In a medical record for a patient who has had an allergic reaction to a drug and an associated nursing diagnosis of Skin integrity, impaired, related to allergic reaction as evidenced by rash and hives, the nurse documents "Subjective: denies itching. Happy with improvement in skin. Objective: rash fading on face, chest, and back; no hives visible on skin. Skin warm, dry, and intact. Assessment: skin integrity improving. Plan: check rash daily until discharge." This type of documentation is an example of:
the case management system
SOAP note
narrative style
charting by exception
The Correct Answer is B
A. The case management system:
Case management involves coordinating comprehensive healthcare services for patients across different settings and healthcare professionals.
This choice doesn't describe the specific style of documentation used in the scenario provided.
B. SOAP Note:
Subjective: Information reported by the patient, like feelings or symptoms.
Objective: Observable and measurable data, such as physical examination findings.
Assessment: The nurse's professional judgment about the patient's condition.
Plan: Interventions and treatments planned for the patient.
In the scenario, the documentation includes subjective information (patient denies itching, happy with improvement), objective data (rash fading, no visible hives), the nurse's assessment (skin integrity improving), and the plan (check rash daily until discharge). This aligns with the structure of a SOAP note.
C. Narrative style:
Narrative charting involves writing out the patient's story in a paragraph form.
While it can contain similar information to a SOAP note, it doesn't follow the structured format of SOAP (Subjective, Objective, Assessment, Plan) and tends to be more detailed and descriptive.
D. Charting by exception:
Charting by exception involves documenting only abnormal findings or significant events.
This method reduces redundant documentation, focusing on deviations from the expected or normal findings.
The scenario provides a mix of both normal (improvement in skin, patient satisfaction) and abnormal (initial rash and hives) findings, so it's not solely charting by exception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The doctor only: This option suggests that only the doctor is responsible for interdisciplinary care. In reality, interdisciplinary care involves a team of professionals from various fields working together, not just the doctor alone.
B. The therapists only: Similar to the previous option, this choice implies that therapists are solely responsible for interdisciplinary care. While therapists play a crucial role, interdisciplinary care encompasses a broader range of healthcare professionals.
C. The nurse only: This choice suggests that nurses alone are responsible for interdisciplinary care. While nurses are vital members of the healthcare team, interdisciplinary care involves collaboration among multiple professionals, not just nurses.
D. All members of the care team: This option correctly emphasizes that interdisciplinary care involves the collective efforts of all healthcare team members, including doctors, nurses, therapists, social workers, and others. Each member contributes their expertise to provide comprehensive and holistic care to the patient, addressing various aspects of their health and well-being.
Correct Answer is B
Explanation
A. Begin nursing interventions without needing an initial assessment: This option is not appropriate. A thorough assessment is crucial before any interventions are initiated. The nurse needs to understand the patient's current condition, medical history, and specific needs to provide safe and effective care.
B. Use critical thinking skills to organize care for the patient: Correct. Reviewing the nursing care plan allows the nurse to critically think about the patient's needs, plan interventions accordingly, and organize care effectively. It helps in understanding the patient's unique requirements and tailoring the care plan to meet those needs.
C. Make revisions in the plan as indicated by the shift report: This option implies that the nurse can modify the care plan based on the shift report. While shift reports are essential for continuity of care, the initial review of the care plan is more about understanding the existing plan and adapting it based on the patient's condition, not just the shift report.
D. Skip the shift report and begin with the initial assessment: This option is not appropriate. Both the shift report and the initial assessment are crucial components of patient care. The shift report provides important information from the previous nursing staff, and the initial assessment is the first step in understanding the patient's current state.
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