Test 1: LA 1-3 Flashcards
Which of the following is an example of a violation in patient confidentiality? (Select all that apply)
a) Providing test results to a family member who has been given privileges by the patient
b) Leaving a computer screen with patient information in view of a visitor
c) Discussing patient information in the cafeteria
d) Leaving copies of confidential patient information lying in a nonsecluded area on a desk
b) Leaving a computer screen with patient information in view of a visitor
c) Discussing patient information in the cafeteria
d) Leaving copies of confidential patient information lying in a nonsecluded area on a desk
Which of the following information entries is included in the patient’s health care record (select all that apply).
a) Continuing health status
b) Treatments delivered
c) Results of the tests
d) Patient’s response to therapy
a) Continuing health status
b) Treatments delivered
c) Results of the tests
d) Patient’s response to therapy
Common issues in malpractice caused by inaccurate or incorrect documentation include: (select all that apply).
a) Failing to document the correct time of events
b) Failing to record verbal orders or failing to have them signed
c) Documenting incorrect data
d) Failing to give a report, or giving an incomplete report
a) Failing to document the correct time of events
b) Failing to record verbal orders or failing to have them signed
c) Documenting incorrect data
d) Failing to give a report, or giving an incomplete report
Patient-centered care includes which of the following: (select all that apply).
a) Respect for the patient’s values and beliefs
b) Understanding of the patient’s culture, ethnicity, spiritual beliefs, and age
c) Recognition of the patient’s spoken language, written language, and literacy level
d) Attention to patient mobility, precautions, and safety risks
a) Respect for the patient’s values and beliefs
b) Understanding of the patient’s culture, ethnicity, spiritual beliefs, and age
c) Recognition of the patient’s spoken language, written language, and literacy level
d) Attention to patient mobility, precautions, and safety risks
5) Which of the following is a classification system that provides standardized language from a nursing diagnosis to describe patient response to health problems?
a) NIC
b) NOC
c) NANDA-I
d) SBAR
c) NANDA-I
A manager is reviewing the nurses’ notes in a client’s medical record. She finds the following entry: “Client is difficult to care for, refuses suggestion for improving appetite.” Which of the following directions should the manager give to the staff nurse who entered the note?
a) Avoid rushing when charting an entry
b) Use correction fluid to remove the entry
c) Draw a single line through the statement and initial it.
d) Enter only objective and factual information about the client
d) Enter only objective and factual information about the client
A client tells the nurse, “I have stomach cramps and feel nauseous.” This is an example of which type of data?
a) Objective
b) Historical
c) Subjective
d) Biographical
c) Subjective
3) As the nurse enters the client’s room, the nurse notices that he is anxious to say something. The client quickly exclaims, “I don’t know what’s going on; I can’t get an explanation from my doctor about the results of my test. I want something done about this. “Which of the following is the most appropriate documentation of the client’s emotional status?
a) The client has a defiant attitude.
b) The client appears to be upset with his physician.
c) The client is demanding and complains frequently.
d) The client stated that he felt frustrated by the lack of information he has received regarding his diagnostic test
d) The client stated that he felt frustrated by the lack of information he has received regarding his diagnostic test
Clients frequently request copies of their medical records. The nurse understands that which of the following is correct?
a) Only the families may read the records.
b) Clients have the right to read those records
c) Clients are not allowed to read those records
d) Only health care professionals have access to the records
b) Clients have the right to read those records
Accurate entries are an important characteristic of good documentation. Which of the following charting entries is most accurate in the way it is written?
a) Client up, out of bed, walked down hallway with assistance, tolerated well.
b) Client up, out of bed, walked 15 meters and back down hallway, tolerated well.
c) Client up, out of bed, walked 15 meters and back down hallway with assistance from the nurse.
d) Client up, out of bed, walked 15 meters and back down hallway with assistance from nurse, heart rate 88 and regular before exercise, 94 and regular after exercise
d) Client up, out of bed, walked 15 meters and back down hallway with assistance from nurse, heart rate 88 and regular before exercise, 94 and regular after exercise
Which of the following represents a breach of confidentiality and privacy?
a) A client is allowed to see and get copies of the client’s medical record
b) A nurse telephones the client’s church to have the client’s name placed on a prayer list.
c) A certified nursing assistant documents vital signs on a graphic sheet in the client’s chart
d) A student nurse covers the client’s identifying information while copying the client’s medication administration record and uses the copy to look up the medications in a drug book while on the unit
b) A nurse telephones the client’s church to have the client’s name placed on a prayer list.
