Exam (elaborations)
5. The Patient Record -New title focus!
- Course
- Nursing Tests
- Institution
- Albany Memorial School Of Nursing
5. The Patient Record -New title focus!
[Show more]
Content preview
Chapter 05: The Patient Record [New title / focus!]MULTIPLE CHOICE
1. Which pa of he info ma ion con ained in he pa ien eco d ma be ed in co ?
a. Subjective information only b. Objective information only c. Diagnostic information only d.
All information
ANS: D
An hing ha i en e ed in o a pa ien eco d, in pape o elec onic fo m, is a legal document and can be used
in court.
DIF: Cognitive Level: Remembering (Knowledge)
OBJ: Integrated process communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
2. Ms. S reports that she is concerned about her loss of appetite. During the history, you learn that her
last child recently moved out of her house to go to college. Rather than infer the cause of M . S lo of
appe i e, i o ld be be e o: a. defer or omit her comments.
b. have her husband call you.
c. quote her concerns verbatim.
d. refer her for psychiatric treatment.
ANS: C
It is best to document what you observe and what is said by the patient rather than documenting your
interpretation. Listening and quoting exactly what the patient says is the better rule to follow.
DIF: Cognitive Level: Applying (Application)
OBJ: Integrated process communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
3. Which is an effective adjunct to document the location of findings during the recording of the physical
examination?
a. Relationship to anatomic landmarks
b. Computer graphics
c. Comparison with other patients of same gender and size
d. Comparison to previous examinations using light pen markings
ANS: A
Abnormal or normal findings are best described in relationship to universal topographic and anatomic
landmarks.
DIF: Cognitive Level: Understanding (Comprehension)
OBJ: Integrated process communication and documentation
MSC: Physiologic Integrity: Basic Care and Comfort
4. The position on a clock, topographic notations, and anatomic landmarks:
a. are methods for recording locations of findings.
, b. are used for noting disease progression.
c. are ways for recording laboratory study results.
d. should not be used in the legal record.
ANS: A
Descriptions of the locations of findings are universally referenced by using positions on a clock,
topographic notations, or anatomic landmarks.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Sirih. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $8.99. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
52510 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now