A nurse manager is discussing documentation standards that reflect Joint Commission safety goals
Which information should the manager share with staff nurses? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "The documentation of assessment of infants and children should reflect standardization of assessment techniques.".
2. "Documentation should reveal that patients are reassessed according to hospital policy.".
3. "Education about pain and pain management should be documented on all appropriate patients.".
4. "Assessment documentation should make it clear that the assessment was conducted by a registered nurse.".
5. "Traditional care plans should be documented for each patient.".
2,3,4
Rationale 1: The assessment process for infants, children, and adolescents should be individualized.
Rationale 2: Each patient should be reassessed at points designated by hospital policy.
Rationale 3: The standard is that patients are educated about pain and pain management.
Rationale 4: The standard states that assessments must be performed by registered nurses.
Rationale 5: Traditional care plans are not required, but an individualized plan of care must be documented.
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In which of the following situations would the use of physical restraints most likely be justified?
A) Mr. Y is agitated and aggressive while he is experiencing severe withdrawal from alcohol and is not responding to chemical sedation. B) Mrs. U, who has a diagnosis of dementia, was found wandering outside the hospital and nurses have been unable to redirect her to stay on the unit. C) Mr. I is delirious during the acute stage of his urinary tract infection and is ringing the call bell nearly continuously. D) Mrs. T is frequently entering other patients' rooms and attempting to crawl into others' beds.
The critical piece of information related to the client's myocardium that is obtained through a PET scan is
a. electrical activity of the heart. b. myocardial viability. c. patency of coronary arteries. d. status of valves.
When appropriately addressing safety issues, the geriatric nurse plans the patient's care plan directed by the standard of care that requires
a. promoting both health and wellness by assuring safety. b. minimizing the patient's risk for physical injury while preserving autonomy. c. identifying safety from injury as a patient right. d. emphasizing beneficence as a an ethical standard of nursing care.
The nurse is caring for a client with an AV fistula. Upon assessment the nurse notes that the extremity with the fistula is pale and cool. The nurse would initially:
1. Auscultate the fistula. 2. Notify the health care provider. 3. Check vital signs. 4. Document the finding.