Question 1

Which of the following is a true statement about documentation?

Accepted Answer

A)  Nurses should keep records of patients' wishes. 
B)  Patients do not have access to their own medical records. 
C)  The DARE approach is a complete record of the health status of a patient. 
D)  The nurse is responsible for completing all of the Minimum Data Set (MDS). 
A)  Nurses should keep records of patients' wishes. 
B)  Patients do not have access to their own medical records. 
C)  The DARE approach is a complete record of the health status of a patient. 
D)  The nurse is responsible for completing all of the Minimum Data Set (MDS). A

Question 2

Mrs. Smadu, who is 80 years of age, was recently admitted to a long-term care setting. Over the past month, Mrs. Smadu appears to be deteriorating. She does not wish to eat, sleeps all the time, and is not able to participate in any of her activities of daily living. Which of the following assessment tools will help inform and guide comprehensive care and planning for this older adult?

Accepted Answer

A)  Clinical Assessment Protocols (CAPs) 
B)  Continuing Care Reporting System (CCRS) 
C)  Resident Assessment Instrument (RAI) 
D)  Utilization Guide (UG) 
A)  Clinical Assessment Protocols (CAPs) 
B)  Continuing Care Reporting System (CCRS) 
C)  Resident Assessment Instrument (RAI) 
D)  Utilization Guide (UG) C

Question 3

Which of the following is a primary reason that documentation is important when caring for an older adult?

Accepted Answer

A)  Documentation enables the team to provide care to meet the older adult's individual needs. 
B)  Documentation helps defend the nurse in the event of a possible lawsuit. 
C)  Documentation enables the older adult to access valuable information about the care he is receiving. 
D)  Documentation is the basis for reimbursement to the older adult after discharge home. 
A)  Documentation enables the team to provide care to meet the older adult's individual needs. 
B)  Documentation helps defend the nurse in the event of a possible lawsuit. 
C)  Documentation enables the older adult to access valuable information about the care he is receiving. 
D)  Documentation is the basis for reimbursement to the older adult after discharge home. A

Question 4

The nurse must inform an older adult whose first language is French and who does not speak any English about patient rights. The nurse also has to have the older adult sign the document about information access. Which intervention should the nurse use to maintain the confidentiality of this older adult?

Accepted Answer

A)  The nurse should present the older adult with a French version of the information access document. 
B)  The nurse should have an English-speaking family member explain the document to the older adult. 
C)  The nurse should explain the document to the older adult using an interpreter to ensure understanding. 
D)  The nurse should instruct an interpreter to read the information access document to the older adult privately. 
A)  The nurse should present the older adult with a French version of the information access document. 
B)  The nurse should have an English-speaking family member explain the document to the older adult. 
C)  The nurse should explain the document to the older adult using an interpreter to ensure understanding. 
D)  The nurse should instruct an interpreter to read the information access document to the older adult privately.

Question 5

The same nursing documentation record is used in every unit of a hospital. Why does a hospital use a standardized form for nursing documentation?

Accepted Answer

A)  Standardized documentation helps to provide continuity of care. 
B)  Standardized documentation assists in maintaining confidentiality. 
C)  Standardized documentation reduces the number of medication errors. 
D)  Standardized documentation guarantees excellence of care between units. 
A)  Standardized documentation helps to provide continuity of care. 
B)  Standardized documentation assists in maintaining confidentiality. 
C)  Standardized documentation reduces the number of medication errors. 
D)  Standardized documentation guarantees excellence of care between units.

Question 6

What is a SOAP note?

Accepted Answer

A)  This is a record of supplies used in patient hygiene. 
B)  This is a record of an event during a patient's stay, formatted according to the Simple Object Access Protocol (SOAP), so that it can be easily transmitted between computers. 
C)  This is a form of bar code. 
D)  This is a record of patient data listing the patient's subjective complaint, objective data recorded by the nurse, the nurse's assessment of the situation, and the nurse's plan of action. 
A)  This is a record of supplies used in patient hygiene. 
B)  This is a record of an event during a patient's stay, formatted according to the Simple Object Access Protocol (SOAP), so that it can be easily transmitted between computers. 
C)  This is a form of bar code. 
D)  This is a record of patient data listing the patient's subjective complaint, objective data recorded by the nurse, the nurse's assessment of the situation, and the nurse's plan of action.

Question 7

Which documentation tool does the nurse use in extended care and long-term care settings to gather definitive information on the resident's functioning?

Accepted Answer

A)  Narrative patient progress notes 
B)  Problem-oriented documentation 
C)  Resource Utilization Group (RUG) 
D)  Resident Assessment Instrument (RAI) 
A)  Narrative patient progress notes 
B)  Problem-oriented documentation 
C)  Resource Utilization Group (RUG) 
D)  Resident Assessment Instrument (RAI)

Question 8

A 75-year-old adult has been admitted to the surgical unit. You are not assigned to admit the older adult; however, you overhear two nurses standing beside the mobile computer in the hallway discussing the admission. Which one of the following outlines rules ensuring privacy for this older adult?

