Chapter 26: Recording Information Test Bank—Nursing (GRADED A) Questions and Answer solutions
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Course
NURSING N 224
Institution
University Of Texas
Chapter 26: Recording Information Test Bank—Nursing MULTIPLE CHOICE 1. If information is purposely omitted from the record, you should: a. erase the notes that are not pertinent. b. accep t that sometimes data are omitted. c. state in the record why the information was omitted. d. use correction ...
chapter 26 recording information test bank—nursing graded a questions and answer solutions
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1 if information is purposely omitted from the re
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NURSING N 224
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Chapter 26: Recording Information
Test Bank—Nursing
MULTIPLE CHOICE
1. If information is purposely omitted from the record, you should:
a. erase the notes that are not pertinent.
b. accept that sometimes data are omitted.
c. state in the record why the information was omitted.
d. use correction fluid to cover the information.
ANS: C
Any deferred or omitted portion of the patient record requires proper documentation that
documents this occurrence, along with a rationale for doing so. Erasures and use of correction
fluid are inappropriate methods.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 616
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
2. Which part of the information contained in the patient’s record may be used in court?
a. Subjective information only
b. Objective information only
c. Diagnostic information only
d. All information
ANS: D
Anything that is entered into a patient’s record, in paper or electronic form, is a legal
document and can be used in court.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 616
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
3. During the course of the interview, you should:
a. take no notes of any kind.
b. take brief written notes.
c. take detailed written notes.
d. repeat pertinent comments into a dictation devise.
ANS: B
During the interviewing process, it is important to maintain eye contact with the patient and to
spend as little time as possible looking at your notes, so brief written notes are more practical.
Later you can go back and formulate a well-versed history by linking all the pieces together.
DIF: Cognitive Level: Applying (Application) REF: p. 616
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
, 4. Ms. S reports that she is concerned about her loss of appetite. During the history, you learn
that her last child recently moved out of her house to go to college. Rather than infer the cause
of Ms. S’s loss of appetite, it would be better to:
a. defer or omit her comments.
b. have her husband call you.
c. quote her concerns verbatim.
d. refer her for psychiatric treatment.
ANS: C
It is best to document what you observe and what is said by the patient rather than
documenting your interpretation. Listening and quoting exactly what the patient says is the
better rule to follow.
DIF: Cognitive Level: Applying (Application) REF: p. 621
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
5. Subjective and symptomatic data are:
a. documented with the physical examination findings.
b. not mentioned in the legal chart.
c. placed in the history section.
d. recorded with the examination technique.
ANS: C
Subjective data, as well as symptomatic data, should be placed in the history section.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 621
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
6. The quality of a symptom, such as pain, is subjective information that should be:
a. deferred until the cause is determined.
b. described in the history.
c. placed in the past medical history section.
d. placed in the history with objective data.
ANS: B
Information about pain is subjective and only the patient can rate the perceived severity. Pain,
therefore, should be recorded in the history.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 616
OBJ: Integrated process—communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
7. Which of the following is an effective adjunct to document the location of findings during the
recording of the physical examination?
a. Relationship to anatomic landmarks
b. Computer graphics
c. Comparison with other patients of same gender and size
d. Comparison to previous examinations using light pen markings
ANS: A
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