A nurse is documenting client care including only unexpected findings related to the client's condition.
Which of the following documentation methods is the nurse utilizing?
Charting by exception (CBE).
Focus charting (DAR).
Problem-oriented medical record (POMR).
SOAP documentation.
The Correct Answer is A
Choice A rationale:
Charting by exception (CBE) is a documentation method in which the nurse documents only unexpected findings or significant deviations from the client's normal condition. It is based on the assumption that the client's baseline status remains within the expected range, and deviations from this norm are documented. CBE is efficient and allows nurses to focus on relevant and critical information, reducing unnecessary documentation. It is particularly useful in clinical settings where frequent assessments are needed.
Choice B rationale:
Focus charting (DAR) is another method of documenting client care that emphasizes a structured approach to documentation, with a focus on data, action, and response (DAR). While it provides a systematic way to document care, it does not necessarily limit documentation to only unexpected findings. Focus charting encourages documentation of care in a problem-oriented manner, which may include expected or routine assessments.
Choice C rationale:
Problem-oriented medical record (POMR) is a documentation system that focuses on organizing client information around specific healthcare problems or diagnoses. It encourages a problem-solving approach to care and promotes the inclusion of a comprehensive client history and care plan. POMR documentation may involve both expected and unexpected findings, so it does not limit documentation to only unexpected findings.
Choice D rationale:
SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documenting healthcare encounters. SOAP notes include a wide range of information, including both subjective (patient's description of symptoms) and objective (clinician's observations) data. While SOAP notes are organized, they do not specifically limit documentation to only unexpected findings.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Standards of care for monitoring clients with a history of blood pressure elevation are important, but they are not the best resource for health promotion activities for clients with hypertension. This choice is more focused on monitoring and care standards.
Choice B rationale:
A critical pathway for clients who have had a stroke is specific to a different condition and not related to health promotion for clients with hypertension. It does not provide the information needed for the presentation.
Choice C rationale:
Acute care facility protocol for clients experiencing a hypertensive crisis is important for managing emergencies, but it is not the best resource for health promotion activities. It deals with crisis management rather than prevention.
Choice D rationale:
Clinical practice guidelines for the management of high blood pressure are the most appropriate resource for the nurse's presentation on health promotion activities for clients with hypertension. These guidelines provide evidence-based recommendations for managing and preventing high blood pressure, making them the best choice for the presentation. .
Correct Answer is D
Explanation
The correct answer is Choice D: Palliative care can be provided while a client is receiving curative treatment.
Choice A rationale:
The goal of palliative care is not to cure an acute illness but to provide relief from symptoms and improve the quality of life for clients with serious illnesses.
Choice B rationale:
Palliative care is not restricted to clients who are terminally ill. It can be provided to anyone with a serious illness, regardless of the stage of the disease or the need for other therapies.
Choice C rationale:
Palliative care is not limited to clients in a healthcare facility. It can be provided in various settings, including at home, in outpatient clinics, and in long-term care facilities.
Choice D rationale:
Palliative care can be provided alongside curative treatments. It is designed to improve the quality of life for both the patient and the family by addressing physical, emotional, and psychosocial needs.
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