Standardized care plans are more effective in goal attainment than individualized care plans. Care plans are controlled by the nurses caring for the client; other members of the interdisciplinary team should develop their own specific plans of care. The first step of creating a nursing care plan is a systematic assessment using a functional health pattern framework. Older adults often have multiple nursing diagnoses and each diagnosis should be addressed at once.
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Healthcare facilities must maintain client medical records for at least 5 years. Clients have no legal rights to obtain copies of their medical records. Clients have the right to view their medical records and ask questions about the information contained in the records. Employees in healthcare institutions may discuss a client situation in a public area as long as the client is not identified.
Answer: 3 Rationale: Clients have the right to review their medical records and ask questions regarding the information contained within the record. Medical records must be maintained at least 7 years by healthcare institutions. Clients have the right to obtain copies of their medical records within a reasonable time and may be charged a fee for the copies.
Healthcare workers may not discuss client cases in public places even when the client is unnamed because the discussion could contain identifying information and violate confidentiality. Safe, Effective Care Environment Knowledge 3. The nurse logs off the computer after accessing the laboratory record of a client. Reports of client radiology tests are faxed to a fax machine that is shared by the payroll department of the hospital.
Employees who have expired passwords for computer access must contact their supervisor for permission to obtain new passwords from the information technology department. A physician is given a password to access computerized client records. The information technology department keeps record logs of when and who has accessed the client records.
The institution needs to improve its transfer of information so that client test results are not transmitted via a fax machine that is accessed by persons who have no need to see the client record. Logging off confidential files, using individual passwords, and maintaining access record logs are proper means of maintaining the privacy of client medical information.
Safe, Effective Care Environment Application 3. Copies of client diagnostic test results are shredded before being discarded. Copies of client records must be rendered unreadable before being discarded.
Client records must be secure, especially when used in departments other than the nursing unit. Persons, including healthcare professionals, who do not legitimately need to see a client record must be kept from accessing the record.
The nurse approaches the client to sign a consent form for the transfusion and finds that the client is confused. The nurse should explain the benefits and burdens of the transfusion, help the client sign the consent, and administer the blood transfusion.
Transfuse the blood after the power of attorney gives consent. Answer: 3 Rationale: The nurse who finds a client to lack the capacity for consent, as in the case of a confused client, must obtain consent from a healthcare proxy, such as the durable power of attorney. The nurse should assent the client in the treatment decision as well.
Explaining the treatment to a confused client and then assisting the client to sign the consent does not meet the test of capacity for consent understanding, reasoning, problem solving, and communicating the decision. A blood transfusion is considered a specialized procedure and requires a separate informed consent form be signed Patient Self-Determination Act. Withholding the transfusion until the client is no longer confused delays the treatment and may result in harm to the client.
The nurse explains the importance of participating in screening tests for physical changes. Which of the following statements indicates understanding by the client? Skin assessments should be done annually. A baseline density assessment should be performed at menopause and then repeated as deemed necessary by the primary healthcare provider. The tetanus booster should be performed every 10 years. Evaluation; Health Promotion and Maintenance; Analysis 3.
The day after the admission, the client becomes unresponsive and experiences cardiac arrest. The nurse caring for the client reports there is no order to withhold resuscitative efforts. Which of the following actions is indicated first?
Resuscitation must be initiated. The homeless shelter must be notified. The admitting physician must be notified. The shift supervisor must be notified. The homeless shelter would have no jurisdiction over the client. The physician will require notification but the focus is on initiating the code.
The supervisor will also require notification but it is not the first step to be taken. The client is 81 years of age. After diagnostic testing is completed, the physician indicates an intestinal obstruction has been located and plans are made for surgical intervention. The nurse is charged with obtaining the surgical consent. A review of the admission information lists the next of kin as a daughter who lives in a neighboring community. Who will be the responsible party to sign the surgical consent?
The client will sign the consent. Both the client and the daughter will sign the consent. Which of the following statements by the nurse indicates understanding of the regulations associated with HIPAA?
Faxing is permitted but only with the permission of the parties involved. Clients are required to sign receipt and understanding of the policy of the healthcare privacy information. Verbalization is not sufficient. She indicates her employer is awaiting the information.
What response by the nurse is indicated? Faxing of health-related information is permissible but consent must be given by the client. The fax number and recipient must be provided by the client.
The student asks when consents are required. After discussing the topic with the student, which of the following statements indicates the need for further instruction? Informed consent is required for all invasive procedures. Informed consent is implied for basic, nonspecialized procedures. The admission of a blood transfusion requires a signed consent. Informed consent is not required for all procedures.
An IV insertion is an invasive procedure. It does not require a signed consent. Consent is implied. The remaining statements are correct.
Evaluation; Assessment; Analysis 3. A review of the medical records reveals no power of attorney is in existence. The nurse is performing an assessment to ensure the client is able to provide consent. Which of the following criteria must be met? The client must voice knowledge of the medications that will be utilized for anesthesia. The client must be able to verbalize the decision to undergo the surgical procedure. The client must be able to acknowledge reasonable treatment options available.
The client must understand that antibiotics may be administered after the procedure. Knowledge of medications for anesthesia or infection is not a requirement for completion of the surgical consent. Verbalization may not be possible for some competent clients.
Diagnosis; Psychological Integrity; Analysis 3. Upon admission, the client was in agreement with the plan of treatment. Since admission, the client has become increasing unhappy with the plan of care and wishes to refuse some of the medications prescribed.
Which of the following statements is most correct? The consent for treatment obtained at admission implies acceptance of the treatments being prescribed and should be followed by the client. The client should be discharged if she is not in agreement with the elements of the plan of care. The client may decline options for treatment as desired.
The client living in an assisted living environment is restricted in his or her decision-making abilities and must consult with the community attorney to make this type of care decision. The client should speak with the healthcare provider about areas of dissatisfaction as they arise to make mutually acceptable decisions. The client residing in the assisted living community has no fewer rights than any other client. The assisted living attorney does not have a role in the planning of the care for this client.
Assessment; Psychological Integrity; Application 3. She reveals her father has a history of hypertension and suffered a mild stroke 30 years ago. What advice should be given in response to the inquiry? The internist has training and specialization in specific areas. Recommending a specific physician would not be prudent. A family practitioner or a nurse practitioner would be able to provide more generalized care and does not present the wisest option for the client, considering his age and health history.
Implementation; Safe, Effective Environment; Application 3. He was found lying in an alley.
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