Which of the following are examples of breaches of patient confidentiality? Select all that apply.
- A. A nurse discusses a patient with a coworker in the elevator.
- B. A nurse shares her computer password with a relative of a patient.
- C. A nurse checks the medical record of a patient to see who should be called in an emergency.
- D. A nurse updates the employer of a patient regarding the patients return to work.
- E. A nurse uses a computer to document a patients response to pain medication.
- F. A head nurse accesses the medical records of a nurse on her shift to check her condition.
Correct Answer: A,B,D,F
Rationale: Discussing patient information in public, sharing passwords, disclosing to unauthorized parties, and accessing records without a care-related purpose are breaches of confidentiality.
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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.
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.
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.
A nurse organizes patient data using the SOAP format. Which of the following would be recorded under S of this acronym?
- A. patient complaints of pain
- B. patient symptoms
- C. patients chief complaint
- D. patient interventions
Correct Answer: A
Rationale: The 'S' in SOAP stands for subjective data, which includes the patient's complaints, such as pain.
Which of the following information would a nurse include as part of a minimum data set when using electronic medical records? Select all that apply.
- A. patient sex
- B. patient admission date
- C. patient physical assessment
- D. patient insurance
- E. patient history
- F. patient ethnicity
Correct Answer: A,B,D,F
Rationale: The minimum data set includes demographic and administrative data like sex, admission date, insurance, and ethnicity to ensure standardized reporting.
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