NURS 5463: Health History &
Documentation Review – Chapter 5
Exam Questions on Patient
Assessment, Record-Keeping, and
Clinical Communication Complete
Verified Questions Provided with A+
Graded Rationales LATEST UPDATED
2026
Which example illustrates a vague or non-descriptive term?
A. "Skin color is normal."
B. "Skin turgor is elastic."
C. "Skin is thin and smooth."
D. "Skin is warm and dry."
A. "Skin color is normal."
Wording of findings should be precise and objective so that their meaning is clear to all health
providers involved in the patient’s care. Use of words such as normal, good,
poor, and negative should be avoided, because these words are open to various interpretations
by other examiners.
Mrs. Tucker is a 57-year-old patient who presents to your office for a routine physical
examination. Most of her physical findings are normal. How are "normal findings" best
documented?
A. Write "normal" or "within normal limits" on the documentation form.
B. Write "NA" (not applicable) on the documentation sheet.
C. Because documentation focuses on abnormal findings, do not write anything down for
normal findings.
D. Document what was actually assessed in specific terms.
D. Document what was actually assessed in specific terms.
, Wording of findings should be precise and objective so that their meaning is clear to all health
providers involved in the patient’s care. Use of words such as normal, good,
poor, and negative should be avoided, because these words are open to various interpretations
by other examiners.
Mrs. Jones brings in her 2-month-old infant for a checkup. One way that a health history for an
infant differs from that of an adult is the inclusion of:
A. nutritional history.
B. chief complaint.
C. prenatal information.
D. personal social information.
C. prenatal information.
For older infants, record information as for adults; however, for newborns, include the details of
the mother's pregnancy and any untoward events occurring since birth.
If a mistake is made in the patient record, it is suggested that a line be drawn through it so that
it is still legible. The basis for this action is related to the fact that:
A. no errors are allowed.
B. the chart is a legal document.
C. a pen is messy when used to obliterate writing.
D. others may want to read what your first impressions were.
B. the chart is a legal document.
The patient's record is a legal document, and any information contained in it may be used in
court and in other legal proceedings, as well as to make health care payment determinations.
Which issue has most recently challenged the health care system in regard to the accuracy of
patient records?
A. Inclusion of detailed family and background data
B. Access to the record by multiple health care professionals
C. EMR recording errors by students in the health care delivery area
D. Inappropriate use of the CPCF function
D. Inappropriate use of the CPCF function
Although potentially being a very effective tool, the ability to easily copy and paste or carry
forward (CPCF) text from one note to another has become the latest hazard in electronic
Documentation Review – Chapter 5
Exam Questions on Patient
Assessment, Record-Keeping, and
Clinical Communication Complete
Verified Questions Provided with A+
Graded Rationales LATEST UPDATED
2026
Which example illustrates a vague or non-descriptive term?
A. "Skin color is normal."
B. "Skin turgor is elastic."
C. "Skin is thin and smooth."
D. "Skin is warm and dry."
A. "Skin color is normal."
Wording of findings should be precise and objective so that their meaning is clear to all health
providers involved in the patient’s care. Use of words such as normal, good,
poor, and negative should be avoided, because these words are open to various interpretations
by other examiners.
Mrs. Tucker is a 57-year-old patient who presents to your office for a routine physical
examination. Most of her physical findings are normal. How are "normal findings" best
documented?
A. Write "normal" or "within normal limits" on the documentation form.
B. Write "NA" (not applicable) on the documentation sheet.
C. Because documentation focuses on abnormal findings, do not write anything down for
normal findings.
D. Document what was actually assessed in specific terms.
D. Document what was actually assessed in specific terms.
, Wording of findings should be precise and objective so that their meaning is clear to all health
providers involved in the patient’s care. Use of words such as normal, good,
poor, and negative should be avoided, because these words are open to various interpretations
by other examiners.
Mrs. Jones brings in her 2-month-old infant for a checkup. One way that a health history for an
infant differs from that of an adult is the inclusion of:
A. nutritional history.
B. chief complaint.
C. prenatal information.
D. personal social information.
C. prenatal information.
For older infants, record information as for adults; however, for newborns, include the details of
the mother's pregnancy and any untoward events occurring since birth.
If a mistake is made in the patient record, it is suggested that a line be drawn through it so that
it is still legible. The basis for this action is related to the fact that:
A. no errors are allowed.
B. the chart is a legal document.
C. a pen is messy when used to obliterate writing.
D. others may want to read what your first impressions were.
B. the chart is a legal document.
The patient's record is a legal document, and any information contained in it may be used in
court and in other legal proceedings, as well as to make health care payment determinations.
Which issue has most recently challenged the health care system in regard to the accuracy of
patient records?
A. Inclusion of detailed family and background data
B. Access to the record by multiple health care professionals
C. EMR recording errors by students in the health care delivery area
D. Inappropriate use of the CPCF function
D. Inappropriate use of the CPCF function
Although potentially being a very effective tool, the ability to easily copy and paste or carry
forward (CPCF) text from one note to another has become the latest hazard in electronic
