Nursing Arts 2 Test #1 Topic 1,2,3 Exam
questions with correct answers
Purpose |of |client |records: |- |CORRECT |ANSWER✔✔-communication, |planning |client |care, |
auditing |health |agencies, |research, |education, |reimbursement, |legal |documentation, |health |
care |analysis, |funding |and |resource |management
Legal |guidelines |of |documentation: |list |do's |and |dont's |- |CORRECT |ANSWER✔✔-Do's: |correct |
errors |promptly, |record |all |facts, |record |only |your |actions, |indicate |date |and |time |and |sign |
your |designation, |record |clarification |of |an |unclear |order.
Dont's |erase, |apply |correction |fluid. |write |critical |comments, |leave |blank |spaces |in |nurses |
notes. |documenting |before |providing |the |care. |record |generalized |phrases |such |as: |" |client |
appears |to |be |anxious"
Narrative |charting |- |CORRECT |ANSWER✔✔-a |descriptive |record |of |client |data |and |nursing |
interventions, |written |in |sentences |and |paragraphs. |this |method |is |time |consuming |and |tends |
to |be |redundant. |difficult |for |reader |to |decipher |key |information. |no |organizing |framework.
SOAP |- |CORRECT |ANSWER✔✔-subjective, |objective |(vital |signs) |, |assessment |( |Diagnosis |based
|on |the |data) |, |plan |( |what |the |provider |plans |to |do |to |help |the |patient |moving |forward)
PIE |- |CORRECT |ANSWER✔✔-Problem, |Intervention, |Evaluation
DAR |- |CORRECT |ANSWER✔✔-Data |( |sub |& |obj) |Action |(nursing |intervention) |Response, |Plan. |
This |is |similar |to |soap. |
* |DAR |is |most |commonly |used |as |it |addresses |clients |concerns |such |as: |a |sign |or |symptom, |a |
condition, |a |nursing |diagnosis, |a |behavior. |A |significant |event, |a |change |in |client |condition.
, Charting |By |Exception: |(CBE) |- |CORRECT |ANSWER✔✔-Progress |notes |are |only |written |to |
record |something |out |of |the |ordinary. |
Focuses |on |documenting |deviations
|CBE |is |a |shorthand |method |of |documenting |normal |findings, |based |on |clearly |defined |
normal's, |standards |of |practice, |and |predetermined |criteria |for |assessments |and |interventions.
|Significant |findings |or |exceptions |to |the |predefined |norms |are |documented |in |detail.
What |is |a |problem |oriented |medical |record? |- |CORRECT |ANSWER✔✔-Medical |record |
organized |by |a |pts |specific |health |problems |and |include |a:
1. |database
2. |problem |list
3. |plan |of |action |for |each |problem
4. |Progress |notes |(in |SOAP |format) |PIE, |SOAPIE, |DAR
Incident |Reports |- |CORRECT |ANSWER✔✔-Event |that |is |not |consistent |with |the |normal |routine,
|ie: |client |falls, |needle |stick |injuries, |medication |errors. |These |are |examples |of |when |you |would
|file |an |incident |report. |
You |always |document |every |single |incident |report |and |as |soon |as |it |happens. |You |would |never
|not |file |an |incident |report |if |it |happens. |
If |you |are |involved |in |an |incident |you |must: |notify |the |charge |nurse/ |your |instructor. |Secure |
the |area. |initiate |immediate |intervention |as |well |as |file |an |online |incident |report.
Admission |History: |form |of |charting |- |CORRECT |ANSWER✔✔-This |documentation |is |used |for |
patients |upon |admission. |It |guides |the |nurse |through |a |complete |overall |assessment |of |the |
client. |Provides |a |baseline |for |comparison, |ie: |vital |signs. |Provides |data |which |is |then |used |to |
determine |a |nursing |diagnosis.
questions with correct answers
Purpose |of |client |records: |- |CORRECT |ANSWER✔✔-communication, |planning |client |care, |
auditing |health |agencies, |research, |education, |reimbursement, |legal |documentation, |health |
care |analysis, |funding |and |resource |management
Legal |guidelines |of |documentation: |list |do's |and |dont's |- |CORRECT |ANSWER✔✔-Do's: |correct |
errors |promptly, |record |all |facts, |record |only |your |actions, |indicate |date |and |time |and |sign |
your |designation, |record |clarification |of |an |unclear |order.
Dont's |erase, |apply |correction |fluid. |write |critical |comments, |leave |blank |spaces |in |nurses |
notes. |documenting |before |providing |the |care. |record |generalized |phrases |such |as: |" |client |
appears |to |be |anxious"
Narrative |charting |- |CORRECT |ANSWER✔✔-a |descriptive |record |of |client |data |and |nursing |
interventions, |written |in |sentences |and |paragraphs. |this |method |is |time |consuming |and |tends |
to |be |redundant. |difficult |for |reader |to |decipher |key |information. |no |organizing |framework.
SOAP |- |CORRECT |ANSWER✔✔-subjective, |objective |(vital |signs) |, |assessment |( |Diagnosis |based
|on |the |data) |, |plan |( |what |the |provider |plans |to |do |to |help |the |patient |moving |forward)
PIE |- |CORRECT |ANSWER✔✔-Problem, |Intervention, |Evaluation
DAR |- |CORRECT |ANSWER✔✔-Data |( |sub |& |obj) |Action |(nursing |intervention) |Response, |Plan. |
This |is |similar |to |soap. |
* |DAR |is |most |commonly |used |as |it |addresses |clients |concerns |such |as: |a |sign |or |symptom, |a |
condition, |a |nursing |diagnosis, |a |behavior. |A |significant |event, |a |change |in |client |condition.
, Charting |By |Exception: |(CBE) |- |CORRECT |ANSWER✔✔-Progress |notes |are |only |written |to |
record |something |out |of |the |ordinary. |
Focuses |on |documenting |deviations
|CBE |is |a |shorthand |method |of |documenting |normal |findings, |based |on |clearly |defined |
normal's, |standards |of |practice, |and |predetermined |criteria |for |assessments |and |interventions.
|Significant |findings |or |exceptions |to |the |predefined |norms |are |documented |in |detail.
What |is |a |problem |oriented |medical |record? |- |CORRECT |ANSWER✔✔-Medical |record |
organized |by |a |pts |specific |health |problems |and |include |a:
1. |database
2. |problem |list
3. |plan |of |action |for |each |problem
4. |Progress |notes |(in |SOAP |format) |PIE, |SOAPIE, |DAR
Incident |Reports |- |CORRECT |ANSWER✔✔-Event |that |is |not |consistent |with |the |normal |routine,
|ie: |client |falls, |needle |stick |injuries, |medication |errors. |These |are |examples |of |when |you |would
|file |an |incident |report. |
You |always |document |every |single |incident |report |and |as |soon |as |it |happens. |You |would |never
|not |file |an |incident |report |if |it |happens. |
If |you |are |involved |in |an |incident |you |must: |notify |the |charge |nurse/ |your |instructor. |Secure |
the |area. |initiate |immediate |intervention |as |well |as |file |an |online |incident |report.
Admission |History: |form |of |charting |- |CORRECT |ANSWER✔✔-This |documentation |is |used |for |
patients |upon |admission. |It |guides |the |nurse |through |a |complete |overall |assessment |of |the |
client. |Provides |a |baseline |for |comparison, |ie: |vital |signs. |Provides |data |which |is |then |used |to |
determine |a |nursing |diagnosis.
