Question 1

A client asks the nurse why they are creating a genogram. Which information should the nurse provide the patient with?

Accepted Answer

A)   Identify genetic risk factors.
B)   Predict genetic illness.
C)   Promote healthy behavior.
D)   Prevent future illness.

Question 2

The nurse is using the principles of documentation. Which principle should the nurse anticipate to incorporate?

Accepted Answer

A)   Ethics.
B)   Accountability.
C)   Professionalism.
D)   Communication.

Question 3

The nurse is using the SBAR tool to notify a healthcare provider about a client that is physically declining. Which statement should the nurse include when communicating the situation?

Accepted Answer

A)   "I think an increase in furosemide will help the patient."
B)   "The patient was admitted yesterday with congestive heart failure."
C)   "The patient's O2 saturation is 89%."
D)   "The patient is experiencing dyspnea."

Question 4

The nurse is preparing to create a pedigree for the client using the client's family history information. Which should the nurse recognize are benefits to using a genogram? Select all that apply.

Accepted Answer

A)   Easy to fill in the family history.
B)   Contains standardized symbols.
C)   Allows for a visualization of disease incidence.
D)   Provides a visual representation of a family's health patterns.
E)   Can predict which generations are more susceptible to family illness. A,B,C,D

Question 5

The preceptor is reviewing the use of the SBAR tool with a new nurse. Which statement made by the nurse indicates an understanding of the tool?

Accepted Answer

A)   "The SBAR tool will help me organize my client's problems."
B)   "The SBAR tool will help me organize the assessment on my client."
C)   "The SBAR tool will help me organize my shift report."
D)   "The SBAR tool will help me organize my documentation."

Question 6

A client tells the nurse that their pain is okay now. Which question should the nurse ask the patient to obtain more accurate information?

Accepted Answer

A)   "Do you feel better?"
B)   "Can you explain what okay means?"
C)   "Are you pain free?"
D)   "Is feeling okay a tolerable condition for you?"

Question 7

The nurse educator is presenting information about the APIE method of charting to the staff nurses. Which statements by the nurses should the preceptor recognize indicates an understanding of the information? Select all that apply.

Accepted Answer

A)   "I will only need to chart by exception with this method."
B)   "Only subjective data are included in the assessment portion."
C)   "The 'P' refers to the chief problem of the client."
D)   "The activities implemented to manage the client's needs will be documented in the 'I' section."
E)   "The 'E' refers to the evaluation that occurs after an intervention is implemented." C,D,E

Question 8

The nurse is documenting an assessment. Which terms should the nurse be mindful of when recording information to ensure the documentation is accurate and complete? Select all that apply.

Accepted Answer

A)   Precise.
B)   Comprehensive.
C)   Professional.
D)   Succinct.
E)   Concise.

Question 9

A client tells the nurse that they are experiencing discomfort above their elbow. Which medical terminology should the nurse use to describe the location of discomfort?

Accepted Answer

A)   Distal to the elbow.
B)   Proximal to the elbow.
C)   Anterior to the elbow.
D)   Inferior to the elbow.

Question 10

The nurse is preparing to document a client's position that is laying on their back facing the ceiling. Which terminology should the nurse use in the documentation?

Accepted Answer

A)   Supine.
B)   Anterior.
C)   Prone.
D)   Lateral.

Question 11

The nurse is using the acronym SOAP to record information obtained from a client assessment. Which should the nurse recognize should be recorded in the "S" category?

Accepted Answer

A)   Blood pressure of 177/93 mmHg.
B)   Inability to afford prescriptions.
C)   Client states they lost their insurance.
D)   Social service referral.

Question 12

The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation?

Accepted Answer

A)   S: The client states, "I am so nauseated."
B)   O: The client reports feeling fatigued.
C)   A: Bowel sounds are high-pitched in all abdominal quadrants.
D)   P: The client will remain NPO.

Question 13

The nurse is reviewing the charting from the previous shift. Which should the nurse recognize is appropriate to chart?

Accepted Answer

A)   "Encouraged the client to ask questions."
B)   "Discussed the plan of care with the parents."
C)   "The client is demanding and tired."
D)   "The client is observed to be crying."

Question 14

The nurse is avoiding the use of a client's personally identifiable information. Which information should the nurse recognize should not be used? Select all that apply.

Accepted Answer

A)   Diagnosis.
B)   Gender.
C)   X-rays.
D)   Age.
E)   Religion.

Question 15

The nurse is reviewing the different types of documentation. Which should the nurse recognize is a benefit to charting by exception?

Accepted Answer

A)   Allows for a focused documentation of symptoms.
B)   The documentation is formatted for a specific purpose.
C)   Focuses on problem-oriented documentation.
D)   Repetition is eliminated from the documentation.

