90 UNIT III THE NURSING PROCESS
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:ALTERNATE-FORMAT QUESTIONS
Multiple Response Questions
Circle the letters that correspond to the best
answers for each question.
1.Which of the following statements are
accurate guidelines for communicating and
documenting patient information? (Select all
that apply.)
a.The patient record is the only permanent
legal document that details the nurse’s
interactions with the patient.
b.The patient record should not be relied on
as a defense against nursing negligence
charges.
c.Omissions and errors in the nursing docu-
mentation always affect patient care.
d.Documentation should be accurate,
concise, legally prudent, and confidential.
e.Only information regarding the patient
that pertains to patient care is considered
confidential.
f.Personal codes of ethics, agency policies,
and state and federal privacy legislation
dictate how patient information can be
communicated.
2.According to HIPAA, patients have the right to
do which of the following with their health
record? (Select all that apply.)
a.See their health record.
b.Copy their health record.
c.Destroy their health record.
d.Change their health record.
e.Update their health record.
f.Request a restriction on all uses and
disclosures.
3.Which of the following are potential
documentation errors that increase the risk
for legal problems? (Select all that apply.)
a.The content reflects patient needs.
b.The content includes descriptions of
situations that are out of the ordinary.
c.The content is not in accordance with
professional or healthcare organization
standards.
d.There are lines between the entries.
e.The documentation is not countersigned.
f.Dates and times of entries are omitted.6.You are finding it difficult to plan and
implement care for Mr. Rivers and decide to
have a nursing care conference. Which of the
following best defines this action?
a.You consult with someone in order to
exchange ideas or seek information, advice,
or instructions.
b.You meet with nurses or other healthcare
professionals to discuss some aspect of
patient care.
c.You and other nurses visit similar patients
individually at each patient’s bedside in
order to plan nursing care.
d.You send or direct someone for action in a
specific nursing care problem.
7.Which of the following is an accurately
written documentation of the effectiveness of
a patient’s pain management?
a.Mr. Gray is receiving sufficient relief from
pain medication.
b.Mr. Gray appears comfortable and is resting
adequately.
c.Mr. Gray reports that on a scale of 1 to 10,
the pain he is experiencing is a 3.
d.Mr. Gray appears to have a low tolerance
for pain and complains frequently about
the intensity of his pain.
8.Which of the following guidelines for charting
patient information is accurate?
a.Nursing interventions should be charted
chronologically on consecutive lines.
b.If a mistake is made on a chart, correcting
fluid should be used to change the
mistake.
c.Charting should be done in pencil to
facilitate correction of mistakes.
d.If a procedure is repeated frequently, it is
proper to use dittos to decrease recording
time.
9.Which of the following is a form used to
record specific patient variables such as pulse,
respiratory rate, blood pressure, and body
temperature?
a.Progress notes
b.Flow sheets
c.Graphic sheets
d.Medical recordsLWBK696-C17_p89-95.qxd 9/2/10 9:28 AM Page 90 Aptara Inc