Chapter 4

Which of the following statements are acceptable under the HIPAA Privacy Rule? Select all that apply. A. Communicate report with the next nurse during change of shift. B. Communicate with the primary care provider about a patient's change in assessment. C. Consult in the hall with the instructor about the patient's unexpected findings. D. Describe patient assessment findings to a colleague in the cafeteria.

A, B

A nursing instructor is teaching students about the principles governing documentation. The teacher emphasizes that quality documentation remains confidential and is also (check all that apply): a) complete b) timely c) concise d) accurate e) biased f) organized

A, B, C, D, F

Which of the following are advantages of the electronic medical record? Select all that apply. A. Nurses can enter data by checking boxes and adding free full text. B. It is economical and easy to learn and implement. C. It allows primary care providers to directly order into the computer. D. It cannot be used as a legal document in case of a lawsuit.

A, C

A health care agency has been asked to compensate a client as per a lawsuit filed against it for not following the Health Insurance Portability and Accountability Act (HIPAA) regulations. Which of the following situations is a HIPAA violation? a) Not informing a client in writing of the purpose of sharing his or her personal details. b) Not informing the auditors of the reaosn for sharing client health details. c) Not informing health authorities before sharing client-specific information. d) Not informing the physician before sharing client-specific information.

A.

A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? a) "Patient complaining of abdominal pain rated 8/10." b) "Patient has a history of recent abdominal pain." c) "2 mg Dilaudid PO administration with good effect." d) "Patient is guarding her abdomen and occasionally moaning."

A.

An inexperienced nurse has just performed percussion on a client's chest and detected hyper-resonance, which would tend to indicate emphysema. However, the client is 35 years old, appears healthy otherwise, and denies ever having smoked. The nurse realizes that the data need to be validated. Which method of validation would be most appropriate in this case? a) Verify the data by having another nurse come in to perform the percussion. b) Clarify the data by asking whether the client has experienced any trouble breathing lately. c) Confirm that the client has truly never been a smoker by asking him. d) Repeat the percussion using the nondominant hand.

A.

The nurse is preparing to notify the physician of a change in the client's condition. Which format would be most appropriate for the nurse to use for this communication? a) SBAR b) PIE c) SOAP d) DAR

A.

What do the different formats of progress notes have in common? A. All use the nursing process in some form to show nursing thinking. B. All identify the patient outcomes or goals to evaluate. C. All include head-to-toe assessment data for completeness. D. All have a section for evaluation of care so that nurses may revise interventions.

A.

Which entry demonstrates correct documentation by a nurse regarding assessment of the client admitted for abdominal pain? a) Client states pain began 2 weeks ago, worse with eating, improves after a bowel movement, rates it 7/10 b) Abdominal pain x 2 weeks, no medications taken, denies diarrhea or constipation c) Bowel sounds are present in all four quadrants, all organ within normal limits d) Abdominal pain most likely due to client's unhealthy lifestyle and poor eating habits

A.

A nurse is reporting assessment findings to another nurse over the telephone. Which of the following should the nurse do to prevent communication errors during this call? a) Communicate face to face with good eye contact b) Provide documentation of the data you are sharing c) Have the other nurse speak with the attending physician to clear up any misunderstandings d) Ask the other nurse to read back what first nurse reported

D.

A nurse is working in a health care facility that is using charting by exception. Which of the following would the nurse expect to document? a) No tenderness on palpation b) Bowel sounds normoactive c) Liver palpation normal d) Aching, burning pain in lower back

D.

A nurse is working on an acute neurological unit. Which assessment form would the nurse most likely use to document assessment data? a) Frequent assessment form b) Ongoing assessment form c) Open-ended form d) Focused assessment form

D.

In some health care settings, the institution uses an assessment form that assesses only one part of a client. These types of forms are termed a) progressive. b) specific. c) checklist. d) focused.

D.

Nursing assessment of trends in an unconscious patient's neurological status over time is best recorded on A. an admission assessment. B. a POC. C. a progress note. D. a focused assessment flowsheet.

D.

The nurse manager is implementing walking patient rounds for the change-of-shift reports. One benefit of this type of reporting over others is: a) It is quicker. b) It frees up the report room. c) It allows for exercise. d) It facilitates active participation of patients.

D.

When recording data regarding the client's health record, the nurse mentions the analysis of the subjective and objective data in addition to detailing the plan for care of the client. Which of the following styles of documentation is the nursing implementing? a) PIE charting b) Narrative charting c) Focus charting d) SOAP charting

D.

Which of the following is the proper technique for correcting written documentation? A. Use correction fluid and write over the error. B. Completely black out the error with a black marker. C. Write over the error in darker ink. D. Draw a single line through the error and initial.

D.

Your patient with a humerus fracture is stating pain of 5 on a 10-point scale. His hand is pale, cool, and swollen. His pain medication is ineffective, and he is at risk for compartment syndrome. What action will the nurse take first? A. Reassess the pain in 30 minutes and contact the provider if unresolved. B. Give additional pain medication and reassess the pain in 30 minutes. C. Document the unexpected findings and give an extra dose of pain medication now. D. Contact the primary care provider and document the findings now

D.

Which example may illustrate a breach of confidentiality and security of patient information? a) The nurse provides information over the phone to the patient's family member who lives in a neighboring state b) The nurse accesses patient information on the computer at the nurse's station then logs off before answering a patient's phone. c) The nurse provides information to a professional caregiver involved in the care of the patient. d) The nurse informs a colleague that she should not be discussing patient information in the hospital cafeteria.

A.

Examples of objective data include all the following except: a) Foul-smelling discharge b) Itchy skin c) Reddened skin d) Coughing

B.

In the SBAR reporting format, which of the following would be an example of data found in the assessment? A. Mrs. Kelly's diagnosis is Stage II breast cancer. B. Mr. Imami's lung sounds are decreased. C. Ms. Choi needs to have a social work consult. D. Mr. Jones was admitted at 10:30 this morning.

B.

When performing an assessment, which of the following would be most helpful in validating a client's chief complaint? a) Past health history b) Objective data c) Family history data d) A genogram

B.

A group of nursing students is reviewing the purposes of assessment documentation in preparation for a class discussion. The students demonstrate understanding of the information when they identify which of the following as one of the primary purposes? a) It replaces the client acuity classification system. b) It creates a database for care that was not rendered to the client. c) It provides a chronologic source of client assessment data. d) It directly formulates the nursing diagnoses.

C.

A nurse has just discussed with a client the quality, severity, and location of the client's back pain. Which of the following is an appropriate guideline for the nurse to follow when documenting these findings? a) Use an eraser to remove any error in the document. b) Record "normal" for all normal findings if required. c) Use phrases instead of sentences to record data. d) Record how data findings were obtained.

C.

A nurse is providing in-service training to a group of nurses in a facility that has just begun to use an integrated cued checklist for documentation. Which of the following would the nurse identify as a major advantage of this type of documentation? a) It standardizes data collection. b) It provides lines for the nurses' comments. c) It helps nurses to cluster assessment data. d) It includes specialized data particular to each client.

C.

The nurse is documenting client care. Which nursing assessment note would be most appropriate? a) "Client does not like her new baby." b) "Client is a drug seeker." c) "Client voices concerns about being able to change abdominal dressings at home." d) "Client sleeping."

C.

The nurse is reviewing and analyzing data from the initial assessment of a newly admitted client who is a 79-year-old man. What assessment finding most clearly indicates a need for further data? a) The man's heart rate is 63 beats per minute. b) The man had an inguinal hernia repair in 2008. c) The man has a diffuse rash on his torso. d) The man has male pattern baldness.

C.

What are some strategies for effective handoffs during change-of-shift report? A. Tape-record the report for efficiency. B. Vary the format to individualize to the patient. C. Allow an opportunity to ask and answer questions. D. Put report in writing so that the next shift care provider can get right to work.

C.

Which of the following is the purpose of auditing charting? A. To enhance nurses' learning and understanding of complex clinical situations B. To identify staff members who document completely and counsel those who do not C. To determine if staff members are providing and documenting standards of care D. To locate data in the chart the evening before a morning clinical visit

C.