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:
Abstract thinking develops during the formal operational stage of Piaget's cognitive development theory. This stage typically occurs in adolescence and beyond. During this stage, individuals can think abstractly, solve complex problems, and reason about hypothetical situations. They can also engage in deductive reasoning, which allows them to think logically and systematically.
Choice B rationale:
The concrete operational stage in Piaget's theory, not the formal operational stage, is characterized by the development of logical thinking and operational thought. It typically occurs in children aged 7 to 11 and is marked by the ability to think logically about concrete events and objects.
Choice C rationale:
The sensorimotor stage is the earliest stage in Piaget's theory, occurring in infants from birth to about 2 years old. This stage is characterized by sensory and motor exploration of the environment, and abstract thinking has not yet developed at this stage.
Choice D rationale:
The preoperational stage in Piaget's theory, which typically occurs in children aged 2 to 7, is marked by the development of symbolic thought and language. However, abstract thinking is not a characteristic of this stage.
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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