CHAPTER 17
PRACTICING FOR NCLEX
MULTIPLE CHOICE QUESTIONS
Circle the letter that corresponds to the best answer for each question.
1. Which of the following is a nurse’s best defense against allegations of negligence by a patient or patient’s surrogate?
a. Nursing team b. Flow sheet
c. Medication record d. Patient record
2. Which of the following statements regarding the patient record is accurate?
a. A patient’s chart may be shared only with close family members.
b. Student nurses are not granted access to patient records.
c. The patient record is generally the responsi-bility of one caregiver.
d. Most patient records are microfilmed and stored in computers.
3. In which of the following systems would a nurse organize data according to the SOAP format?
a. Source-oriented method b. PIE charting method
c. Problem-oriented method d. Focus charting method
4. Abnormal status can be seen immediately with narrative easily retrieved in which of the following documentation formats?
a. Charting by exception b. PIE
c. Narrative notes d. SOAP notes
5. Which of the following is a key component to facilitate data and outcome comparisons by using uniform definitions to create a common language among multiple healthcare data users?
a. Kardex care plan b. Minimum data sets
c. Computer-based records d. Critical/collaborative pathways
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90 UNIT III THE NURSING PROCESS
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:
The Art and Science of Nursing Care, 7th Edition.
ALTERNATE-FORMAT QUESTIONS Multiple Response Questions
Circle the letters that correspond to the best answers for each question.
1. Which of the following statements are accurate guidelines for communicating and documenting patient information? (Select all that apply.)
a. The patient record is the only permanent legal document that details the nurse’s interactions with the patient.
b. The patient record should not be relied on as a defense against nursing negligence charges.
c. Omissions and errors in the nursing docu-mentation always affect patient care.
d. Documentation should be accurate, concise, legally prudent, and confidential.
e. Only information regarding the patient that pertains to patient care is considered confidential.
f. Personal codes of ethics, agency policies, and state and federal privacy legislation dictate how patient information can be communicated.
2. According to HIPAA, patients have the right to do which of the following with their health record? (Select all that apply.)
a. See their health record.
b. Copy their health record.
c. Destroy their health record.
d. Change their health record.
e. Update their health record.
f. Request a restriction on all uses and disclosures.
3. Which of the following are potential documentation errors that increase the risk for legal problems? (Select all that apply.)
a. The content reflects patient needs.
b. The content includes descriptions of situations that are out of the ordinary.
c. The content is not in accordance with professional or healthcare organization standards.
d. There are lines between the entries.
e. The documentation is not countersigned.
f. Dates and times of entries are omitted.
6. You are finding it difficult to plan and implement care for Mr. Rivers and decide to have a nursing care conference. Which of the following best defines this action?
a. You consult with someone in order to exchange ideas or seek information, advice, or instructions.
b. You meet with nurses or other healthcare professionals to discuss some aspect of patient care.
c. You and other nurses visit similar patients individually at each patient’s bedside in order to plan nursing care.
d. You send or direct someone for action in a specific nursing care problem.
7. Which of the following is an accurately written documentation of the effectiveness of a patient’s pain management?
a. Mr. Gray is receiving sufficient relief from pain medication.
b. Mr. Gray appears comfortable and is resting adequately.
c. Mr. Gray reports that on a scale of 1 to 10, the pain he is experiencing is a 3.
d. Mr. Gray appears to have a low tolerance for pain and complains frequently about the intensity of his pain.
8. Which of the following guidelines for charting patient information is accurate?
a. Nursing interventions should be charted chronologically on consecutive lines.
b. If a mistake is made on a chart, correcting fluid should be used to change the
mistake.
c. Charting should be done in pencil to facilitate correction of mistakes.
d. If a procedure is repeated frequently, it is proper to use dittos to decrease recording time.
