A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?

Charting by exception (CBE).

Focus charting (DAR).

Problem-oriented medical record (POMR).

SOAP documentation.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Charting by exception (CBE) is a documentation method in which the nurse documents only unexpected findings or significant deviations from the client's normal condition. It is based on the assumption that the client's baseline status remains within the expected range, and deviations from this norm are documented. CBE is efficient and allows nurses to focus on relevant and critical information, reducing unnecessary documentation. It is particularly useful in clinical settings where frequent assessments are needed.

Choice B rationale:

Focus charting (DAR) is another method of documenting client care that emphasizes a structured approach to documentation, with a focus on data, action, and response (DAR). While it provides a systematic way to document care, it does not necessarily limit documentation to only unexpected findings. Focus charting encourages documentation of care in a problem-oriented manner, which may include expected or routine assessments.

Choice C rationale:

Problem-oriented medical record (POMR) is a documentation system that focuses on organizing client information around specific healthcare problems or diagnoses. It encourages a problem-solving approach to care and promotes the inclusion of a comprehensive client history and care plan. POMR documentation may involve both expected and unexpected findings, so it does not limit documentation to only unexpected findings.

Choice D rationale:

SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documenting healthcare encounters. SOAP notes include a wide range of information, including both subjective (patient's description of symptoms) and objective (clinician's observations) data. While SOAP notes are organized, they do not specifically limit documentation to only unexpected findings.

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Correct Answer is C

Explanation

Choice A rationale:

The role of a case manager involves coordinating and managing a client's care across various healthcare providers and services. This role focuses on the coordination of care and resources, not obtaining informed consent.

Choice B rationale:

The nurse manager is responsible for managing and overseeing nursing staff within a healthcare unit or department. Their primary role is related to administration and staff supervision, not obtaining informed consent.

Choice D rationale:

Researchers are individuals who conduct research studies and investigations to generate new knowledge and evidence. Their role is not related to obtaining informed consent from clients.

Choice C rationale:

The nurse is demonstrating the role of an advocate when obtaining informed consent from a client. Advocacy involves supporting the client's right to make informed decisions about their care. The nurse ensures that the client has all the necessary information, understands the procedure or treatment, and consents voluntarily. This includes explaining the risks and benefits, answering questions, and advocating for the client's autonomy and self-determination.

A. Temperature of 39°C (102.2°F). B. History of cigarette smoking. C. Report of dizziness. D. Hypoglycemia.

Correct Answer is C

Explanation

Choice A rationale:

A heart rate of 56 beats per minute is within the normal range for an adult, so a high temperature of 39°C (102.2°F) is not directly related to the heart rate. While elevated body temperature can increase heart rate, the given temperature does not indicate a significant fever.

Choice B rationale:

History of cigarette smoking may be a risk factor for cardiovascular issues, but it does not directly correlate with the current heart rate of 56 beats per minute. The low heart rate is more likely related to other factors.

Choice C rationale:

A heart rate of 56 beats per minute is considered bradycardia, which can lead to dizziness, fatigue, and other symptoms. Dizziness is a common finding in individuals with a slow heart rate, and addressing this symptom is essential for patient safety.

Choice D rationale:

Hypoglycemia (low blood sugar) can cause symptoms like dizziness, but the heart rate is not typically affected directly by hypoglycemia. It is important to address both the bradycardia and the reported dizziness to determine the underlying cause and provide appropriate care.

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A nurse is documenting client care including only unexpected findings related to the client's condition.Which of the following documentation methods is the nurse utilizing?

Nursing Test Bank

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A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?