A client has specific cultural needs that affect the plan of care. In which part of the client's problem-oriented medical record should the nurse document this information?
1. Database
2. Problem list
3. Plan of care
4. Progress notes
Correct Answer: 2
Rationale 1: The database includes information about the client when admitted to the facility.
Rationale 2: The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs.
Rationale 3: The plan of care is made with reference to the active problems.
Rationale 4: Progress notes are chart entries made by all health professionals involved in a client's care.
You might also like to view...
A patient recovering from a partial spinal cord lesion is experiencing muscle spasticity. Relative to this complication, what is the nursing priority?
A) Monitor neurologic status every 4 hours B) Ensure compliance with exercise program C) Medicate often for pain and discomfort D) Emphasize nutritional balance
The patient is receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP). He complains of a "spasmlike" pain over his lower abdomen
Which of these actions should the nurse perform first in response to this complaint? a. Inform the nurse in charge. b. Decrease the continuous bladder irrigation flow. c. Administer the prescribed analgesic. d. Check the catheter and drainage system for obstruction.
The use of garlic is contraindicated in patients taking which drug?
a. Acetaminophen (Tylenol) b. Warfarin (Coumadin) c. Aluminum hydroxide (ALternaGEL) d. Gentamicin (Garamycin)
An adolescent client with type I diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?
a) sweating and tremors b) hunger and hypertension c) cold, clammy skin and irritability d) fruity breath and decreasing level of consciousness