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In a court of law, there is a standard regarding documentation in patients' records. What is this standard and what does it mean?
- A. If it wasn't documented, it wasn't done
- B. Document only what you observe
- C. Document only what the patient reports
- D. Document only physician orders
Correct Answer: A
Rationale: This standard means that undocumented actions are assumed not to have occurred in legal proceedings.
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What would be your legal responsibility regarding this information?
- A. Report suspected abuse to authorities
- B. Document findings and inform supervisor
- C. Discuss concerns with the mother
- D. Monitor the patient without reporting
Correct Answer: A,B
Rationale: Nurses are mandated reporters and must document and report suspected abuse to protect the patient.
Which of the following nursing actions would be considered proactive prevention of lawsuits?
- A. Meeting your patient's needs
- B. Treating your patient with dignity
- C. Developing good nurse-patient rapport
- D. Keeping conversation with your patient to a minimum to reduce chances of offending the patient
- E. Explaining procedures and ensuring the patient's understanding before performing the procedure
Correct Answer: A,B,C,E
Rationale: These actions foster trust, respect, and clear communication, reducing the likelihood of misunderstandings or complaints that could lead to lawsuits.
What further concerns you the most about this child's situation?
- A. Flinching when mother gestures
- B. Inadequate clothing for cold weather
- C. Multiple bruises on back and arms
- D. Rapid eating and requesting more food
Correct Answer: C
Rationale: Multiple bruises indicate potential physical abuse, a serious safety concern.
The federal agency that supports health promotion and prevention of disease that also helps health-care professionals be prepared to respond to outbreaks of diseases and illnesses is called the
- A. Centers for Disease Control and Prevention (CDC)
- B. Food and Drug Administration (FDA)
- C. National Institutes of Health (NIH)
- D. Department of Health and Human Services (HHS)
Correct Answer: A
Rationale: The CDC is the federal agency responsible for health promotion, disease prevention, and preparedness for disease outbreaks.
Which of the following data should be included in an incident report regarding each incident?
- A. A patient was found on the floor in the bathroom. Include what you believe happened to result in the patient being on the floor.
- B. You administered an incorrect medication to a patient. Include the name, dose, and route of the medication administered.
- C. A patient fell while you were ambulating the patient in the hallway. Include vital signs assessed after the fall.
- D. A patient suffered a skin tear while you were assisting the patient to get out of bed. Include the location, size, and description of the skin tear.
Correct Answer: B,C,D
Rationale: Incident reports should include objective, factual details like medication specifics, vital signs, and injury descriptions, not assumptions.