Question 1

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type.This is known as a:

Accepted Answer

A) nursing order. 
B) Kardex. 
C) nursing care plan. 
D) critical pathway. 
A) nursing order. 
B) Kardex. 
C) nursing care plan. 
D) critical pathway.

Question 2

What does documentation of type of care,time of care,and signature of the person prove?

Accepted Answer

A) The person who signed the documentation did all the work noted. 
B) No litigation can be brought against the person who signed. 
C) Interventions were implemented to meet the patient's needs. 
D) The patient's response to the intervention was positive. 
A) The person who signed the documentation did all the work noted. 
B) No litigation can be brought against the person who signed. 
C) Interventions were implemented to meet the patient's needs. 
D) The patient's response to the intervention was positive.

Question 3

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?

Accepted Answer

A) SOAP 
B) Block 
C) CBE 
D) Focus 
A) SOAP 
B) Block 
C) CBE 
D) Focus

Question 4

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?

Accepted Answer

A) Assessment 
B) Planning 
C) Implementation 
D) Evaluation 
A) Assessment 
B) Planning 
C) Implementation 
D) Evaluation

Question 5

What is the purpose of QA (quality assurance)?

Accepted Answer

A) To screen employment applications 
B) To evaluate care results against accepted standards 
C) To conduct in-services for "quality documentation" 
D) To report deviation from standards to the state health department 
A) To screen employment applications 
B) To evaluate care results against accepted standards 
C) To conduct in-services for "quality documentation" 
D) To report deviation from standards to the state health department

Question 6

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

Accepted Answer

A) Provide information only to another nurse 
B) Provide information only to an attorney 
C) Share information only with the family 
D) Have a clinical reason for reading the record 
A) Provide information only to another nurse 
B) Provide information only to an attorney 
C) Share information only with the family 
D) Have a clinical reason for reading the record

Question 7

What form explains the lapse when events are not consistent with facility or national standards of expected care?

Accepted Answer

A) Subjective data 
B) Focus chart 
C) Incident report 
D) Nursing assessment 
A) Subjective data 
B) Focus chart 
C) Incident report 
D) Nursing assessment

Question 8

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply.)

Accepted Answer

A) Description of injury, including diagrams of injury placement 
B) Date, time, and location of incident 
C) Name of physician and family members notified 
D) Chronologic order of events of the incident 
E) Confirmation that an incident report was initiated 
A) Description of injury, including diagrams of injury placement 
B) Date, time, and location of incident 
C) Name of physician and family members notified 
D) Chronologic order of events of the incident 
E) Confirmation that an incident report was initiated

Question 9

What are some problems associated with electronic (or computerized)charting? (Select all that apply.)

Accepted Answer

A) Security 
B) Expense of training staff 
C) Legibility 
D) Easy retrieval 
E) New terminology 
A) Security 
B) Expense of training staff 
C) Legibility 
D) Easy retrieval 
E) New terminology

Question 10

A new patient is being admitted to a long-term care facility.Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the nursing diagnoses identified?

Accepted Answer

A) Physician 
B) Registered nurse 
C) Nursing assistant 
D) Licensed practical nurse/licensed vocational nurse 
A) Physician 
B) Registered nurse 
C) Nursing assistant 
D) Licensed practical nurse/licensed vocational nurse

Exam 3: Documentation

The staff from all disciplines is developing integrated care plans for a projected length of stay for patients of a specific case type.This is known as a:

What does documentation of type of care,time of care,and signature of the person prove?

The nurse charts only additional treatments done,changes in patient condition,and new concerns.What is this system of documentation?

Documentation is necessary for the evaluation of patient care.Of which phase of the nursing process is this an integral part?

What is the purpose of QA (quality assurance)?

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record?

What form explains the lapse when events are not consistent with facility or national standards of expected care?

When documenting an incident in the nurse's notes,what should the nurse include? (Select all that apply.)

What are some problems associated with electronic (or computerized)charting? (Select all that apply.)

A new patient is being admitted to a long-term care facility.Who has primary responsibility for each patient's initial admission nursing history,physical assessment,and development of the care plan based on the nursing diagnoses identified?

Evolution of Nursing

Legal and Ethical Aspects of Nursing

Communication

Nursing Process and Critical Thinking

Cultural and Ethnic Considerations

Asepsis and Infection Control

Body Mechanics and Patient Mobility

Hygiene and Care of the Patient’s Environment

Safety

Vital Signs

Physical Assessment

Admission, Transfer, and Discharge

Surgical Wound Care

Specimen Collection and Diagnostic Testing

Care of Patients Experiencing Urgent Alterations in Health

Complementary and Alternative Therapies

Pain Management, Comfort, Rest, and Sleep

Nutritional Concepts and Related Therapies

Fluids and Electrolytes

Mathematics and Medication Administration

Care of Patients with Alterations in Health

Life Span Development

Loss, Grief, Dying, and Death

Health Promotion and Pregnancy

Labor and Delivery

Care of the Mother and Newborn

Care of the High-Risk Mother, Newborn, and Family with Special Needs

Health Promotion for the Infant, Child, and Adolescent

Basic Pediatric Nursing Care

Care of the Child with a Physical and Mental or Cognitive Disorder

Health Promotion and Care of the Older Adult

Concepts of Mental Health

Care of the Patient with a Psychiatric Disorder

Care of the Patient with an Addictive Personality

Home Health Nursing

Long-Term Care

Rehabilitation Nursing

Hospice Care

Professional Roles and Leadership

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