Author Question: The student nurse is preparing a care plan for an assigned client. When writing the nursing diagnose ... (Read 170 times)

dakota nelson · **on:** Jun 25, 2018

The student nurse is preparing a care plan for an assigned client. When writing the nursing diagnose for this client, which elements are required?

Select all that apply.
1. Medical diagnosis.
2. Risk or related factors.
3. Defining characteristics.
4. A diagnostic label.
5. A definition.

Question 2

The health care organization is planning to change the type of documentation done on the client care units. The nurses have requested a system that will reduce time spent writing out routine tasks and will still allow for documentation of exceptions.

Which type of documentation will best meet the needs of the nursing staff?
1. Focus documentation.
2. Flow sheets.
3. SOAP charting.
4. APIE charting.

Briannahope · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 2, 3, 4, 5

The nursing diagnosis is composed of four components. These components are a diagnostic label, definition, defining characteristics, and risks or related factors. A medical diagnosis is not included in the nursing diagnosis.

Answer to Question 2

Correct Answer: 2

Flow sheets use columns or categories to log in assessment findings and to note interventions performed. Focused documentation records client problems and strengths. Flow sheets reduce repetition and are time efficient. Focused documentation records client problems and strengths. SOAP charting is detailed and includes subjective and objective data, assessment findings, and planning information. APIE charting includes assessment, planning, intervention, and evaluation.