A nurse is a member of an interdisciplinary team that uses ...

[LCritchfi]

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair.
 
  What should the nurse do? a. Focus charting using the DAR format.
  b. Add this data to the problem list.
  c. Document the variance in the patient's record.
  d. Report a positive variance in the next interdisciplinary team meeting.

Question 2

A visiting nurse completes an assessment of the ambulatory client in the home and determines the nursing diagnosis of Risk for injury related to decreased vision.
 
  Based on this assessment, the client will benefit the most from which of the following actions? a. Installing fluorescent lighting throughout the house
  b. Evaluating the need to reposition furniture
  c. Maintaining complete bed rest in a hospital bed with side rails
  d. Applying physical restraints

[catron30]

Answer to Question 1

C
A variance occurs when the activities on the critical pathway are not completed as predicted, or the patient does not meet expected outcomes. An example of a variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A type of narrative format charting is focus charting. It involves the use of DAR notes, which include DData (both subjective and objective), AAction or nursing intervention, and RResponse of the patient (i.e., evaluation of effectiveness).

Answer to Question 2

B
Evaluating the positioning of furniture in the room and stairways is the best intervention to help prevent falls for the client with decreased vision.
Attempts should be made to reduce glare. Light bulbs that are 60 watts or less may be increased to 75 watts non-glare to help improve visibility. The best intervention to prevent falls is first to orient the client to the surroundings.
Maintaining complete bed rest is not the best option. Complete bed rest can cause other health problems because of a lack of mobility.
The client should not be restrained for poor vision. Attempts should be made to help compensate for the decreased vision to prevent falls.