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What factors in the data presented contribute to your increasing concern for this patient's safety?
- A. Multiple bruises, thin appearance, inadequate clothing, flinching
- B. Patient's age, fractured tibia, hospital admission
- C. Mother's dismissive comments, patient eating quickly
- D. No family support, cold weather
Correct Answer: A
Rationale: Bruises, thinness, inadequate clothing, and flinching suggest possible abuse or neglect.
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Who owns a hospitalized patient's medical record?
- A. The patient
- B. The physician
- C. The hospital
- D. The patient's primary care nurse
- E. The patient's insurance company
Correct Answer: C
Rationale: The hospital owns the physical medical record, though the patient has rights to access the information.
Documenting something that you did not actually do would be legally considered as what?
- A. Fraud
- B. Negligence
- C. Malpractice
- D. Battery
Correct Answer: A
Rationale: Falsifying documentation is considered fraud, as it misrepresents care provided.
The law that provides legal protection to the voluntary caregiver at sites of accidents and emergencies is called the law.
- A. Good Samaritan
- B. HIPAA
- C. EMTALA
- D. Tort
Correct Answer: A
Rationale: The Good Samaritan law protects voluntary caregivers from legal liability when providing emergency care.
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.
Explain how to legally correct an error a nurse makes in documentation.
- A. Draw a single line through the error, initial, and date it
- B. Erase the error completely
- C. Use correction fluid to cover the error
- D. Write over the error
Correct Answer: A
Rationale: A single line through the error with initials and date preserves transparency and maintains legal integrity.