If an agency is using computer-assisted charting, the nurse is responsible for:
Guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal.
Learning the passwords of the staff nurses and primary care providers so that they can communicate with one another.
Choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation.
Patient education to input information about herself, such as intake and output or symptoms the patient may experience.
The Correct Answer is A
A. Guarding the confidentiality of the patient record by not leaving the patient screen "on" if he leaves the terminal. Protecting patient confidentiality is essential in electronic charting to prevent unauthorized access.
B. Learning the passwords of the staff nurses and primary care providers so that they can communicate with one another. Sharing or learning others' passwords violates security protocols and confidentiality rules.
C. Choosing whether he will use the computer to help in documentation or continue to use traditional paper documentation. In facilities using electronic charting, all staff are typically required to use the system to maintain consistent, accessible records.
D. Patient education to input information about herself, such as intake and output or symptoms the patient may experience. Patients typically do not have access to chart directly into their medical records.
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Correct Answer is D
Explanation
A. “Taking fluids poorly, but more than yesterday."
This assessment is vague (“taking fluids poorly”), lacks measurable details, and does not meet the clarity standard required in documentation.
B. "Apparently comfortable all night. Offers no complaints of pain."
“Apparently comfortable” is an assumption rather than an observable, objective statement, which could be legally questionable.
C. "Patient says she is still slightly nauseated, would like to try some toast and tea."
While this is clear, “slightly nauseated” could be more specific, and this does not objectively quantify the patient’s condition.
D. "4 cm reddened area over sacrum. Skin intact, warm, and dry."
This statement is concise, uses precise measurements, and includes objective data, meeting legal documentation guidelines.
Correct Answer is D
Explanation
A. interrupting frequently.
Interrupting can make adolescents feel disrespected and unheard, which may hinder effective communication and trust.
B. using active listening.
Active listening is essential in communication, especially with adolescents, as it shows respect and builds rapport. The nurse should not avoid this.
C. offering advice.
Offering unsolicited advice can lead to resistance or defensiveness in adolescents. It’s often better to guide them towards their own conclusions.
D. asking embarrassing questions.
Asking questions perceived as embarrassing may make adolescents uncomfortable, leading to reduced openness and cooperation. It is important to be sensitive and respectful when choosing questions to avoid making them feel awkward or judged.