Nokea
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Which of these following types of data should be included in weekly summaries in a long-term care facility?
- A. Use of prosthesis
- B. Activity level
- C. Length of time the resident has been at the facility
- D. Whether continent or incontinent of bowel and bladder
- E. Whether the resident can speak
- F. Whether the resident routinely has relatives and visitors
- G. Social activities in which the resident participates
Correct Answer: A,B,D,E,F,G
Rationale: Weekly summaries should include prosthesis use (A), activity level (B), continence (D), speech ability (E), visitors (F), social activities (G), self-care ability (I), and diet (J). Length of stay (C), staff conflicts (H), and payment status (K) are not typically included.
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Indicate whether the following statements are True (T) or False (F). When documenting patient teaching, the only thing that must be included is the subject that was taught and the methods used to teach the subject.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): Documentation should also include patient understanding and response to teaching.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. Some of the following documentation phrases include subjective terminology that needs to be changed to objective terminology. Select the phrases with subjective terms and underline the subjective word(s) that need(s) to be changed to objective.
- A. Snored loudly most of night between 0030 and 0530.
- B. Green purulent drainage increased from yesterday. ABD pad has 6' circle of drainage.
- C. Procedure tolerated well.
- D. ADA diet-ate 75% tolerated poorly.
- E. Bouncing foot almost continually. Rubbing hands and flicking finger with thumb at intervals. Verbally denies feeling nervous or anxious.
- F. Got mad while ambulating in the hall.
- G. Has a bad attitude.
Correct Answer: C,D,F,G
Rationale: Subjective terms: 'tolerated well' (C), 'tolerated poorly' (D), 'got mad' (F), 'bad attitude' (G). These should be replaced with objective descriptions. A, B, and E are objective.
Choose the correct answer(s). In some questions, more than one answer is correct. Select all that apply. When using electronic (or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered?
- A. Charting in code
- B. Logging off
- C. Charting in privacy
- D. Signing on with a password
Correct Answer: B
Rationale: Logging off (B) prevents unauthorized access and alterations. Charting in code (A) is not standard, privacy (C) is important but not preventive, and passwords (D) are for access, not alteration prevention.
Indicate whether the following statements are True (T) or False (F). A federal law known as OBRA mandates that an extensive assessment form called the MDS must be completed on every patient admitted to the hospital.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): OBRA mandates the MDS for long-term care facilities, not hospitals.
Indicate whether the following statements are True (T) or False (F). Failure to document administration of a medication does not carry a potential legal risk.
- A. TRUE
- B. FALSE
Correct Answer: B
Rationale: False (F): Failing to document medication administration poses a legal risk due to potential patient harm and accountability issues.