The general rule is that the initial care plan for a patient is:
developed by an RN
completed on the day of admission.
used as the basis of care throughout a hospital stay without alteration.
developed by the primary care provider and incorporated into the nursing care
The Correct Answer is B
A. Developed by an RN:
This option suggests that an RN (Registered Nurse) is solely responsible for creating the initial care plan. While nurses significantly contribute to the care plan, it is often a collaborative effort involving various healthcare professionals, including doctors, nurses, and other specialists.
B. Completed on the day of admission:
This choice means that the initial care plan, outlining the patient's immediate healthcare needs and interventions, is developed and documented on the day the patient is admitted to the healthcare facility. It's essential to establish a plan promptly to ensure the patient receives appropriate and timely care.
C. Used as the basis of care throughout a hospital stay without alteration:
This option suggests that the initial care plan remains unchanged throughout the patient's hospital stay. However, healthcare plans need to be dynamic, adapting to the patient's evolving condition. Care plans are continuously assessed and modified based on the patient's response to treatments and interventions.
D. Developed by the primary care provider and incorporated into the nursing care:
This choice implies that the initial care plan is created by the primary care provider (which could be a doctor) and then integrated into the nursing care. While doctors provide medical diagnoses and orders, nurses play a crucial role in implementing and coordinating the care plan, ensuring the patient's needs are met.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. itching:
This is a subjective symptom. Itching is a feeling experienced by the patient and cannot be directly observed by the nurse. The patient's report of itching is subjective until the nurse observes any visible signs of scratching or a rash.
B. headache:
Similar to itching, a headache is a subjective symptom. It is a feeling experienced by the patient and cannot be directly observed by others. The patient's report of a headache is subjective until the nurse observes signs such as the patient holding their head or wincing in pain.
C. rash:
In the given context, a red rash on the face and neck is objective data. Objective data refers to measurable and observable information about a patient's condition. In this case, the nurse can directly observe the rash, making it objective. Objective data is factual and can be verified by others.
D. nausea:
Nausea is also a subjective symptom. It is a feeling experienced by the patient and cannot be directly observed by others. The patient's report of nausea is subjective until the nurse observes signs such as the patient looking pale, sweating, or exhibiting other physical symptoms associated with nausea.
Correct Answer is B
Explanation
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.
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