The primary source of assessment information is:

the patient's friends

past medical records

the patient's record

the patient

Answer and Explanation

The Correct Answer is D

A. The patient's friends: While family and friends can provide secondary information, they are not the primary source of assessment data.

B. Past medical records: Past records can provide valuable history, but they do not replace real-time data from the patient.

C. The patient's record: The medical record is a collection of past documentation but is not a source of new assessment data.

D. The patient: The patient is the primary source of assessment data, as they provide information about their symptoms, medical history, and concerns.

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Correct Answer is C

Explanation

A. Ensure subjective documentation: JCAHO (Joint Commission on Accreditation of Healthcare Organizations) promotes objective documentation to ensure accuracy and reliability in patient care records.

B. Make sure that all nurses use the same charting system: JCAHO does not mandate a uniform charting system, as institutions may use different electronic health record (EHR) systems.

C. Ensure quality patient care: JCAHO’s primary role is to establish and enforce standards to improve patient safety and healthcare quality.

D. Make sure insurance companies get paid correctly: JCAHO’s focus is on patient care quality, not financial reimbursement.

A. validated data B. data clustering C. subjective data D. objective data

Correct Answer is B

Explanation

A. Validated data: While accurate data is crucial, validated data alone does not form a nursing diagnosis.

B. Data clustering: Data clustering involves grouping related signs, symptoms, and risk factors to determine patterns that lead to a nursing diagnosis.

C. Subjective data: Subjective data (e.g., pain, nausea) is part of assessment but must be combined with objective data to establish a diagnosis.

D. Objective data: Objective data (e.g., lab results, physical exam findings) is important, but a nursing diagnosis requires a comprehensive approach, including data clustering.

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The primary source of assessment information is:

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JCAHO regulates standards of care to:

Correct Answer is C

Explanation

Which of the following assists the nurse in the identification of nursing diagnoses?

Correct Answer is B

Explanation

The nurse administered the stat insulin dose as ordered, in the presence of the nurse's aide and the dietary aide, however, the nurse failed to chart the medication on the MAR. During a legal deposition regarding charges of professional malpractice, it was determined that:

Clarify the primary purpose of nursing orders:

A charge nurse is reviewing documentation with a group of newly hired nurses. Which of the following guidelines should be followed when documenting in a patient record? (select all that apply)

A focused assessment should be done by the nurse in all of the following situations EXCEPT:

Which of the following statements is correct about abbreviations?

When discovering subjective data, recognize that they relate to:

To what does objective data refer when assessing a patient?

The patient is confined to bed rest. This contributes to immobility of the patient. How should bed rest be indicated on the nursing care plan?