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
Give this one a try later!
, 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.
Give this one a try later!
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.
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.
Give this one a try later!
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
Give this one a try later!
, 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.
Give this one a try later!
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.
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.
Give this one a try later!
