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

validated data

data clustering

subjective data

objective data

Answer and Explanation

The Correct Answer is B

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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Correct Answer is D

Explanation

A. Ethically can look at a friend's chart to see the diagnosis: Accessing a patient’s chart without a legitimate medical reason violates HIPAA and patient confidentiality laws.

B. Shares information from a chart to protect a friend: Confidentiality applies regardless of personal relationships. Unauthorized sharing of patient information is illegal and unethical.

C. Knows that only the Patient’s Bill of Rights advocates confidentiality: Multiple regulations, including HIPAA, protect patient confidentiality, not just the Patient’s Bill of Rights.

D. Reads charts only for professional reasons: Nurses can only access patient records when directly involved in care. Unnecessary access is a breach of confidentiality.

A. it increases cost B. it promotes individualization of the medical record C. it improves legibility D. it minimizes the number of forms to be completed

Correct Answer is C

Explanation

A. It increases cost.: While initial implementation is costly, computerized charting ultimately reduces costs by improving efficiency and reducing errors.

B. It promotes individualization of the medical record.: Computerized systems standardize documentation rather than individualizing it. However, personalization can be added through specific notes.

C. It improves legibility.: Handwritten notes can be illegible, leading to errors. Computerized charting eliminates handwriting issues and ensures clarity.

D. It minimizes the number of forms to be completed.: While it may reduce paperwork, it does not necessarily minimize documentation, as structured data entry is still required.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

Correct Answer is D

Explanation

One benefit of computerized charting is that:

Correct Answer is C

Explanation

During the shift, the nurse charts only additional treatments done or withheld, changes in patient condition, and new concerns. Charting these factors demonstrates which of the following type of charting?

Show that documentation of patient care by the nurse is very important by selecting from the following: (select all that apply)

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

When using the SOAP method of charting, S stands for subjective data which means:

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

Identify the two primary methods used to collect data:

What is the major concern when using a computer for documentation?

A nurse is receiving a provider's prescription by telephone for morphine for a patient who is reporting moderate to severe pain. Which of the following nursing actions should the nurse take? (Select all that apply)