9. Which of the following is a form used to record specific patient variables such as pulse, respiratory rate, blood pressure, and body temperature?
a. Progress notes b. Flow sheets
c. Graphic sheets d. Medical records
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4. Which of the following are incidental
disclosures of patient health information that are permitted by HIPAA? (Select all that apply.)
a. The use of sign-in sheets that contain information about the reason for the patient visit
b. The possibility of a confidential
conversation being overheard, provided that the surroundings are appropriate and voices are kept down
c. The unlimited use of white boards d. X-ray light boards that can be seen by
passersby, provided that patient x-rays are not left unattended on them
e. Calling out names in the waiting room, provided that the reason for the patient visit is not mentioned
f. Leaving detailed appointment reminder messages on a patient’s voice mail
5. Which of the following statements accurately describe a method of documentation? (Select all that apply.)
a. In a source-oriented record, each healthcare group keeps data on its own separate form.
b. In a problem-oriented record, the entire healthcare team works together in identify-ing a master list of patient problems and contributes collaboratively to the plan of care.
c. In the PIE charting system, a separate plan of care is developed.
d. In focus charting, a problem list of nursing or medical diagnoses is used that
incorporates many aspects of a patient and patient care.
e. In charting by exception, only significant findings or “exceptions” to these standards are documented.
f. In the case management model, a collabo-rative pathway is part of a computerized documentation system that integrates the collaborative pathway and documentation flow sheets designed to match each day’s expected outcomes.
6. Which of the following are basic components of the Resident Assessment Instrument (RAI)?
(Select all that apply.) a. Patient record b. Maximum data set
c. Triggers
d. Resident assessment protocols e. Utilization guidelines
f. Resident nurse practice acts Hot Spot Question
1. Place an X on the clock below that shows the military time of 2230.
12
6
9 3
12
6
9 3
12
6
9 3
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92 UNIT III THE NURSING PROCESS
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:
The Art and Science of Nursing Care, 7th Edition.
DEVELOPING YOUR KNOWLEDGE BASE
FILL-IN-THE-BLANKS
1. A(n) is a compilation of a patient’s health information.
2. The usual format for charting is the unexpected event, the cause of the event, actions taken in response to the event, and discharge planning if appropriate.
3. are a key component to facilitate data and outcome comparisons. They are spe-cific categories of information that use
uniform definitions to create a common language among multiple healthcare data users.
4. The is a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality
improvement.
5. Documentation in long-term care settings is specified by the , which helps the staff gather definitive information on a
resident’s strengths and needs and address these in an individualized plan of care.
6. A nurse who communicates oral, written, or audiotaped patient data to the nurse replacing him/her on the next shift is giving a(n)
report.
7. A(n) is a tool used by healthcare agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a patient, employee, or visitor.
8. A(n) is a meeting of nurses to discuss some aspect of a patient’s care.
MATCHING EXERCISES
Match the formats of nursing documentation listed in Part A with their appropriate example listed in Part B.
PART A
a. Initial nursing assessment b. Plan of nursing care
c. Critical/collaborative pathways d. Progress notes
e. Graphic record
f. 24-hour fluid balance record g. Medication record
h. 24-hour nursing care record i. Discharge and transfer summary j. Home care documentation k. Long-term care documentation PART B
1. The nurse documents the case manage-ment plan for a patient population with a designated diagnosis, which includes expected outcomes, interventions to be performed, and the sequence and timing of these interventions.
2. The nurse documents a diabetic patient’s intake and output of fluids.
3. The nurse summarizes a patient’s reason for treatment, significant findings, procedures performed and treatment rendered, and any specific instructions for the patient/family.
4. The nurse uses this form to record a patient’s pulse, respiratory rate, blood pressure, body temperature, weight, and bowel movements.
5. The nurse documents routine aspects of care that promote goal achievement, safety, and well-being.
6. The nurse records the database obtained from the nursing history and physical assessment.
7. The nurse documents the
administration of Cipro IV, 400 mg every 12 hours.
