When attempting to locate recent lab results, the new nurse employee notices that each department has a separate section in the client's chart. Which type of documentation system is the nurse using?
1. Source-oriented record
2. Problem-oriented record
3. Case management
4. Focus charting
Correct Answer: 1
Rationale 1: The traditional client record is a source-oriented record in which each person or department makes notations in a separate section or sections of the client's chart.
Rationale 2: In the problem-oriented medical record, the data are arranged according to the problems the client has rather than the source of the information.
Rationale 3: Case management uses a multidisciplinary approach to documenting client care, called critical pathways.
Rationale 4: Focus charting is intended to make the client and client concerns the focus of care, utilizing a three-column format.
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1. Bleeding and inflamed gums. 2. Smooth and shiny tongue. 3. Red, swollen tonsils. 4. Ulcerations on the lip or under the tongue.
A 12-year-old child with Down syndrome is admitted to the hospital for surgical correction of a heart defect. The boy's mental age is that of a 3-year-old child. The nurse should prepare the child and family for surgery by what method?
a. Extend preoperative teaching over several days. b. Explain the surgery to the child and the parents in detail. c. Exclude the child from preoperative teaching; teach only the parents. d. Provide teaching to the parents, keeping the information to the child simple.
The nurse is preparing to conduct an abdominal assessment on a client and realizes that this assessment should be performed in the order of:
1. inspection, palpation, auscultation, and percussion. 2. inspection, auscultation, percussion, and palpation. 3. auscultation, palpation, percussion, and inspection. 4. percussion, palpation, inspection, and auscultation.
Ordered: Ibuprofen 800 mg po qid for 30 daysOn hand: Ibuprofen 400 mg tablets Calculate the amount to dispense: ________.
Fill in the blank(s) with the appropriate word(s).