Author Question: The nurse is reviewing a client's chart. When reading the history, physical, and physician progress ... (Read 56 times)

BrownTown3 · **on:** Jul 23, 2018

The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following?

A) The physician's assessment and treatment
B) Results of laboratory and diagnostic studies
C) Nursing documentation and plan of care
D) Information from other members of the health care team

Question 2

The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone.

Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care

A) ISBAR
B) EMAR
C) SOAP
D) CBE

Ddddd · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: A

The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

Answer to Question 2

Ans:
Feedback:
The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.