C HAPTER 26: I NFORMATICS AND
D OCUMENTATION
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. Regarding access to client records, the nursing facult y informs the nursing
students to be prepared to:
A. Show the unit staff proper student identification
B. Sign a confidentiality agreement when on the unit to preplan
C. Review the medical record onl y in the presence of unit st aff
D. Obtain permission from the client to access his or her medical
record
ANS: A
When nurses and other health care professionals have a legitimate
reason to use records for data gathering, research, or continuing
education, they obtain appropriate author ization according to agency
policy. Nursing students and facult y may be required to present
identification indicating access to the record is authorized. The
remaining options are not required if the student is properl y identified
and shows need to access the material.
DIF: C REF: 385 OBJ: Anal ysis TOP: Nursing Process:
Planning MSC: NC LEX test plan designation: Safe, Effective
Care Environment
,2. Which of the following nursing actions is most directl y aimed at affording
a client confidential treatment of his or her medical information while
minimizing delay in accessing needed medical and nursing care?
A. Notifying the client of the institutions privacy policy
B. Denying nonessential personal access to the clients medical records
C. Acquiring the clients verbal con sent to share his or her medical
record with essential personnel
D. Requiring that the client sign the Health Insurance Portabilit y and
Accountabilit y Act (HIPAA) form
ANS: A
Under new regulations, Health Insurance Portabilit y and Accountabilit y
Act (HIPAA), in order to eliminate barriers that could delay access to
care, required onl y that health care providers notify clients of their
privacy policy and make a reasonable effort to get written
acknowledgment of this notification.
DIF: A REF: 385 OBJ: Compreh ension TOP: Nursing
Process: Planning MSC: NC LEX test plan designation: Safe,
Effective Care Environment
3. When another health care professional is asked to assess a client for the
purpose of suggesting treatment to the primary health care provider, this
is called a:
A. Referral
B. Consultation
C. Transfer report
D. Multidisciplinary meeting
, ANS: A
Referrals are the request for services by another care provider usuall y
for the purpose of determining appropriate client care. Consultations
are a form of discussion whe reby one professional caregiver actuall y
gives formal advice about the care of a client to another caregiver. The
remaining options are methods of exchanging general information
regarding a client.
DIF: A REF: 386 OBJ: Comprehension TOP: Nursing
Process: Planning MSC: NC LEX test plan designation: Safe,
Effective Care Environment
4. Which of the following nursing notations shows the best understanding
regarding the need to document onl y objective client assessment data?
A. Client was angry because breakfast wa s not to her liking.
B. Client is depressed; was observed crying while alone in room.
C. Client expressed pain as an 8 out of 10, was diaphoretic, guarding
her abdomen and clenching her fists.
D. Client was verball y abusive to staff when approached concerning
clients continued attempts to smoke in the bathroom.
ANS: C
Do not write personal opinions. Document observable, measurable
client-oriented data onl y. The remaining options either make
assumptions regarding observed client behavior or fail to objectivel y
describe the noted client behavior.
D OCUMENTATION
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. Regarding access to client records, the nursing facult y informs the nursing
students to be prepared to:
A. Show the unit staff proper student identification
B. Sign a confidentiality agreement when on the unit to preplan
C. Review the medical record onl y in the presence of unit st aff
D. Obtain permission from the client to access his or her medical
record
ANS: A
When nurses and other health care professionals have a legitimate
reason to use records for data gathering, research, or continuing
education, they obtain appropriate author ization according to agency
policy. Nursing students and facult y may be required to present
identification indicating access to the record is authorized. The
remaining options are not required if the student is properl y identified
and shows need to access the material.
DIF: C REF: 385 OBJ: Anal ysis TOP: Nursing Process:
Planning MSC: NC LEX test plan designation: Safe, Effective
Care Environment
,2. Which of the following nursing actions is most directl y aimed at affording
a client confidential treatment of his or her medical information while
minimizing delay in accessing needed medical and nursing care?
A. Notifying the client of the institutions privacy policy
B. Denying nonessential personal access to the clients medical records
C. Acquiring the clients verbal con sent to share his or her medical
record with essential personnel
D. Requiring that the client sign the Health Insurance Portabilit y and
Accountabilit y Act (HIPAA) form
ANS: A
Under new regulations, Health Insurance Portabilit y and Accountabilit y
Act (HIPAA), in order to eliminate barriers that could delay access to
care, required onl y that health care providers notify clients of their
privacy policy and make a reasonable effort to get written
acknowledgment of this notification.
DIF: A REF: 385 OBJ: Compreh ension TOP: Nursing
Process: Planning MSC: NC LEX test plan designation: Safe,
Effective Care Environment
3. When another health care professional is asked to assess a client for the
purpose of suggesting treatment to the primary health care provider, this
is called a:
A. Referral
B. Consultation
C. Transfer report
D. Multidisciplinary meeting
, ANS: A
Referrals are the request for services by another care provider usuall y
for the purpose of determining appropriate client care. Consultations
are a form of discussion whe reby one professional caregiver actuall y
gives formal advice about the care of a client to another caregiver. The
remaining options are methods of exchanging general information
regarding a client.
DIF: A REF: 386 OBJ: Comprehension TOP: Nursing
Process: Planning MSC: NC LEX test plan designation: Safe,
Effective Care Environment
4. Which of the following nursing notations shows the best understanding
regarding the need to document onl y objective client assessment data?
A. Client was angry because breakfast wa s not to her liking.
B. Client is depressed; was observed crying while alone in room.
C. Client expressed pain as an 8 out of 10, was diaphoretic, guarding
her abdomen and clenching her fists.
D. Client was verball y abusive to staff when approached concerning
clients continued attempts to smoke in the bathroom.
ANS: C
Do not write personal opinions. Document observable, measurable
client-oriented data onl y. The remaining options either make
assumptions regarding observed client behavior or fail to objectivel y
describe the noted client behavior.
