Page 185 - Saunders Comprehensive Review For NCLEX-RN

stamped on the entry in the EHR. An occurrence report is not necessary in this
situation.
Test-Taking Strategy: Focus on the subject, correcting a documentation error, and
use principles related to documentation. Recalling the purpose of an occurrence
report will assist in eliminating option 1. From the remaining options, focusing on
the subject of the question and using knowledge regarding the principles related to
documentation will direct you to the correct options.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Leadership/Management: Ethical/Legal
Health Problem: N/A
Priority Concepts: Communication; Professionalism
References: Potter et al. (2017), p. 358.

23. Answer: 1, 2, 5

Rationale: Factual documentation contains descriptive, objective information
about what the nurse sees, hears, feels, or smells. The use of inferences without
supporting factual data is not acceptable, because it can be misunderstood. The use
of vague terms, such as seemed or appears, is not acceptable because these words
suggest that the nurse is stating an opinion.
Test-Taking Strategy: Focus on the subject, accurate documentation notations.
Eliminate options 3 and 4 because they are comparable or alike and include vague
terms (seemed, appears).
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Leadership/Management: Ethical/Legal
Health Problem: N/A
Priority Concepts: Communication; Professionalism
Reference: Potter et al. (2017), pp. 361-362.

24. Answer: 4

Rationale: Invasion of privacy occurs with unreasonable intrusion into an
individual’s private affairs. Performing a procedure without consent is an example
of battery. Threatening to give a client a medication constitutes assault. Telling the
client that the client cannot leave the hospital constitutes false imprisonment.
Test-Taking Strategy: Focus on the subject, invasion of privacy. Noting the words
without the client’s permission will direct you to this option.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management: Ethical/Legal
Health Problem: N/A
Priority Concepts: Ethics; Professionalism

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