A client is being transferred to a subacute care facility. A printed copy of the electronic medical record is sent with the client. Which documents should be included in the client's legal health record? (SELECT ALL THAT APPLY)

Event/unusual occurrence reports

Physician/nurse practitioner orders

Living will

Vital sign flow records

Proof of residence or deed to their home

Nurses assessments

Answer and Explanation

Correct Answer : B,C,D,F

B. Physician and nurse practitioner orders specify the medical treatments, medications, and interventions prescribed for the client. These orders are essential for guiding care at the subacute care facility and are a critical part of the legal health record.

C. A living will, also known as an advance directive, outlines the client's preferences for medical treatment and care in the event they are unable to communicate their wishes. It is a legal document that guides decision-making regarding end-of-life care.

D. Vital sign flow records document the client's vital signs over time, including measurements such as blood pressure, heart rate, respiratory rate, and temperature. These records are essential for monitoring the client's health status and detecting trends or changes.

F. Nurses' assessments document the nursing observations, assessments, and interventions provided to the client. These assessments are crucial for ongoing nursing care and should be included in the legal health record.

A. Event or unusual occurrence reports document any incidents or deviations from the standard of care that occur during the client's hospitalization. These reports are important for quality improvement and risk management but are typically not included in the legal health record unless they directly impact the client's care.

E. Proof of residence or property ownership documents are not typically included in the legal health record. These documents are unrelated to the client's medical care and are considered personal or administrative records.

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Correct Answer is ["1705"]

Explanation

To calculate the cumulative fluid intake for the client from 3 p.m. to 11 p.m., convert all measurements to the same unit and then sum them up.

First, convert ounces to milliliters (1 ounce = 29.5735 ml). The tea is 4 ounces, which is approximately 118 ml, and the soda is 6 ounces, approximately 177 ml.

Add all the liquid intake: chicken broth (120 ml) + tea (118 ml) + ice cream (assumed to be 240 ml for 1 cup) + soda (177 ml) + water (550 ml) + half the volume of ice chips (as half the volume of ice chips is water, so 250 ml). The total intake is 120 + 118 + 240 + 177 + 550 + 500= 1705 ml.

Since the intake and output are calculated at 2200, and the client has not consumed anything after 2115, the cumulative fluid intake for the shift is 1705 ml.

A. Introductory B. Noncongruent C. Nonverbal D. Congruent

Correct Answer is D

Explanation

D. Congruent communication occurs when verbal and nonverbal messages are consistent with each other. In the scenario, the nurse's direct eye contact, pleasant expression, and verbal statement ("The colostomy looks good") appear to be aligned and supportive of each other. This demonstrates congruence in communication, where both verbal and nonverbal cues are reinforcing a positive message to the client.

A. Introductory communication typically refers to the initial phase of interaction where the nurse establishes rapport, introduces themselves, and sets the tone for the interaction. This does not directly apply to the nurse's actions described in the scenario of changing a client's colostomy bag.

B. Noncongruent communication occurs when there is a mismatch between verbal and nonverbal messages. In this scenario, the nurse makes direct eye contact, has a pleasant expression, and verbally reassures the client that "the colostomy looks good." If these nonverbal cues (eye contact, pleasant expression) are not aligned with the verbal message (reassuring statement), it would be noncongruent communication. However, based on the scenario, it seems the nurse's nonverbal cues (eye contact, pleasant expression) support the verbal message, so this option is less likely.

C. Nonverbal communication includes gestures, facial expressions, eye contact, body language, and tone of voice. In the scenario described, the nurse demonstrates nonverbal communication by making direct eye contact and having a pleasant expression while interacting with the client. Nonverbal communication is an important aspect of nursing care as it conveys empathy, reassurance, and attentiveness to the client's needs.

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A client is being transferred to a subacute care facility. A printed copy of the electronic medical record is sent with the client. Which documents should be included in the client's legal health record? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1705"]

Explanation

The nurse makes direct eye contact and has a pleasant expression on her face when changing a client's colostomy bag. The nurse tells the client, "The colostomy looks good." What type of communication is the nurse demonstrating?

Correct Answer is D

Explanation

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