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A nurse is documenting the intensity of a patients pain. What would be the most accurate entry?
- A. Patient complaining of severe pain.
- B. Patient appears to be in a lot of pain and is crying.
- C. Patient states has pain; walking in hall with ease.
- D. Patient states pain is a 9 on a scale of 1 to 10.
Correct Answer: D
Rationale: Using a standardized pain scale, such as 1 to 10, provides a precise and measurable documentation of the patient's pain intensity, making it the most accurate entry.
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A nurse is documenting information about a patient in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)?
- A. PIE system
- B. minimum data set
- C. OASIS
- D. charting by exception
Correct Answer: B
Rationale: The minimum data set is a standardized tool used in Medicare-certified facilities for comprehensive resident assessment and RAI development.
A student has reviewed a patients chart before beginning assigned care. Which of the following actions violates patient confidentiality?
- A. writing the patients name on the student care plan
- B. providing the instructor with plans for care
- C. discussing the medications with a unit nurse
- D. providing information to the physician about laboratory data
Correct Answer: A
Rationale: Including the patient's name on a student care plan can expose confidential information if not properly secured, violating confidentiality.
What is the nurses best defense if a patient alleges nursing negligence?
- A. testimony of other nurses
- B. testimony of expert witnesses
- C. patients record
- D. patients family
Correct Answer: C
Rationale: The patient's record is the most objective and reliable evidence of the care provided, serving as the nurse's best defense against allegations of negligence.
Which of the following are examples of incidental disclosures of patient health information that are permitted? Select all that apply.
- A. A nurse working in a physicians office puts out a sign-in sheet for incoming patients.
- B. Two nurses are overheard talking about a patient through the door of an empty patient room.
- C. A nurse places a patient chart in a holder on the examining room door with the name facing out.
- D. A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms.
- E. A nurse calls out the name of a patient who is seated in the waiting room.
- F. A nurse leaves a reminder for an appointment on a patients answering machine along with the results of lab work.
Correct Answer: A,B,E
Rationale: Incidental disclosures like sign-in sheets, overheard conversations in clinical settings, and calling names in waiting rooms are permitted if reasonable safeguards are in place.
Which of the following methods of documenting patient data is least likely to hold up in court if a case of negligence is brought against a nurse?
- A. problem-oriented medical record
- B. charting by exception
- C. PIE charting system
- D. focus charting
Correct Answer: B
Rationale: Charting by exception only documents deviations from the norm, which may omit critical details, making it less defensible in court.