Deck 6: Documentation

Question 1

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?

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."

Answer 1

"I will document for my colleague during an emergency."

Question 2

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?

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

Answer 2

Client states they lost their insurance.

Question 3

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.

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

Answer 3

Precise.
Professional.
Succinct.
Concise.

Question 4

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?

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 5

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

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

Question 6

The preceptor is discussing the principles of documentation with a new nurse. Which principles should the preceptor include? Select all that apply.

A) Completeness.
B) Professionalism.
C) Accuracy.
D) Timeliness.
E) Confidentiality.

Question 7

The nurse is documenting a client's family medical history in a genogram. Which standardized symbol should the nurse use to identify the patient's biological mother?

A) Square.
B) Circle.
C) Diamond.
D) Rectangle.

Question 8

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.

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

Question 9

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.

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.

Question 10

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?

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

Question 11

The nurse is using the SBAR communication tool to communicate with a healthcare provider. Which statement should the nurse use to communicate the background?

A) "I think that the client's medication has caused the confusion."
B) "The client's mental status is confused."
C) "I am calling about Mr. X's blood pressure."
D) "I would suggest decreasing the dosage of the medication."

Question 12

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?

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 13

The nurse is constructing a pedigree for a client. Which symbol should the nurse use to represent the client's biological father?

A) Circle.
B) Square.
C) Diamond.
D) Rectangle.

Question 14

The nurse is assessing the family history of a client that has children. Which should the nurse plan to do when creating a genogram?

A) Obtain information for at least two generations.
B) Depict members of each generation along a vertical line.
C) Begin the genogram with a proband.
D) At the top of the genogram indicate the gender of the patient.

Question 15

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?

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 16

The nurse has incorporated the principles of documentation into written communication. Which should the nurse recognize reflects the accuracy of the documentation?

A) Documentation that is limited to factualness.
B) Uniform language used throughout the documentation.
C) Limited sharing of the information.
D) Documentation that is completed promptly and is easily readable.

Question 17

The nurse is preparing to document a narrative note. Which format should the nurse use?

A) Paragraph.
B) Acronyms.
C) Bullet points.
D) Short sentences.

Question 18

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

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

Question 19

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

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 20

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?

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 21

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

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 22

The nurse is creating a genogram for a client. Which standard symbol should the nurse use to identify a male carrier?

A) Square half shaded.
B) Diamond shaded.
C) Fully shaded square.
D) Fully shaded circle.

Question 23

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.

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."

Question 24

The nurses have requested a documentation system that will reduce the time spent writing out routine tasks but will still allow for documentation of exceptions. Which type of documentation should the nurse manager consider implementing in the healthcare organization?

A) Focus documentation.
B) Flow sheets.
C) SOAP charting.
D) APIE charting.

Question 25

The nurse is preparing to record a narrative health history. Which assessments should the nurse include in the health history? Select all that apply.

A) Spirituality.
B) Biographic data.
C) Family history.
D) Sexuality.
E) Medications.

Question 26

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?

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

Question 27

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?

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 28

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

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 29

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?

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 30

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

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