When the nurse charts only additional treatments done, abnormal findings, changes in patient condition, and new concerns, the system of documentation is:
SBAR.
Focused charting.
Charting by exception.
SOAP.
The Correct Answer is C
Choice A rationale
SBAR (Situation, Background, Assessment, Recommendation) is a structured communication tool used for verbal or written reports, focusing on concise information transfer during transitions of care or urgent situations, not a comprehensive charting system based on exceptions.
Choice B rationale
Focused charting centers on specific patient problems or concerns, using a DAR (Data, Action, Response) format. It addresses particular issues in detail rather than documenting only deviations from the norm.
Choice C rationale
Charting by exception (CBE) is a documentation system where nurses only document findings that are outside the normal range or significant changes in a patient's condition. Standardized care and expected outcomes are assumed to be met and are not routinely documented, saving time and reducing redundancy.
Choice D rationale
SOAP (Subjective, Objective, Assessment, Plan) is a problem-oriented charting method commonly used by physicians and other healthcare providers to organize patient information around specific problems identified during assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A medical diagnosis identifies a specific disease or pathological process based on signs, symptoms, diagnostic tests, and medical history. It focuses on the disease itself and its etiology, which differs from evaluating a patient's response to health issues.
Choice B rationale
A nursing diagnosis is a clinical judgment concerning a human response to health conditions, life processes, or vulnerability for that response by an individual, family, group, or community. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.
Choice C rationale
A collaborative problem is a potential or actual physiological complication that nurses monitor to detect the onset of changes in a patient’s status. These problems require both nurse-prescribed and physician-prescribed interventions, focusing on managing potential complications rather than the response itself.
Choice D rationale
A physician's order is a directive from a medical doctor or other legally recognized healthcare provider that outlines specific treatments, medications, tests, or other interventions for a patient. It guides medical care, not the identification of patient responses.
Correct Answer is A
Explanation
Choice A rationale
To convert 12: am to military time, for any time between 12: am and 12: am, the 12 is replaced with 00. Therefore, 12: am becomes 0018 in military time.
Choice B rationale
2418 is not a valid representation of time in either standard or military format. Military time ranges from 0000 to 2359.
Choice C rationale
1218 in military time represents 12: pm in standard time, not 12: am. In the afternoon and evening, 12 is added to the standard hour to convert to military time (e.g., 1 pm is 1300).
Choice D rationale
0118 in military time represents 1: am in standard time. The hour remains the same for times between 1: am and 9: am, with a leading zero added to the hour. .
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