed until a higher level need (success, safety) is met. It is very likely that no one else can meet that need for him and the lower need must still be met eventually. Which statement by the client best represents the contemplation stage of the stages of behavior change? 1. "I currently do not need to exercise and do not intend to start in the next six months." 2. "I have tried several times to exercise 30 minutes three times a week but am seriously thinking of trying again in the next month." 3. "I currently do not exercise 30 minutes three times a week, but I am thinking about starting to do so within the next six months." 4. "I have exercised 30 minutes three times a week regularly for more than six months." Answer: 3 Rationale: A person in this stage recognizes there is a problem, is seriously considering changing, actively gathers information, and verbalizes plans to change in the near future. Option 1 reflects the precontemplation stage in which the person denies there is a problem. Option 2 reflects the planning stage in which the person makes final plans to accomplish the change, and option 4 is the maintenance stage in which the person made the change and demonstrates the appropriate behavioral change.