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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The role of the Board of Nursing (BON) includes regulating and monitoring laws set by the Nurse Practice Act. The BON ensures that nurses practice within the legal framework established by the state's Nurse Practice Act, which defines the scope of nursing practice, licensing requirements, and standards of care. This helps maintain the safety and quality of nursing care in the state.
Choice B rationale:
Establishing a protocol for care to provide for a specific health problem is typically not within the role of the Board of Nursing (BON). The BON focuses on setting and enforcing broader standards of nursing practice and licensure requirements, rather than creating specific protocols for individual health problems. Protocols are often developed by healthcare institutions or professional organizations.
Choice C rationale:
Promoting excellence in nursing education is an important goal, but it is not the primary role of the Board of Nursing (BON). While the BON may have some involvement in accrediting nursing education programs, its primary responsibility is to regulate nursing practice and ensure public safety through licensing and adherence to the Nurse Practice Act.
Choice D rationale:
Determining competencies for nurses to achieve before licensure is a role of the Board of Nursing (BON). The BON sets the standards and requirements that nurses must meet to become licensed, which includes establishing the necessary competencies and qualifications. This helps ensure that nurses entering the profession are adequately prepared to provide safe and competent care.
Correct Answer is ["A","B","E","F"]
Explanation
Choice A rationale:
Givingtheclientprintedinformationisaneducationalmethodthatinvolvesreadingandcomprehension,whicharekeycomponentsofthecognitivedomain.
Choice B rationale:
Teaching about expected reference ranges and target blood glucose levels is based on the cognitive domain of learning. This involves understanding and comprehending information, which is a key aspect of cognitive learning. It's important for a client with diabetes to know what their blood glucose levels should be and what values to aim for to manage their condition effectively.
Choice C rationale:
Asking the client how they feel about checking their blood glucose levels is related to the affective domain of learning. It focuses on the client's emotions and attitudes rather than cognitive understanding, which is not directly mentioned in the question.
Choice D rationale:
Asking the client to demonstrate checking their blood glucose level is based on the psychomotor domain of learning. This involves physical skills and actions, which are not explicitly mentioned in the question.
Choice E rationale:
Giving the client a fill-in-the-blank quiz is also based on the cognitive domain of learning. Quizzes and assessments are tools that help assess a client's understanding and retention of information, which aligns with cognitive learning.
Choice F rationale:
Asking the client to describe the manifestations of hypoglycemia and hyperglycemia is also based on the cognitive domain of learning. It requires the client to recall and explain information, which is a cognitive process.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.