NRSE 260 EXAM 4 QUESTIONS AND CORRECT DETAILED
ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED
A+||BRAND NEW
Information regarding a patient's health status may not be released to
non-health care team members because:
A. legal and ethical obligations require health care providers to keep
information strictly confidential.
B. regulations require health care institutions to document evidence of
physical and emotional well-being.
C. reimbursement issues related to patient care and procedures may be
of concern.
D. fragmentation of nursing and medical care procedures may be
identified. Ans✓✓✓A- Rationale: Under HIPAA laws, a patient's
medical information can only be released to team members, unless
express written consent is given by the patient.
A nurse has just admitted a patient with a medical diagnosis of
congestive heart failure. When completing the admission paper work,
the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entry using lay terminology.
D. abbreviations familiar to the nurse. Ans✓✓✓B- Rationale: Objective
data are part of the assessment portion of the nursing process. All data
collected during the nursing process should be documented.
,A nurse records that the patient stated his abdominal pain is worse now
than last night. This is an example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception. Ans✓✓✓C- Rationale: Writing subjective
data, which includes the information the patient verbalizes, is written in
narrative charting.
A patient you are assisting has fallen in the shower. You must complete
an incident report. The purpose of an incident report is to:
A. exchange information among health care members.
B. provide information about patients from one unit to another unit.
C. ensure proper care for the patient.
D. aid in the hospital's quality improvement program. Ans✓✓✓D-
Rationale: Any deviation from the norm, such as a patient fall, can be
used to improve quality. Incidents are gathered and assessed to see if
there is a way to prevent it from happening again.
What does EHR stand for? Ans✓✓✓Electronic Health Record:
- digital record of health info
- streamlined sharing of updated info
- allows patients medical info to move with them
-access to tools that providers can use for decision making
, What does EMR stand for? Ans✓✓✓Electric Medical Record:
- digital version of the chart
-not designated to be shared outside the individual practice
- patient record does not easily travel outside of practice
- mainly used by providers for diagnosis and treatment
What is HIPPA? Ans✓✓✓the privacy rule requires that nurses protect
all written and verbal communication about patients
Information Security Protocols Ans✓✓✓• Log off from the computer
before leaving the workstation to ensure that others cannot view
protected health information on the monitor
• Never share a user ID or password with anyone
• Never leave a medical record or other printed or written PHI where
others can access it.
• Shred any printed or written patient information for reporting or patient
care after use.
Handling and Disposing of Information Ans✓✓✓• You must safeguard
any information that is printed from the record or extracted for report
purposes
ANSWERS (VERIFIED ANSWERS) |ALREADY GRADED
A+||BRAND NEW
Information regarding a patient's health status may not be released to
non-health care team members because:
A. legal and ethical obligations require health care providers to keep
information strictly confidential.
B. regulations require health care institutions to document evidence of
physical and emotional well-being.
C. reimbursement issues related to patient care and procedures may be
of concern.
D. fragmentation of nursing and medical care procedures may be
identified. Ans✓✓✓A- Rationale: Under HIPAA laws, a patient's
medical information can only be released to team members, unless
express written consent is given by the patient.
A nurse has just admitted a patient with a medical diagnosis of
congestive heart failure. When completing the admission paper work,
the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entry using lay terminology.
D. abbreviations familiar to the nurse. Ans✓✓✓B- Rationale: Objective
data are part of the assessment portion of the nursing process. All data
collected during the nursing process should be documented.
,A nurse records that the patient stated his abdominal pain is worse now
than last night. This is an example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception. Ans✓✓✓C- Rationale: Writing subjective
data, which includes the information the patient verbalizes, is written in
narrative charting.
A patient you are assisting has fallen in the shower. You must complete
an incident report. The purpose of an incident report is to:
A. exchange information among health care members.
B. provide information about patients from one unit to another unit.
C. ensure proper care for the patient.
D. aid in the hospital's quality improvement program. Ans✓✓✓D-
Rationale: Any deviation from the norm, such as a patient fall, can be
used to improve quality. Incidents are gathered and assessed to see if
there is a way to prevent it from happening again.
What does EHR stand for? Ans✓✓✓Electronic Health Record:
- digital record of health info
- streamlined sharing of updated info
- allows patients medical info to move with them
-access to tools that providers can use for decision making
, What does EMR stand for? Ans✓✓✓Electric Medical Record:
- digital version of the chart
-not designated to be shared outside the individual practice
- patient record does not easily travel outside of practice
- mainly used by providers for diagnosis and treatment
What is HIPPA? Ans✓✓✓the privacy rule requires that nurses protect
all written and verbal communication about patients
Information Security Protocols Ans✓✓✓• Log off from the computer
before leaving the workstation to ensure that others cannot view
protected health information on the monitor
• Never share a user ID or password with anyone
• Never leave a medical record or other printed or written PHI where
others can access it.
• Shred any printed or written patient information for reporting or patient
care after use.
Handling and Disposing of Information Ans✓✓✓• You must safeguard
any information that is printed from the record or extracted for report
purposes