Which of the following is one purpose of the client’s medical record?
a) Education and research
b) Communication and change-of-shift reports
c) Legal documentation and maintenance of incident reports
d) Auditing–monitoring and ease in locating procedure guidelines
a) Education and research
8) Which of the following is a guideline for legally sound documentation?
a) Record all entries legibly and in blue ink.
b) If an order is questioned, record that clarification was sought.
c) To use time more efficiently, wait until the end of shift to record what happened throughout the shift.
d) If an error is made, use correction fluid to maintain neatness. Then record the note correctly over dried correction fluid to make optimum use of space.
b) If an order is questioned, record that clarification was sought.
Which of the following is the best example of quality documentation?
a) Enema administered as ordered.
b) Client seemed depressed today; not doing as well as before.
c) Quarter-sized lump noted on left elbow; client states pain is “better.”
d) 6-cm incision on right lower quadrant, edges pink and well-approximated with sutures; no drainage noted.
d) 6-cm incision on right lower quadrant, edges pink and well-approximated with sutures; no drainage noted.
When a nurse follows the SOAP method of charting, the information the nurse would record under “O” would be which of the following?
a) “My foot keeps throbbing.”
b) Right foot red, +4 pitting edema, capillary refill less than 3 seconds.
c) Alteration in comfort related to swelling in right foot and keeping foot in dependent position.
d) Offer “as needed” pain medication every 4 hours as ordered. Instruct client on nonpharmacological pain-relieving measures. Elevate foot on pillows.
b) Right foot red, +4 pitting edema, capillary refill less than 3 seconds.
Which of the following is a method of charting in which the nurse writes a progress note only when the standardized statement on the form is not met?
a) Narrative method
b) Source record
c) Problem-oriented medical record
d) Charting by exception
d) Charting by exception
Why are critical pathways a valuable tool in client care?
a) They assist the physician in developing variances for the client.
b) They contain graphic sheets, flow sheets, and Kardex forms to aid in providing continuity of care.
c) They are used only by the nursing service, which increases access to notes and reduces the amount of charting.
d) They provide members of the health care team with a way to document their contributions to the client’s total plan of care.
d) They provide members of the health care team with a way to document their contributions to the client’s total plan of care.
Which of the following is one advantage of standardized care plans?
a) They do not have to be updated.
b) They establish clinically sound standards of care for similar groups of clients.
c) They inhibit nurses’ identification of unique, individualized therapy for clients.
d) They make quality improvement audits unnecessary.
b) They establish clinically sound standards of care for similar groups of clients.
A nursing instructor is helping a student nurse with discharge planning for a client. The instructor realizes that further education is needed when the student nurse says which of the following?
a) “I need to go over the client’s medications with him in terms he will understand.”
b) “I really can’t start discharge planning until the physician writes the discharge orders.”
c) “I will give the client’s wife the appointment time I scheduled for follow-up and a list of agencies that provide medical supplies.”
d) “I will review signs and symptoms of infection with the client so he will know what to watch for and will know to seek medical treatment if these occur.”
b) “I really can’t start discharge planning until the physician writes the discharge orders.”
You are giving a change-of-shift report. Which of the following is the most appropriate report statement?
a) “I gave Mrs. Blake a bath, combed her hair, and brushed her teeth. I changed her linens and took her vital signs. After she rested, I gave her some apple juice.”
b) “I think Mrs. Frank in 120-2 needs to go home! She is constantly on her light wanting her pillow fluffed! She acts like she’s a queen and we are her servants! I heard she is pretty wealthy.”
c) “You’re going to have a busy shift. Mrs. Adams will need to be transferred for her radiation treatment, Mr. Brown needs to go to x-ray, the preoperative medication should be given to Mrs. Jones, and Mr. Henry’s daughter will be coming in to talk with you.”
d) “David Jackson, in 121-1, a 92-year-old client of Dr. Able, is here with pneumonia. He is receiving oxygen at 2 L per nasal cannula. He has rales in his right lower lobe, clear rest. He can get up with assistance of one. He has been coughing up thick yellow-tinged sputum after his breathing treatments. He gets them every 6 hours. His next treatment will be at 0800.”
d) “David Jackson, in 121-1, a 92-year-old client of Dr. Able, is here with pneumonia. He is receiving oxygen at 2 L per nasal cannula. He has rales in his right lower lobe, clear rest. He can get up with assistance of one. He has been coughing up thick yellow-tinged sputum after his breathing treatments. He gets them every 6 hours. His next treatment will be at 0800.”
