Chapter 08: Recognizing and Analyzing
Cues in Gerontological Nursing Touhy:
Ebersole and Hess’ Gerontological
Nursing & Healthy Aging, 6th Edition
Which of the following is a true statement about documentation?
a. Nurses should keep records of clients' wishes.
b. Clients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete record of the
health status of a client.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS). correct
answers ANS: A
Entering clients' expressed wishes in the medical or clinical record helps ensure that the
interdisciplinary team respects these wishes. According to regulations after the
enactment of the Health Insurance Portability and Accountability Act (HIPAA), the client
has access to his or her own medical records and may designate others to have
access. The OASIS is used to measure outcomes for quality improvement purposes; it
does not contain all of the necessary information for care, such as vital signs. The MDS
should be completed jointly by all members of the interdisciplinary team.
Which one of the following is connected with the nursing home reform mandated by a
1987 law?
a. Resident Assessment Instrument (RAI)
b. HIPAA
c. OASIS
d. Fulmer SPICES correct answers ANS: A
The RAI must be completed for all residents receiving Medicare or Medicaid. The
HIPAA was passed in 1996 and mandates privacy practices. The OASIS is an
assessment designed for use in the home health care setting. Fulmer SPICES is an
overall assessment tool developed in 2007.
An older adult client has diabetes mellitus and requires hemodialysis for renal failure.
The client is discharged to home to recover from a sternal wound infection and coronary
artery bypass graft surgery (CABG). A home care nurse will provide wound care. Which
of the following is the major justification for the complete and accurate documentation of
this client's care?
a. Requires complex health care
, b. Has needs in multiple settings
c. Is at risk for iatrogenic problems
d. Has significant health care expenses correct answers ANS: A
The major reason that documentation of this client's health care must be accurate and
complete is that she has complex health care needs in multiple settings and
experiences a high risk for iatrogenic problems and high reimbursement expenses. The
duration of her care is likely to be lengthy; the sternal wound infection after CABG is
serious because of the potential for sternal osteomyelitis. In addition, individuals with
diabetes are at high risk for infection and are slow to heal. The complexity of the care
includes receiving care in multiple settings—at home, at dialysis, and in primary care for
post discharge follow-up care. For an older adult with diabetes, coronary artery disease,
renal failure, and a serious infection, each facet of health care depends on complete
and accurate data on the other aspects of her care to help her achieve optimal health
and wellness. This older adult is at risk for iatrogenic problems because of the
complexity of care. Each type of care, each illness or condition, and each setting
exposes this older adult to a separate set of risks. In addition, individuals with diabetes
can have peripheral neuropathies that increase the risk for falls and injuries. This older
adult incurs health care expenses dealing with complex health care requirements
including a recent hospital stay for surgery and complicated by an infection, ongoing
needs for hemodialysis, and home care. Because much of the care is nurse driven,
documentation is the basis for which reimbursement is provided.
Which documentation tool does the nurse use to achieve optimal functional status for a
nursing home resident?
a. Narrative client progress notes
b. Problem-oriented documentation
c. Resource Utilization Group (RUG)
d. Resident Assessment Instrument (RAI) correct answers ANS: D
Mandated by the federal government to improve the quality of care for nursing home
residents, the nurse uses the RAI to help residents in nursing homes achieve optimal
functional status. The RAI includes identification of issues with the MDS, a
comprehensive assessment from Resident Assessment Protocols (RAPs), and the
foundation for reimbursement using the RUG. Narrative progress notes are used in
nursing homes to describe events that are unsuitable for other forms of documentation
in the medical record. Problem-oriented documentation identifies resident problems, the
plan of care to resolve the problem, and the outcome of the problem or response to
treatment. The RUG is the reimbursement tool in the RAI.
Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger for a
male nursing home resident who requires an indwelling urinary catheter from the
Minimum Data Set (MDS). Which should the nurse do next?
a. Develop an individualized care plan.
b. Assign suitable nursing interventions.
c. Refer to the appropriate quality measures.
