CLINICAL NURSING SKILLS AND TECHNIQUES, 10TH EDITION BY ANNE GRIFFIN PERRY ISBN- 978-0323708630 Chapter 4: Documentation and Informatics Verified 2024 Practice Questions and 100% Correct Answers with Explanations for Exam Preparation, Graded A+

CLINICAL NURSING SKILLS AND TECHNIQUES, 10TH EDITION BY ANNE GRIFFIN PERRY ISBN- 978-0323708630 Chapter 4: Documentation and Informatics Verified 2024 Practice Questions and 100% Correct Answers with Explanations for Exam Preparation, Graded A+ MULTIPLE CHOICE 1. 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? a. The patients parents b. The patients significant other only c. No one in the hospital until the patient says so d. The patients physician, significant other, and laboratory personnel ANS: D All members of the health care team are legally and ethically obligated to keep patient information confidential. Do not discuss the patients examinations, observations, conversations, or treatments with other patients or staff not involved in the patients care, unless permission is granted by the patient. DIF: Cognitive Level: Application REF: Text reference: p. 49 OBJ: Describe measures to maintain confidentiality of patient information. TOP: Confidentiality KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe and Effective Care Environment 2. Which of the following is the best example of objective charting? a. The patient states that he has been having severe chest discomfort. b. The patient is lying in bed and seems to be in considerable pain. c. The patient appears to be pale and diaphoretic and complains of nausea. d. The patients skin is ashen and respiratory rate is 32 and labored. ANS: D A record or report contains descriptive, objective information about what you see, hear, feel, and smell. An objective description is the result of direct observation and measurement, such as respiratory rate 20 and unlabored. Objective documentation should include your observations of patient behavior. For example, objective signs of pain include increased pulse rate, increased respiration, diaphoresis, and guarding of a body part. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patients exact words whenever possible. For example, you record, Patient states, my stomach hurts. Avoid terms such as appears, seems, and apparently, which are often subject to interpretation. For example, the description the patient seems to be in pain does not accurately communicate the facts to another caregiver. The phrase seems is not supported by any objective facts. DIF: Cognitive Level: Analysis REF: Text reference: p. 50 OBJ: List guidelines for effective communication and reporting. TOP: Objective Documentation KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity