NUR 1400 Exam 2 Documentation Questions and Answers Solved Correctly Latest Update
2025-2026
Assertiveness - Answers - confined, open body posture
-eye contact
- use of clean, concise "I" statements
- the ability to share through, feelings, and emotions
-attitude toward work is characterized by working to capacity with or without supervision
-the ability to remain calm under supervision
-the freedom to ask for help when necessary
-the ability to give and accept compliments
-honesty in admitting mistakes and taking responsibility for them
documenting and reporting - Answers What are the two main communications in nursing
- identity/introduction
- situation
- background
- assessment
- recommendation/ request
- questions - Answers What is ISBARQ?
Situation
Background
Assessment
Recommendation - Answers What is SBAR?
- Change-of-shift report of handoff report
- transfer
- discharge
- telephone reports (labs, imaging, providers)
, - Reports to family members and significant others - Answers When does reporting occur?
- If the patient is unable to communicate information
- Information should be shared in a manner that is honest, compassionate, and respectful of the
person's ability to understand medical concepts - Answers When can a nurse give report to
family members and significant others?
Purposeful rounds - Answers involves repositioning, toileting, personal needs, and pain present
ADPIE - Answers Documentation is a written or electronic record of all pertinent interactions
with the pt:
Patient's health information - Answers PHI
crucial omissions and meaningless repetitious or inaccurate entries - Answers What should be
avoided when documenting?
accessible, accurate, consistent, cena, complete, thoughtful, timely, reflective of the nursing
process - Answers What are the characteristics of effective documentations?
- written on paper
- saved on a computer
- spoken aloud - Answers All information about patients is considered private or confidential,
whether ______, ____, or _____
Heath Insurance Portability and Accountability Act - Answers HIPAA
- see and copy their health record
- update their health record
- see an itemized bill
- request restrictions on sharing information
- choose how to receive health information - Answers Patients have right to?
Electronic Health Records - Answers Digital computerized versions of patients' paper medical
records
- admission, shift assessment
- care plan
- work list
2025-2026
Assertiveness - Answers - confined, open body posture
-eye contact
- use of clean, concise "I" statements
- the ability to share through, feelings, and emotions
-attitude toward work is characterized by working to capacity with or without supervision
-the ability to remain calm under supervision
-the freedom to ask for help when necessary
-the ability to give and accept compliments
-honesty in admitting mistakes and taking responsibility for them
documenting and reporting - Answers What are the two main communications in nursing
- identity/introduction
- situation
- background
- assessment
- recommendation/ request
- questions - Answers What is ISBARQ?
Situation
Background
Assessment
Recommendation - Answers What is SBAR?
- Change-of-shift report of handoff report
- transfer
- discharge
- telephone reports (labs, imaging, providers)
, - Reports to family members and significant others - Answers When does reporting occur?
- If the patient is unable to communicate information
- Information should be shared in a manner that is honest, compassionate, and respectful of the
person's ability to understand medical concepts - Answers When can a nurse give report to
family members and significant others?
Purposeful rounds - Answers involves repositioning, toileting, personal needs, and pain present
ADPIE - Answers Documentation is a written or electronic record of all pertinent interactions
with the pt:
Patient's health information - Answers PHI
crucial omissions and meaningless repetitious or inaccurate entries - Answers What should be
avoided when documenting?
accessible, accurate, consistent, cena, complete, thoughtful, timely, reflective of the nursing
process - Answers What are the characteristics of effective documentations?
- written on paper
- saved on a computer
- spoken aloud - Answers All information about patients is considered private or confidential,
whether ______, ____, or _____
Heath Insurance Portability and Accountability Act - Answers HIPAA
- see and copy their health record
- update their health record
- see an itemized bill
- request restrictions on sharing information
- choose how to receive health information - Answers Patients have right to?
Electronic Health Records - Answers Digital computerized versions of patients' paper medical
records
- admission, shift assessment
- care plan
- work list