Cues in Gerontological Nursing Touhy:
Ebersole and Hess’ Gerontological
Nursing & Healthy Aging, 6th Edition
Which of the following is a true statement about documentation?
a. Nurses should keep records of clients' wishes.
b. Clients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete record of the
health status of a client.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS). correct
answers ANS: A
Entering clients' expressed wishes in the medical or clinical record helps ensure that the
interdisciplinary team respects these wishes. According to regulations after the
enactment of the Health Insurance Portability and Accountability Act (HIPAA), the client
has access to his or her own medical records and may designate others to have
access. The OASIS is used to measure outcomes for quality improvement purposes; it
does not contain all of the necessary information for care, such as vital signs. The MDS
should be completed jointly by all members of the interdisciplinary team.
Which one of the following is connected with the nursing home reform mandated by a
1987 law?
a. Resident Assessment Instrument (RAI)
b. HIPAA
c. OASIS
d. Fulmer SPICES correct answers ANS: A
The RAI must be completed for all residents receiving Medicare or Medicaid. The
HIPAA was passed in 1996 and mandates privacy practices. The OASIS is an
assessment designed for use in the home health care setting. Fulmer SPICES is an
overall assessment tool developed in 2007.
An older adult client has diabetes mellitus and requires hemodialysis for renal failure.
The client is discharged to home to recover from a sternal wound infection and coronary
artery bypass graft surgery (CABG). A home care nurse will provide wound care. Which
of the following is the major justification for the complete and accurate documentation of
this client's care?
a. Requires complex health care
, b. Has needs in multiple settings
c. Is at risk for iatrogenic problems
d. Has significant health care expenses correct answers ANS: A
The major reason that documentation of this client's health care must be accurate and
complete is that she has complex health care needs in multiple settings and
experiences a high risk for iatrogenic problems and high reimbursement expenses. The
duration of her care is likely to be lengthy; the sternal wound infection after CABG is
serious because of the potential for sternal osteomyelitis. In addition, individuals with
diabetes are at high risk for infection and are slow to heal. The complexity of the care
includes receiving care in multiple settings—at home, at dialysis, and in primary care for
post discharge follow-up care. For an older adult with diabetes, coronary artery disease,
renal failure, and a serious infection, each facet of health care depends on complete
and accurate data on the other aspects of her care to help her achieve optimal health
and wellness. This older adult is at risk for iatrogenic problems because of the
complexity of care. Each type of care, each illness or condition, and each setting
exposes this older adult to a separate set of risks. In addition, individuals with diabetes
can have peripheral neuropathies that increase the risk for falls and injuries. This older
adult incurs health care expenses dealing with complex health care requirements
including a recent hospital stay for surgery and complicated by an infection, ongoing
needs for hemodialysis, and home care. Because much of the care is nurse driven,
documentation is the basis for which reimbursement is provided.
Which documentation tool does the nurse use to achieve optimal functional status for a
nursing home resident?
a. Narrative client progress notes
b. Problem-oriented documentation
c. Resource Utilization Group (RUG)
d. Resident Assessment Instrument (RAI) correct answers ANS: D
Mandated by the federal government to improve the quality of care for nursing home
residents, the nurse uses the RAI to help residents in nursing homes achieve optimal
functional status. The RAI includes identification of issues with the MDS, a
comprehensive assessment from Resident Assessment Protocols (RAPs), and the
foundation for reimbursement using the RUG. Narrative progress notes are used in
nursing homes to describe events that are unsuitable for other forms of documentation
in the medical record. Problem-oriented documentation identifies resident problems, the
plan of care to resolve the problem, and the outcome of the problem or response to
treatment. The RUG is the reimbursement tool in the RAI.
Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger for a
male nursing home resident who requires an indwelling urinary catheter from the
Minimum Data Set (MDS). Which should the nurse do next?
a. Develop an individualized care plan.
b. Assign suitable nursing interventions.
c. Refer to the appropriate quality measures.
