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Summary

  • Patient assessment and documentation are essential for safe and effective nursing care.

  • The assessment patient process includes preparation, data collection, data analysis, and data validation.

  • Documentation and reporting should be accurate, complete, clear, concise, timely, confidential, and accountable.

  • Special considerations include adapting to patient population and setting characteristics.

  • Nursing roles in patient assessment and documentation involve initiating assessments, collaborating with other providers, documenting and reporting, and evaluating effectiveness.

  • Patient assessment and documentation support quality care, and nurses should follow systematic processes and consider individual needs.

Questions on Summary

Correct Answer is C

Explanation

<p>This is an expected finding in clients with COPD, due to the narrowing of the airways caused by inflammation, mucus production, and bronchospasm. It does not require immediate intervention.</p>

Correct Answer is C

Explanation

<p>This is a common symptom of meningitis, due to the sensitivity of the optic nerve to light caused by inflammation of the meninges. However, it is not a specific sign that warrants performing a Kernig&#39;s sign test.</p>

Correct Answer is D

Explanation

<p>The nurse should document all aspects of wound care, including the type and amount of dressing used, the location and size of the wound, and the appearance and odor of the wound. This information helps to monitor the healing process, evaluate the effectiveness of interventions, and identify any signs of infection or complications.</p>

Correct Answer is B

Explanation

<p>This is not the rationale for discontinuing metformin, as metformin does not cause nephrotoxicity by itself. However, the client should be advised to maintain adequate hydration before and after the procedure to prevent dehydration and renal impairment.</p>

Correct Answer is A

Explanation

<p>Clamping the chest tube is not recommended unless ordered by the provider or necessary for changing the drainage system. Clamping the chest tube can cause a buildup of pressure in the pleural space and lead to complications such as tension pneumothorax.</p>

<p>This is a correct statement, as alcohol can increase uric acid levels and cause gout attacks in clients taking hydrochlorothiazide. Alcohol can also lower blood pressure and increase the risk of orthostatic hypotension.</p>

<p>This is not an appropriate action, as the nurse should report the error as soon as possible, preferably within an hour of its occurrence. Delaying reporting could compromise client safety and quality of care, as well as increase the risk of legal action.</p>

<p>This is not relevant information for the rehabilitation nurse, as these are subjective data that can be obtained from direct communication with the client and family. The rehabilitation nurse will address these aspects as part of holistic care, but they are not critical for planning care.</p>

<p>Is not an appropriate action as it adds an unnecessary step and delays the implementation of the order. The nurse should confirm the order with the physician, not the pharmacist, and administer it to the client according to the prescribed schedule. The pharmacist will review the order for any pot
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