The charge nurse is evaluating patient documentation of a new ...

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The charge nurse is evaluating patient documentation of a new staff nurse. Based on which of the following does the charge nurse note, on review of the new nurse's charting, that appropriate documentation is evident?
 
  a. A pencil was used to make the entries.
  b. Correction fluid was used to correct written errors.
  c. An error made by the attending physician was documented.
  d. All of the entries he or she made in the record were dated and signed.

Question 2

When discussing spirituality with adolescent clients, the nurse is aware that which of the following is true regarding clients in this age group?
 
  a. They often have a good concept of a supreme being.
  b. They question religious practices and values.
  c. They fully accept the higher meaning of their faith.
  d. They give of themselves to others as spiritual tasks.

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Answer to Question 1

D

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A All entries should be recorded legibly and in black ink, because pencil can be erased.
B The nurse should never erase entries or use correction fluid, and never use a pencil. The use of correction fluid could render the charting illegible, and it might appear as if the nurse were attempting to hide something or deface the record.
C If the physician made an error, the nurse should not document it in the patient's chart; the error should be documented in an incident report.
D Each entry should begin with the time of entry and end with the signature and title of the nurse who recorded the entry.

Answer to Question 2

B
Adolescents often reconsider their childlike concept of a spiritual power, and in the search for an identity, they may either question practices and values or find the spiritual power as the motiva-tion to seek a clearer meaning to life.
Adolescents do not necessarily have a good concept of a supreme being. This occurs as people mature.
Adolescents do not necessarily fully accept the higher meaning of their faith.
Older adults, not adolescents, often turn to important relationships and the giving of themselves to others as spiritual tasks.

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