Question 16

The nurse manager is reviewing tips for appropriate documentation with the nursing staff. Which statement made by the nursing staff indicates further education is required?

Accepted Answer

A)   "I will document the exact time the events occurred."
B)   "I will document why the client refused their medication."
C)   "I will document for my colleague during an emergency."
D)   "I will document client statements using quotations." C

Question 17

A client tells the nurse that her mother has type II diabetes. Which information about the patient's mother should the nurse include in genogram?

Accepted Answer

A)   The current geographical residence.
B)   The medications her mother takes.
C)   The current age of her mother.
D)   The age of onset of the type II diabetes.

Question 18

A client tells the nurse that they have pain in their lower abdomen. Which should the nurse record to reflect accuracy in the documentation of the information?

Accepted Answer

A)   The client told me they have "pain" in their lower abdomen.
B)   The client states, "I have pain in my lower abdomen."
C)   The client complains they have pain in their lower abdomen.
D)   The client states they are having pain in their abdomen.

Question 19

The nurse manager is discussing the principles of documentation with the nursing staff. Which statement made by a nurse indicates an understanding of the principle of professionalism?

Accepted Answer

A)   "I will maintain the privacy of the information that I document."
B)   "I will use uniform language so my documentation can be understood."
C)   "I will use quotation marks when I record my subjective data."
D)   "I will make sure I immediately document all of my assessments."

Question 20

The nurse is preparing to describe a location in the body in the documentation of an assessment. Which terminology should the nurse anticipate using?

Accepted Answer

A)   Anatomic definition.
B)   Anatomic plane.
C)   Anatomic alignment.
D)   Anatomic pathology.

Exam 6: Documentation

A client asks the nurse why they are creating a genogram. Which information should the nurse provide the patient with?

Correct AnswerverifiedShow Answer

The nurse is using the principles of documentation. Which principle should the nurse anticipate to incorporate?

Correct AnswerverifiedShow Answer

The nurse is using the SBAR tool to notify a healthcare provider about a client that is physically declining. Which statement should the nurse include when communicating the situation?

Correct AnswerverifiedShow Answer

The nurse is preparing to create a pedigree for the client using the client's family history information. Which should the nurse recognize are benefits to using a genogram? Select all that apply.

Correct AnswerverifiedA,B,C,D

The preceptor is reviewing the use of the SBAR tool with a new nurse. Which statement made by the nurse indicates an understanding of the tool?

Correct AnswerverifiedShow Answer

A client tells the nurse that their pain is okay now. Which question should the nurse ask the patient to obtain more accurate information?

Correct AnswerverifiedShow Answer

The nurse educator is presenting information about the APIE method of charting to the staff nurses. Which statements by the nurses should the preceptor recognize indicates an understanding of the information? Select all that apply.

Correct AnswerverifiedC,D,E

The nurse is documenting an assessment. Which terms should the nurse be mindful of when recording information to ensure the documentation is accurate and complete? Select all that apply.

Correct AnswerverifiedShow Answer

A client tells the nurse that they are experiencing discomfort above their elbow. Which medical terminology should the nurse use to describe the location of discomfort?

Correct AnswerverifiedShow Answer

The nurse is preparing to document a client's position that is laying on their back facing the ceiling. Which terminology should the nurse use in the documentation?

Correct AnswerverifiedShow Answer

The nurse is using the acronym SOAP to record information obtained from a client assessment. Which should the nurse recognize should be recorded in the "S" category?

Correct AnswerverifiedShow Answer

The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation?

Correct AnswerverifiedShow Answer

The nurse is reviewing the charting from the previous shift. Which should the nurse recognize is appropriate to chart?

Correct AnswerverifiedShow Answer

The nurse is avoiding the use of a client's personally identifiable information. Which information should the nurse recognize should not be used? Select all that apply.

Correct AnswerverifiedShow Answer

The nurse is reviewing the different types of documentation. Which should the nurse recognize is a benefit to charting by exception?

Correct AnswerverifiedShow Answer

The nurse manager is reviewing tips for appropriate documentation with the nursing staff. Which statement made by the nursing staff indicates further education is required?

Correct AnswerverifiedC

A client tells the nurse that her mother has type II diabetes. Which information about the patient's mother should the nurse include in genogram?

Correct AnswerverifiedShow Answer

A client tells the nurse that they have pain in their lower abdomen. Which should the nurse record to reflect accuracy in the documentation of the information?

Correct AnswerverifiedShow Answer

The nurse manager is discussing the principles of documentation with the nursing staff. Which statement made by a nurse indicates an understanding of the principle of professionalism?

Correct AnswerverifiedShow Answer

The nurse is preparing to describe a location in the body in the documentation of an assessment. Which terminology should the nurse anticipate using?

Correct AnswerverifiedShow Answer

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A,B,C,D

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C,D,E

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C

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