During a health history interview, a client tells the nurse that they do not feel that they completely empty the bladder when they void. How would the nurse report this findings to the provider?
"Patient with complaints of urinary incontinence."
"Patient reports urinary retention."
"Patient reports urinary frequency."
"Patient has an enlarged prostate."
The Correct Answer is B
A. "Patient with complaints of urinary incontinence." The patient did not report involuntary leakage of urine, which defines incontinence.
B. "Patient reports urinary retention." Urinary retention refers to the inability to completely empty the bladder, which matches the patient's description.
C. "Patient reports urinary frequency." Urinary frequency means voiding frequently (e.g., every 1-2 hours), but the patient described difficulty emptying.
D. "Patient has an enlarged prostate." While an enlarged prostate (BPH) could cause retention, the nurse should not diagnose—only report symptoms.
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Related Questions
Correct Answer is C
Explanation
A. Take the report home and keep it locked up: Incident reports are confidential legal documents that must remain within the healthcare facility per policy.
B. Place the report in the client's medical record: Incident reports should not be included in the client’s medical record to prevent liability issues. Instead, objective documentation of the event and any interventions should be recorded in the chart.
C. Maintain the report according to agency policy: The report must be handled per facility protocols, typically submitted to the risk management department to improve patient safety.
D. Email the report to their nursing supervisor: Incident reports contain sensitive information and should be submitted securely following facility policy, not via email.
Correct Answer is C
Explanation
A. Security and Privacy: While security and privacy are critical in electronic health records (EHR), they do not directly relate to improving documentation efficiency. Security measures protect client data from unauthorized access but do not necessarily enhance the speed of documentation.
B. Gamification: Gamification involves using game-like elements (e.g., rewards, challenges) to engage users. While it may be useful in staff training, it does not directly facilitate documentation of critical changes in client conditions.
C. Data Analytics: Data analytics helps in tracking trends, identifying high-risk patients, and improving documentation efficiency. By setting up real-time alerts and decision-support tools, the system can assist nurses in capturing critical changes efficiently.
D. Copy and Paste: While copy-and-paste functionality can save time, it is often discouraged in healthcare documentation due to the risk of carrying forward outdated or inaccurate information.
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