Question 1

The nurse is reviewing the charting from the previous shift. Which should the nurse recognize is appropriate to chart?

Accepted Answer

The answer of The nurse is reviewing the charting from...

Question 2

The nurse is creating a genogram for a client. Which standard symbol should the nurse use to identify a male carrier?

Accepted Answer

A square half shaded is the standard symbol used in genograms to identify a male carrier of a trait or condition.

Question 3

The nurse educator is presenting information about the APIE method of charting to the staff nurses. Which statements by the nurses should the preceptor recognize indicates an understanding of the information? Select all that apply.

Accepted Answer

The APIE method of charting includes assessment (A), problem (P), intervention (I), and evaluation (E). Only subjective data are not included in the assessment portion. The chief problem of the client is documented in the "P" section. The activities implemented to manage the client's needs are documented in the "I" section. The evaluation that occurs after an intervention is implemented is documented in the "E" section.

Question 4

The nurses have requested a documentation system that will reduce the time spent writing out routine tasks but will still allow for documentation of exceptions. Which type of documentation should the nurse manager consider implementing in the healthcare organization?

Accepted Answer

Flow sheets are designed to allow healthcare providers to quickly document routine tasks and observations, making them ideal for reducing the time spent on writing out these tasks. They also provide a structured format that can accommodate the documentation of exceptions when they occur.

Question 5

The nurse is preparing to record a narrative health history. Which assessments should the nurse include in the health history? Select all that apply.

Accepted Answer

The answer of The nurse is preparing to record a...

Question 6

The nurse is preparing to document a client's position that is laying on their back facing the ceiling. Which terminology should the nurse use in the documentation?

Accepted Answer

The correct term for a position where a person is lying on their back facing the ceiling is "supine." This term specifically refers to this orientation, distinguishing it from other positions such as prone (lying face down), lateral (lying on the side), and anterior (referring to the front aspect of the body but not a specific position).

Question 7

The nurse manager is reviewing SOAP entries in the medical record for a novice nurse. Which entry indicates that the nurse needs further instruction concerning documentation?

Accepted Answer

B) is incorrect because it is labeled as an "O" (Objective) entry, but it actually describes subjective information (the client's report of feeling fatigued). Objective data should be observable and measurable by the nurse, such as vital signs or physical examination findings.

Question 8

The nurse is reviewing the different types of documentation. Which should the nurse recognize is a benefit to charting by exception?

Accepted Answer

Charting by exception eliminates unnecessary repetition in documentation by focusing only on deviations from predefined norms, making the documentation process more efficient.

Question 9

A client tells the nurse that her mother has type II diabetes. Which information about the patient's mother should the nurse include in genogram?

Accepted Answer

The age of onset of type II diabetes is relevant for a genogram as it provides insight into the hereditary and familial patterns of the disease, which can be important for assessing the patient's risk.

Question 10

A client asks the nurse why they are creating a genogram. Which information should the nurse provide the patient with?

Accepted Answer

A genogram is a tool used to identify genetic risk factors by mapping out family history and relationships, which can help in understanding inherited health issues.

Quiz 6: Documentation