8. The nurse documents a patient’s diagno-sis of AIDS, expected outcomes, and specific nursing interventions.
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3. Briefly explain the following purposes of the patient record.
a. Communication:
b. Care planning:
c. Quality review:
d. Research:
e. Decision analysis:
f. Education:
g. Legal documentation:
h. Reimbursement:
i. Historical document:
4. List five guidelines nurses should follow when reporting a significant change in a patient’s condition to other healthcare professionals by telephone.
a.
b.
c.
d.
e.
5. List four benefits of using the Resident Assess-ment InstruAssess-ment (RAI).
a.
b.
c.
d.
9. A nurse documents that a patient is homebound and still needs nursing care.
10. A nurse uses RAI to document care.
SHORT ANSWER
1. List four areas of nursing care data that, accord-ing to the Joint Commission, must be perma-nently integrated into the patient record.
a.
b.
c.
d.
2. Briefly describe the following methods of reporting patient data.
a. Change-of-shift reports:
b. Telephone reports:
c. Telephone orders:
d. Transfer and discharge reports:
e. Reports to family members and significant others:
f. Incident reports:
g. Conferring about care:
h. Consultations and referrals:
i. Nursing care conference:
j. Nursing care rounds:
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Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:
The Art and Science of Nursing Care, 7th Edition.
Documentation Method Description/Advantages/Disadvantages
SOURCE-ORIENTED RECORD Description:
Advantages:
Disadvantages:
PROBLEM-ORIENTED MEDICAL RECORDS Description:
Advantages:
Disadvantages:
PIE–PROBLEM, INTERVENTION, EVALUATION Description:
Advantages:
Disadvantages:
FOCUS CHARTING Description:
Advantages:
Disadvantages:
CHARTING BY EXCEPTION Description:
Advantages:
Disadvantages:
CASE MANAGEMENT MODEL Description:
Advantages:
Disadvantages:
VARIANCE CHARTING Description:
Advantages:
Disadvantages:
COMPUTERIZED RECORDS Description:
Advantages:
Disadvantages:
6. Complete the chart below listing the purpose, advantages, and disadvantages of the various methods of documentation.
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APPLYING YOUR KNOWLEDGE
CRITICAL THINKING QUESTIONS
1. Consider the following patient: A 79-year-old woman with Alzheimer’s disease is admitted to a long-term care unit. She has a history of falls and has fractured her left hip in the past.
She no longer recognizes her daughter, who was taking care of her. The daughter states she can no longer handle her mother’s condition.
The daughter insists that the nurses restrain her mother physically to prevent falls.
Think about the information the team will need to provide safe, quality care for this patient. What types of data should the admitting nurse record, and what system of documentation is most likely to bring the information to the attention of everyone who needs it?
2. How would you go about scheduling a consul-tation for a male amputee who needs physical therapy? Write a brief summary of the
patient’s condition and how you would pre-sent his case to the referred agency.
3. Make an appointment to interview the risk manager of a healthcare system. Find out how important the documentation of patient care is to the patient, nurse, and health agency when legal questions arise. How can this knowledge help to safeguard your practice?
REFLECTIVE PRACTICE USING CRITICAL THINKING SKILLS
Use the following expanded scenario from Chapter 17 in your textbook to answer the questions below.
Scenario: Philippe Baron, age 52, is being dis-charged from the outpatient surgery department
after undergoing a colonoscopy for removal of three polyps. Upon admittance, Mr. Baron stated that he was allergic to a pain medication but couldn’t remember the name of it. The RN phoned the doctor’s office to check his medical record. His attending gave an order via phone for a PRN analgesic that worked in the past. He will be going home with his wife, who is a nurse, and they require discharge teaching.
1. What should be the focus of discharge teach-ing for Mr. Baron and his wife?
2. What would be a successful outcome for this patient?
3. What intellectual, technical, interpersonal, and/or ethical/legal competencies are most likely to bring about the desired outcome?
4. What resources might be helpful for Ms. Baron?
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