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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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Economic stability is one of the key factors of the social determinants of health (SDOH) that significantly impacts an individual's well-being. In this case, the client reporting unemployment indicates a lack of economic stability. Economic stability encompasses factors such as employment, income, and financial resources, and it can affect access to healthcare, nutrition, housing, and other social determinants of health. The client's unemployment is a challenge to their overall health.
Choice B rationale:
Neighborhood environment is another SDOH factor, which includes aspects like the quality of housing, safety, and access to parks and recreational areas. While neighborhood environment can impact health, the client's unemployment directly relates to economic stability and its challenges, making choice A the more appropriate answer.
Choice C rationale:
Education is a crucial SDOH factor, as it can influence employment opportunities, income, and health literacy. However, in this specific scenario, the client's primary concern is their unemployment. While education is a related factor, choice A (economic stability) is more directly applicable to the client's situation.
Choice D rationale:
Social and community context includes factors like social support, social norms, and community engagement. While this factor is important for overall health, the client's immediate challenge is economic stability due to unemployment. Social and community context may play a role in addressing unemployment, but it is not the factor that is currently challenging the client the most.
Correct Answer is D
Explanation
Choice A rationale:
Rounding the amount to be administered to the nearest whole number is a step that may be necessary, but it should not be the first action taken. The nurse should first ensure that the dosage calculation is accurate and based on the client's weight in kilograms. Once the dosage in milligrams is calculated, rounding can be considered.
Choice B rationale:
Calculating the dosage in milligrams is an essential step, but it is not the first action the nurse should take. To determine the correct dosage in milligrams, the nurse needs to convert the client's weight from pounds to kilograms first, as the medication order is given in milligrams per kilogram.
Choice C rationale:
Calculating the dosage in milliliters is not the first action to take because the medication is available in milligrams, and the order is based on weight in kilograms. Converting the weight to kilograms is the initial step to ensure that the dose is calculated correctly.
Choice D rationale:
Converting the client's weight to kilograms is the first and most crucial step in this dosage calculation. The medication order is given in milligrams per kilogram, and the client's weight is provided in pounds. To ensure accurate dosing, the nurse must convert the weight to kilograms, as this is the foundation for calculating the correct dosage in milligrams.
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