Application and Critical Thinking Questions Choose the correct answer(s). In som

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Application and Critical Thinking Questions Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Some of the following documentation phrases include subjective terminology that to be changed to objective terminology. Select the phrases with subjective terms and underline the subjective word(s) that need(s) to be changed to objective. a. Snored loudly most of night between 0030 and 0530. b. Green purulent drainage increased from yesterday. ABD pad has 6" circle of drainage. c. Procedure tolerated well. d. ADA diet-are 75% tolerated poorly. e. Bouncing foot almost continually. Rubbing hands and flicking finger with thumb at intervals, Verbally denies feeling ambulating in the half. g. Has a bad attitude. Which of the following entries are succinct? a. I took her temp and it was up to 104.2 degrees Fahrenheit. b. After giving a complete bed bath, oral care was performed with toothpaste. toothbrush, and mouthwash. Lotion was applied liberally over arms back, legs, feet, and hands. Her feet and back were massaged for quite a while. c. 18 Fr. Foley catch inserted without difficulty & hung to gravity drainage. Returned 275 mL clear pale yellow urine. d. The patient said she it really nauseated badly, but that she hasn't vomited yet. She asked for her nausea medication that comes in an injection. e. C/O constant sharp, stabbing pain in RL great toe. began 1 hr ago, now a 7 on 0-10 scale. Situation Questions For questions 42 through 44. first, underline the pieces of data in the scenario that are pertinent and should be documented. Second, make a charting entry: Write the data in succinct, accurate, and objective phrases that would be appropriate for documentation using the narrative charting formal. Scenario: you are working 7 a.m. -7 p.m. and it is 0.830. Millie Norris has insulin-dependent diabetes and is hospitalized because her blood sugar has been out of control. She is acting differently than she did yesterday: she is awake but confused, her skin is flushed, hot, and dry. She slept normally on the previous shift, according to the report. You perform an FSBS and find it is 475 mg/dL. You find Regular Insulin 8 units charted on the MAR for the previous evening at 2115. Scenario: You are working the 7 p.m.-7 a.m. shift. It is now 2010. The patient is Mike Gibson, who has been admitted with pneumonia. In the report you were told that an antitussive (cough syrup 1 was administered to Mr. Gibson for frequent, nonproductive coughing at 1445 and acetaminophen for a headache at 1855. During your initial shift assessment he tells you that his headache is completely gone, but that he is feeling slightly short of breath and cannot slop coughing. You empty and clean his emesis basin, which contains a large amount of thick yellowish sputum, which he tells you just started to "come up" in the last hour or so. You find that he took his evening shower right after taking the acetaminophen. Me tells you that it was a hotter than-usual shower and it felt so good that he slaved in the shower for 20 to 25 minutes, when normally he jumps in, showers quickly, and gels out. Maying 7 to 8 minutes at the most.

Explanation / Answer

40 – The phrases below:

ANS – The patient was showing discomfort while asleep between 0030 and 0530

ANS – The patient showed improvement in tolerance towards procedure

ANS – Patient on ADA diet, out of which finished around 75 % eaten and low improvement in tolerance.

ANS – The patient lost his control while ambulating within hall premises.

ANS – The patient has a low tolerance towards staff.

41 – The following entries:

(c) 18 French Foley catheter inserted without difficulty and hung to gravity drainage. Returned 275 ml clear pale yellow urine.

(e) C/O constant harp pain, stabbing pain in Rt great toe, began 1 hr ago, now a 7 on 0-10 scale.

42 – Pt Millie Noris awake and confused. C/O hot, dry and flushed skin. FSBS reads = 475 mg/dl at 0830.

43 – Pt Mike Gibson C/O of SOB and continuous cough. Emesis of yellow thick sputum noted, and elevated body temperature before and during shower noted.

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