A client is complaining of pain at 0400. The nurse telephones Dr. Rice and receive an order for oxycodone hydrochloride 5 mg 1 tablet every 4 hours as needed. It is wise for the nurse to do which one of the following?
a) Repeat the prescribed order back to the physician.
b) Document the following immediately on the physician’s order sheet: “0415 oxycodone hydrochloride 5 mg q4h prn. T.O. Dr Rice.”
c) Complete an incident report to assist the unit’s quality improvement program so that awakening physicians during the night can be avoided.
d) Wait until the physician makes rounds in the morning and remind him to write the order to cover the nurse for the oxycodone hydrochloride the nurse gave during the night
a) Repeat the prescribed order back to the physician.
According to the guidelines, quality documentation and reporting should be which of the following? (Select all that apply.)
a) Current
b) Factual
c) Accurate
d) Available
a) Current
b) Factual
c) Accurate
An important difference between a situational crisis and a maturational crisis is that the onset of the maturational crisis is:
a) Associated with personal growth
b) Validated by other people
c) Complicated by the experience of multiple traumas
d) Foreseeable
d) Foreseeable
Which of the following client statements best reflects the client’s recognition of the nature of crisis?
a) “I feel numb-like this is not really happening to me.”
b) “This is just like any other emergency.”
c) Within 6 weeks, for better or worse, we will be past this place.”
d) “This must be what people with chronic illness feel like- never knowing what is coming next.”
c) Within 6 weeks, for better or worse, we will be past this place.”
During which point in a crisis should the nurse anticipate providing survivors with the most intense nurturing?
a) Impact
b) Recoil
c) Posttrauma
d) Anniversary date
b) Recoil
A peer in nursing school is going through a divorce. Most of her family is overseas. When you offer assistance, she smiles and states, “I handle things myself. I always have.” Then she changes the subject. Which of the following statements your peer provides you with the greatest assurance that she has what she needs?
a) “I know where to get help if I need it”
b) “My brother and I were always there for each other when we were children., I will ask him for help if I need it.”
c) “I’ll use the student health service if I need it”
d) “I will ask for help if I need it”
b) “My brother and I were always there for each other when we were children., I will ask him for help if I need it.”
5) Identical twin adolescents experience the same crisis. The older twin reports the experience as one associated with personal growth, while the younger twin never regains the precrisis level of functioning. Their mother asks the nurse, “They have had the same life experiences. How could they react so differently?” Which of the following statements by the nurse best describes resilience?
a) “Coping style, as well as the number and depth of supportive relationships, may explain the difference.”
b) “The twins probably perceived the crisis differently.”
c) “Perhaps the younger twin had an undiagnosed psychiatric problem prior to the crisis.”
d) “The younger twin may feel inferior to the older twin.”
a) “Coping style, as well as the number and depth of supportive relationships, may explain the difference.”
Which of the following interventions are most appropriate for individuals experiencing a crisis? (Select all that apply.)
a) Cognitive behavioral interventions
b) Pharmacological interventions
c) Stress management techniques
d) Self-help support groups
e) Insight-oriented group psychotherapy
a) Cognitive behavioral interventions
b) Pharmacological interventions
c) Stress management techniques
Which of the following nursing interventions is inconsistent with the ABCs of crisis counseling?
a) “Let me see if I understand: Your chief concerns are for temporary housing and employment. Is that what you need?”
b) “What kind of resolution were you hoping for?”
c) “Do you feel comfortable enough with me to share what has been happening to you?”
d) “That must bring up a lot of thoughts and fears from your past. For this session, let’s focus on your childhood.”
d) “That must bring up a lot of thoughts and fears from your past. For this session, let’s focus on your childhood.”
8) During a statewide environmental disaster, the most up-to-date and accurate psychoeducational resources most often include:
a) Mass media
b) Other victims of the crisis
c) Local mental health professionals
d) Family members
a) Mass media
