Author Question: Which of the following nursing notations shows the best understanding regarding the need to document ... (Read 58 times)

saliriagwu · **on:** Jul 23, 2018

Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data?

1. Client was angry because breakfast was not to her liking.
2. Client is depressed; was observed crying while alone in room.
3. Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists.
4. Client was verbally abusive to staff when approached concerning client's con-tinued attempts to smoke in the bathroom.

Question 2

Which of the following nursing statements regarding the release of a client's medical record to another institution requires immediate follow-up by the nurse's manager?

1. I'm pretty sure this will require the client's permission.
2. Are you sure of the exact policy? Do you know what I should do?
3. The client agreed to the consultation, so I'll have the chart sent over.
4. I think the client will need to give a verbal consent before it can be sent.

nhea · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 3
Do not write personal opinions. Document observable, measurable client-oriented data only. The remaining options either make assumptions regarding observed client behavior or fail to objec-tively describe the noted client behavior.

Answer to Question 2

ANS: 3
Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information. The other options have the nurse asking for help or expressing doubt about the proper protocol for the release of the rec-ords; these would be appropriate statements and the manager should provide the correct infor-mation.