Communication and Therapeutic Relationships > Fundamentals
Exam Review
Documentation and Interprofessional Communication
Total Questions : 5
Showing 5 questions, Sign in for moreA nurse is preparing to document a client's care in the electronic health record. Which action should the nurse take to ensure confidentiality and security of the client's information?
Explanation
Correct answer: C) Log out of the system after completing the documentation.
Rationale: The nurse should log out of the system after completing the documentation, as this prevents unauthorized access to the client's information by other users. Logging out also ensures that the nurse's name and time stamp are accurate for each entry.
Incorrect options:
A) Use a personal identification number (PIN) to access the system. - This is a correct action, but not the best answer, as using a PIN alone does not ensure confidentiality and security of the client's information. The nurse should also log out of the system after completing the documentation.
B) Share the PIN with another nurse who needs to update the record. - This is an incorrect action, as sharing the PIN with another nurse violates the client's privacy and compromises the security of the system. The nurse should never share the PIN with anyone, and each nurse should use their own PIN to access and document in the record.
D) Leave the computer screen on while attending to another client. - This is an incorrect action, as leaving the computer screen on while attending to another client exposes the client's information to anyone who can view the screen. The nurse should log out of the system or lock the screen before leaving the computer.
A nurse is communicating with a client who has aphasia due to a stroke. Which strategy should the nurse use to facilitate effective communication with this client?
Explanation
Correct answer: B) Use gestures and pictures to supplement verbal communication.
Rationale: The nurse should use gestures and pictures to supplement verbal communication, as this helps to convey meaning and clarify messages for clients who have difficulty understanding or producing speech due to aphasia. Gestures and pictures can also help to reduce frustration and anxiety for both parties.
Incorrect options:
A) Speak loudly and slowly to the client. - This is an inappropriate strategy, as speaking loudly and slowly to the client may imply that they are hard of hearing or cognitively impaired, which can be insulting and demeaning. The nurse should speak clearly and at a normal volume and pace, unless there is evidence of hearing loss or cognitive impairment.
C) Ask open-ended questions to elicit more information from the client. - This is an ineffective strategy, as asking open-ended questions may overwhelm or confuse clients who have difficulty expressing themselves due to aphasia. The nurse should ask simple, yes-or-no questions or offer choices that require minimal verbal responses from the client.
D) Finish the client's sentences when they have difficulty expressing themselves. - This is a disrespectful strategy, as finishing
the client's sentences may interrupt their thoughts or impose words that they do not intend to say. The nurse should allow adequate time for the client to communicate and encourage them to use alternative methods, such as writing or pointing, if needed.
A nurse is collaborating with an interprofessional team to develop a plan of care for a client who has multiple chronic conditions. Which action should the nurse take to promote effective teamwork?
Explanation
Correct answer: D) Respect different opinions and perspectives from other team members.
Rationale: The nurse should respect different opinions and perspectives from other team members, as this fosters a culture of mutual trust, collaboration, and shared decision-making among interprofessional team members. Respecting diversity also enhances creativity and innovation in problem-solving and improves client outcomes.
Incorrect options:
A) Delegate tasks according to each team member's scope of practice and expertise. - This is a correct action, but not
the best answer, as delegating tasks according to each team member's scope of practice and expertise is only one aspect of effective teamwork. The nurse should also respect different opinions and perspectives from other team members, as this is more relevant to promoting effective teamwork than delegating tasks.
B) Communicate with other team members using abbreviations and jargon for efficiency. - This is an incorrect action, as communicating with other team members using abbreviations and jargon may lead to miscommunication, errors, or confusion among interprofessional team members who may not be familiar with the terms. The nurse should communicate with other team members using clear, concise, and standardized language for accuracy and clarity.
C) Make decisions based on evidence-based practice and best available data. - This is a correct action, but not the best answer, as making decisions based on evidence-based practice and best available data is a common goal and expectation for all interprofessional team members, not a specific action that promotes effective teamwork. The nurse should respect different opinions and perspectives from other team members, as this is more relevant to promoting effective teamwork than making decisions.
A client is admitted to the hospital with a diagnosis of pneumonia. The nurse notes that the client has a do-not-resuscitate (DNR) order in their chart. Which action should the nurse take regarding the DNR order?
Explanation
Correct answer: C) Document the DNR order in the nursing care plan and communicate it to other health care team members.
Rationale: The nurse should document the DNR order in the nursing care plan and communicate it to other health care team members, as this ensures that the client's wishes are respected and followed in the event of a cardiac or respiratory arrest. Documenting and communicating the DNR order also prevents unnecessary or unwanted interventions that may cause harm or distress to the client.
Incorrect options:
A) Review the DNR order with the client and their family to ensure their understanding and agreement. - This is an unnecessary action, as reviewing the DNR order with the client and their family implies that they may not have made an informed decision or that they may change their mind, which can be disrespectful or coercive. The nurse should assume that the client and their family have already discussed and agreed on the DNR order with the health care provider who wrote it, unless there is evidence of misunderstanding or disagreement.
B) Notify the health care provider of the DNR order and request a written confirmation. - This is an unnecessary action, as notifying
the health care provider of the DNR order and requesting a written confirmation implies that there may be a discrepancy or doubt about
the validity of the order, which can be disrespectful or suspicious. The nurse should assume that the health care provider who wrote
the DNR order has already obtained informed consent from the client and their family and has documented it appropriately, unless there is evidence of error or omission.
D) Initiate a palliative care consultation for the client and their family to discuss end-of-life care options. - This is an inappropriate action, as initiating a palliative care consultation for the client and their family implies that they have a terminal condition or a poor prognosis, which may not be true for clients with pneumonia who have a DNR order. The nurse should not assume that all clients with a DNR order need or want palliative care, unless they express an interest or a need for it.
A nurse is receiving a handoff report from another nurse at shift change. Which information should the nurse prioritize when receiving the report?
Explanation
Correct answer: D) The client's current condition, changes, interventions, and outcomes.
Rationale: The nurse should prioritize the client's current condition, changes, interventions, and outcomes when receiving
the report, as this provides essential information about the client's status, progress, response to treatment, and plan of care. This information also helps to identify any potential problems or issues that need immediate attention or follow-up.
Incorrect options:
A) The client's name, age, diagnosis, and allergies. - This is important information, but not the most important when receiving
the report, as this provides basic demographic and background information about the client that can be easily accessed from
the chart or other sources. This information does not reflect the client's current condition or needs.
B) The client's vital signs, laboratory results, and medications. - This is important information, but not the most important when receiving
the report, as this provides objective data about the client's physiological status that can be easily accessed from
the chart or other sources. This information does not reflect the client's subjective experience or response to treatment.
C) The client's goals, preferences, values, and expectations. - This is important information,
but not the most important when receiving
the report, as this provides subjective data about
the client's psychosocial status that can be easily accessed
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