Accepted Answer

A)  The Continuing Care Reporting System (CCRS) 
B)  Personal Health Information Protection Act (PHIP
A)  
C)  Health Insurance Portability and Accountability Act (HIPA
A)  
D)  The Canadian Nurses Association's Code of Ethics 
A)  The Continuing Care Reporting System (CCRS) 
B)  Personal Health Information Protection Act (PHIP
A)  
C)  Health Insurance Portability and Accountability Act (HIPA
A)  
D)  The Canadian Nurses Association's Code of Ethics

Question 9

Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger from the Minimum Data Set (MDS) for an older adult in a nursing home who requires an indwelling urinary catheter. Which should the nurse do next?

Accepted Answer

A)  The nurse should develop a patient-centred plan of care. 
B)  The nurse should assign suitable nursing interventions. 
C)  The nurse should use the Resident Assessment Protocols (RAPs). 
D)  The nurse should institute agency-approved catheter care. 
A)  The nurse should develop a patient-centred plan of care. 
B)  The nurse should assign suitable nursing interventions. 
C)  The nurse should use the Resident Assessment Protocols (RAPs). 
D)  The nurse should institute agency-approved catheter care.

Which of the following is a true statement about documentation?

Which of the following is a primary reason that documentation is important when caring for an older adult?

The same nursing documentation record is used in every unit of a hospital. Why does a hospital use a standardized form for nursing documentation?

What is a SOAP note?

Which documentation tool does the nurse use in extended care and long-term care settings to gather definitive information on the resident's functioning?

A 75-year-old adult has been admitted to the surgical unit. You are not assigned to admit the older adult; however, you overhear two nurses standing beside the mobile computer in the hallway discussing the admission. Which one of the following outlines rules ensuring privacy for this older adult?

Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger from the Minimum Data Set (MDS) for an older adult in a nursing home who requires an indwelling urinary catheter. Which should the nurse do next?

Introduction to Healthy Aging

Gerontological Nursing History, Education, and Roles

Communicating With Older Adults

Culture, Ethnicity, and Aging

Biological Theories of Aging and Physical Changes of Aging

Social, Psychological, Spiritual, and Cognitive Aspects of Aging

Nutritional Needs

Hydration and Continence

Rest, Sleep, and Activity

Promoting Healthy Skin and Feet

Maintaining Mobility and Environmental Safety

Assessment Tools in Gerontological Nursing

Safe Medication Use for Older Adults

Living With Chronic Illness

Pain and Comfort

Diabetes Mellitus

Bone and Joint Health

Visual and Auditory Changes

Cardiovascular and Respiratory Disorders

Cognitive Impairment

Economic and Legal Issues

Relationships, Roles, and Transitions

Mental Health and Wellness in Later Life

Loss, Grief, Dying, and Death in Later Life

Care Across the Continuum

Filters

Exam 5: Nursing Documentation for Optimal Care

Which of the following is a true statement about documentation?

Which of the following is a primary reason that documentation is important when caring for an older adult?

The same nursing documentation record is used in every unit of a hospital. Why does a hospital use a standardized form for nursing documentation?

What is a SOAP note?

Which documentation tool does the nurse use in extended care and long-term care settings to gather definitive information on the resident's functioning?

A 75-year-old adult has been admitted to the surgical unit. You are not assigned to admit the older adult; however, you overhear two nurses standing beside the mobile computer in the hallway discussing the admission. Which one of the following outlines rules ensuring privacy for this older adult?

Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger from the Minimum Data Set (MDS) for an older adult in a nursing home who requires an indwelling urinary catheter. Which should the nurse do next?

Introduction to Healthy Aging

Gerontological Nursing History, Education, and Roles

Communicating With Older Adults

Culture, Ethnicity, and Aging

Biological Theories of Aging and Physical Changes of Aging

Social, Psychological, Spiritual, and Cognitive Aspects of Aging

Nutritional Needs

Hydration and Continence

Rest, Sleep, and Activity

Promoting Healthy Skin and Feet

Maintaining Mobility and Environmental Safety

Assessment Tools in Gerontological Nursing

Safe Medication Use for Older Adults

Living With Chronic Illness

Pain and Comfort

Diabetes Mellitus

Bone and Joint Health

Visual and Auditory Changes

Cardiovascular and Respiratory Disorders

Cognitive Impairment

Economic and Legal Issues

Relationships, Roles, and Transitions

Mental Health and Wellness in Later Life

Loss, Grief, Dying, and Death in Later Life

Care Across the Continuum

Filters