A nurse is reviewing electronic health record (EHR) documentation with an assistive personnel (AP). The nurse should reinforce that the AP is permitted to document in which of the following sections of the EHR?

Plan of care

Graphic record

Nurses' notes

Discharge teaching

Answer and Explanation

The Correct Answer is B

A. Plan of care: The plan of care is developed and updated by licensed nursing staff and other providers. Assistive personnel (AP) are not authorized to document assessments, interventions, or changes in the plan of care, as this requires professional judgment and accountability.

B. Graphic record: APs can document routine, objective data such as vital signs, intake and output, and other measurable observations in the graphic or flow sheet section of the EHR. This allows for accurate tracking of trends while remaining within their scope of practice.

C. Nurses' notes: Nurses’ notes require professional assessment, analysis, and evaluation of client responses to care. APs do not have the licensure to make these judgments, so they should not document in this section.

D. Discharge teaching: Documentation of discharge teaching reflects the nurse’s evaluation of client understanding and education provided, which is a licensed nursing responsibility. APs can reinforce teaching but are not authorized to document it as part of the official discharge record.

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Correct Answer is C

Explanation

A. Place the client in restraints: Physical restraints are used only as a last resort when the client poses an immediate danger to self or others. In delirium, restraints can worsen agitation, increase confusion, and elevate the risk of injury or further cognitive decline. Nonpharmacologic de-escalation and environmental modifications are preferred initial interventions.

B. Offer the client a variety of activities to choose from: Clients with delirium have impaired attention, fluctuating levels of consciousness, and reduced ability to process multiple stimuli. Providing numerous choices can increase confusion and cognitive overload. Care should focus on structured, simple activities rather than offering multiple options.

C. Communicate with the client using simple, direct statements: Delirium impairs cognition, attention, and comprehension, making complex communication difficult. Using short, clear, and direct statements helps reduce misinterpretation and supports orientation. Consistent, simple communication decreases anxiety and promotes better understanding in hallucinations.

D. Limit how often the client's partner can visit: Familiar individuals can provide reassurance, assist with reorientation, and decrease anxiety in clients with delirium. Restricting visits may increase confusion and agitation. Encouraging the presence of trusted family members often supports cognitive stabilization and emotional comfort.

A. Wheat toast and jelly B. Graham crackers with peanut butter C. Beef barley soup D. Corn tortillas with black beans

Correct Answer is D

Explanation

A. Wheat toast and jelly: Wheat contains gluten, which triggers an immune response in clients with celiac disease. Consuming wheat products can damage the intestinal villi and exacerbate malabsorption and gastrointestinal symptoms, making this an inappropriate choice.

B. Graham crackers with peanut butter: Graham crackers are typically made with wheat flour and contain gluten. Even paired with peanut butter, this snack is unsafe for a child with celiac disease and should be avoided to prevent intestinal injury and nutrient deficiencies.

C. Beef barley soup: Barley contains gluten and is contraindicated for clients with celiac disease. Including barley in the diet can provoke symptoms such as diarrhea, abdominal pain, and long-term intestinal damage.

D. Corn tortillas with black beans: Corn and black beans are naturally gluten-free and safe for children with celiac disease. This combination provides a balanced source of carbohydrates and protein without triggering the autoimmune response associated with gluten ingestion.

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A nurse is reviewing electronic health record (EHR) documentation with an assistive personnel (AP). The nurse should reinforce that the AP is permitted to document in which of the following sections of the EHR?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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