Nokea
Patient health care records are:
- A. not used by anyone else but the direct care providers
- B. concise, legal records of all care given and responses
- C. owned by the patient, who has a right to see the data any time he/she wishes
- D. confidential information and cannot be taken to court
Correct Answer: B
Rationale: Records (B) are legal, concise documentation of care and responses, used by multiple parties. A, C, and D are incorrect regarding usage, ownership, and legal status.
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Identify the two primary methods used to collect data:
- A. interview and physical examination
- B. review of the doctor's orders and the Kardex
- C. written report by patient and family
- D. review of the chart and the nurse's notes
Correct Answer: A
Rationale: Interview and physical examination (A) collect subjective and objective data directly. B, C, and D are secondary or supportive methods.
When using the SOAP method of charting, S stands for subjective data which means:
- A. patient provided data
- B. all of the answers are correct
- C. observed data
- D. measured data
Correct Answer: A
Rationale: Subjective data (A) includes patient-reported information like pain or symptoms. Observed (C) and measured (D) data are objective, and B is incorrect as only A is accurate.
How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?
- A. It serves as a reminder of human growth and development across the life span
- B. It helps in prioritizing nursing diagnoses and care
- C. It outlines the basic psychological needs that people have when they are hospitalized and feel anxiety
- D. It is a framework for thinking critically
Correct Answer: B
Rationale: Maslow's hierarchy (B) prioritizes care by addressing physiological needs first, then safety, love, esteem, and self-actualization. A, C, and D are less accurate uses.
When documenting events in a patient's chart, the nurse should chart:
- A. the specific time of all sudden changes in the patient's condition
- B. the period the shift covers
- C. every 2 hours
- D. every hour on the hour
Correct Answer: A
Rationale: Charting sudden changes with specific times (A) ensures accuracy and supports care decisions. B, C, and D are less precise or unnecessary.
Identify the person responsible for analyzing and interpreting data to arrive at a nursing diagnosis:
- A. CNA
- B. Technician
- C. RN
- D. LPN/LVN
Correct Answer: C
Rationale: The RN (C) is responsible for analyzing data and formulating nursing diagnoses, as it requires critical thinking within their scope of practice. CNAs (A) and Technicians (B) assist with care but do not diagnose. LPNs/LVNs (D) collect data but do not formulate diagnoses.