Christensen chapter 7

Question 1

The appraisal of the manner in which an individual nurse conducts practice, education, or research by a professional coworker is:

Assessment

Documentation

Peer review

Accountability

Answer 1

Peer review

Question 2

2.The form on the patient’s chart on which nurses record their observations, care given, and the patient’s responses is:

a) Physicians orders
b) Nurses notes .
c) Health record
d) . DRGs

Answer 2

Nurses Notes

Question 3

3.When documenting patient care, the nurse knows that the best time to document is:

a) At the end of the shift
b) During lunch
c) Only when necessary
d) As soon as possible after completion of care

Answer 3

As soon as possible

Question 4

4.During which phase of the nursing process does documentation take place?

a) Assessment
b) Planning
c) Documentation
d) Evaluation

Answer 4

Evaluation

Question 5

5. Since the patient’s medical record is a legal document, the nurse know that it is important to chart:
   a) In a very detailed, defensive manner

b) As little as possible so as to not incriminate yourself
c) Only what the patient says
d) Only the abnormal activities that occur

Answer 5

In a very detailed, defensive manner

Question 6

6. As a newly hired nurse, what is the best way to chart using correct abbreviations?
   a) Ask the other nurses on the unit.
   b) Check to see if the facility has a published list of abbreviations.
   c) Chart using the abbreviations learned in school.

d)Most facilities have a published list of generally accepted medical abbreviations and terms approved for use in charting.
Correct

Answer 6

check to see if the facility has a published list of abbreviations

Question 7

7.Select all of the following writing skills that are important in documentation.

Spelling

Grammar

Punctuation

Penmanship

complete and accurate

Answer 7

All are important

Question 8

.Computer charting is becoming an increasingly common way to document about your patients. One way to maintain security and confidentially of patient information is to change the passwords. How often should the password be changed?

Every 6 months

Every 4 months

Every 2 months

Every month

Answer 8

Every Month

Question 9

8.When charting by exception, which acronym is generally used?

SOAPE

SOAPIER

PIE

DARE

Answer 9

PIE

Question 10

.A patient has been admitted to the medical floor. The patient’s initial admission nursing history, physical assessment, and development of the care plan is the responsibility of the:

RN

Physician

LPN

Social worker

Answer 10

RN