Question 1

Related to Problem Oriented Medical Record (POMR)documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?

Accepted Answer

A)  "His surgery corrected the mobility problem,so I drew a line through it and dated it." 
B)  "The client's problem list has several resolved problems on it;should I take them off?" 
C)  "The client no longer has anxiety issues so I highlighted that problem on his problem list." 
D)  "He doesn't experience any dizziness now that we have his medication regulated,so I've erased that from his problem list."

Question 2

Regarding access to client records,the nursing faculty informs the nursing students to be prepared to:

Accepted Answer

A)  Show the unit staff proper student identification 
B)  Sign a confidentiality agreement when on the unit to preplan 
C)  Review the medical record only in the presence of unit staff 
D)  Obtain permission from the client to access his or her medical record

Question 3

When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider,this is called a:

Accepted Answer

A)  Referral 
B)  Consultation 
C)  Transfer report 
D)  Multidisciplinary meeting

Question 4

Which of the following nursing statements regarding the release of a client's medical record to another institution requires immediate follow-up by the nurse's manager?

Accepted Answer

A)  "I'm pretty sure this will require the client's permission." 
B)  "Are you sure of the exact policy? Do you know what I should do?" 
C)  "The client agreed to the consultation,so I'll have the chart sent over." 
D)  "I think the client will need to give a verbal consent before it can be sent."

Question 5

The nurse makes a late entry in a client's record.Which of the following is the best example of how to document this type of situation?

Accepted Answer

A)  "2:45 PM-ASA gr X given for temperature of 38.1° C." 
B)  "8:30 AM-Client received Percodan (1 tablet)PO an hour before going to radiology." 
C)  "12:15 PM-I gave the client morphine 10 mg IM at 11:10 AM but did not document it then." 
D)  "8:30 PM-Abdominal dressing change at 7:30 PM.No s/s of infection,and wound edges approximating well."

Question 6

Which of the following is an example of a problem statement used in the Problem-Intervention-Evaluation documentation method?

Accepted Answer

A)  Risk for injury related to falling due to dizziness 
B)  Client fell while walking to bathroom unassisted 
C)  Client continues to report periods of dizziness upon sitting up 
D)  Educated to the purpose of dangling on the bedside before standing

Question 7

The following statement: "Upon exertion,the client is wheezing and experiencing some dyspnea," is an example of:

Accepted Answer

A)  The "P" of PIE 
B)  FOCUS documentation 
C)  The "R" in DAR documentation 
D)  The "S" in SOAP documentation

Question 8

The nurse realizes that the incorrect spelling of terms in the medical record most importantly:

Accepted Answer

A)  Shows a lack of competency 
B)  Displays little attention to detail 
C)  Contributes to serious treatment errors 
D)  Negatively affects the accuracy of the documentation

Question 9

To locate the recording of a nurse's description of the teaching provided to the client on performance of self-medication administration,one would look in a(n):

Accepted Answer

A)  Kardex 
B)  Incident report 
C)  Nursing history form 
D)  Discharge summary form

Exam 26: Documentation and Informatics

Related to Problem Oriented Medical Record (POMR) documentation,which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem?