Author Question: Before the end of the shift, the nurse records the occurrences for each patient in the electronic ... (Read 42 times)

ENagel · **on:** Jul 23, 2018

Before the end of the shift, the nurse records the occurrences for each patient in the electronic medical record. Which statement below indicates that the nurse understands the main principle of accurate charting?

a. Charting communicates to members of the healthcare team the patient's care and responses during my shift.
b. Charting is important so that I may share with the healthcare team my opinions of what happened with the patient.
c. Charting allows the other nurses to understand the patient care provided during my shift.
d. Charting is important to comply with practice guidelines and institutional policies.

Question 2

Identify interventions that would be effective when assisting a client in making behavior changes that would reduce his health risk factors. Select all that apply.

a. Ask the client to follow a plan you wrote for him.
b. Have the client identify two or three goals for change.
c. Help the client to understand the benefits of change.
d. Allow the client to identify available support and resources within the community.

stallen · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

A
Accurate charting is needed to clearly communicate the patient's care and responses to other members of the healthcare team, not just the other nurses. This statement reflects the nurse's understanding of this principle. The nurse's opinions are not to be placed in a chart because they are not factual. While charting is important to comply with standards of practice and institutional policy, it is not the main principle of accurate charting.

Answer to Question 2

B, C, D
Nurses have been recognized as leaders in health promotion for a long time. The nurse's role is to motivate clients and facilitate change. You will need to help clients to identify goals that are individualized. To create positive change, the client will need to understand the benefits of change, and most will need support to make the change.