Fundamental-Concepts-and-Skills-for-Nursing-
(7th-Edition)
Unit-III:-Communication-in-Nursing
Study-Question-Bank-(Original)
Author:-Patricia-A.-Williams,-MSN,-RN,-CCRN-(textbook-author)
Contents
1.-Chapter-7:-Documentation-of-Nursing-Care
2.-Communication-and-the-Nurse-Patient-Relationship
3.-Patient-Education-and-Health-Promotion
4.-Leadership-and-Management
,Chapter-7:-Documentation-of-Nursing-Care
Quick-reminders
Focus Key-point
1 Chart-promptly,-objectively,-and-professionally.
2 Include-date/time-and-your-signature/ID-for-
every-entry.
3 Document-assessments,-interventions,-patient-
response,-and-follow-up.
Example:-SOAP-Note-Structure-(summary)
S-(Subjective) O-(Objective) A-(Assessment) P-(Plan)
Patient-reports-pain- RR-18,-BP-128/76,- Acute-post-op-pain. Administer-analgesic;-
8/10. guarding-noted. reassess-in-30–60-min.
,Questions-and-Answers
Q1.-Which-documentation-entry-best-demonstrates-objectivity?
A.-Patient-seems-anxious-and-annoying.
B.-Patient-reports-'I-feel-nervous'-and-is-pacing-in-the-room.
C.-Patient-is-manipulative-and-refuses-care.
D.-Patient-is-stable-and-doing-fine.
A1.-Correct:-B
Patient-reports-'I-feel-nervous'-and-is-pacing-in-the-room.
Rationale:-Objective-charting-uses-observable-behaviors-and-the-patient's-exact-words-rather-than-
labels-or-judgments.
Q2.-When-correcting-an-error-in-a-paper-record,-the-nurse-should:
A.-Erase-it-completely-and-rewrite.
B.-Use-correction-fluid-and-initial-later.
C.-Draw-a-single-line-through-the-error,-write-'error',-initial,-and-date/time.
D.-Tear-out-the-page-and-replace-it.
A2.-Correct:-C
Draw-a-single-line-through-the-error,-write-'error',-initial,-and-date/time.
Rationale:-Records-must-preserve-the-original-entry;-a-single-line-keeps-it-readable-and-maintains-
integrity.
Q3.-A-late-entry-should-include:
A.-Only-the-new-information,-without-noting-it-is-late.
B.-The-time-the-event-occurred-and-the-current-date/time-of-the-documentation,-labeled-as-a-late-
entry.
C.-A-new-progress-note-dated-yesterday.
D.-Nothing;-late-entries-are-prohibited.
A3.-Correct:-B
The-time-the-event-occurred-and-the-current-date/time-of-the-documentation,-labeled-as-a-late-
entry.
Rationale:-Late-entries-are-acceptable-when-clearly-labeled-and-time-stamped-with-both-the-event-
time-and-the-entry-time.
Q4.-Which-statement-about-incident-reports-is-correct?
A.-They-are-part-of-the-patient's-medical-record.
B.-They-document-unusual-events-for-risk-management-and-quality-improvement.
C.-They-should-include-blame-statements.
D.-They-replace-charting-about-the-event.
A4.-Correct:-B
They-document-unusual-events-for-risk-management-and-quality-improvement.
Rationale:-Incident-reports-are-internal-tools;-document-the-patient's-assessment-and-care-in-the-
chart-separately.
, Q5.-Charting-by-exception-is-most-appropriate-when:
A.-The-unit-uses-standardized-normal-findings-and-the-nurse-documents-only-deviations.
B.-The-nurse-wants-to-reduce-documentation-for-legal-safety.
C.-The-patient-is-unstable-and-needs-frequent-narrative-notes.
D.-The-nurse-is-unfamiliar-with-the-EHR.
A5.-Correct:-A
The-unit-uses-standardized-normal-findings-and-the-nurse-documents-only-deviations.
Rationale:-Charting-by-exception-relies-on-defined-norms;-deviations-and-significant-events-must-
still-be-documented-in-detail.
Q6.-In-documentation,-the-primary-purpose-of-using-approved-abbreviations-is-to:
A.-Save-time,-even-if-terms-are-unclear.
B.-Improve-clarity-and-reduce-misinterpretation.
C.-Allow-each-nurse-to-use-personal-shorthand.
D.-Avoid-documenting-patient-quotes.
A6.-Correct:-B
Improve-clarity-and-reduce-misinterpretation.
Rationale:-Standardized-abbreviations-reduce-ambiguity-and-improve-patient-safety.
Q7.-In-documentation,-the-primary-purpose-of-using-approved-abbreviations-is-to:
A.-Save-time,-even-if-terms-are-unclear.
B.-Improve-clarity-and-reduce-misinterpretation.
C.-Allow-each-nurse-to-use-personal-shorthand.
D.-Avoid-documenting-patient-quotes.
A7.-Correct:-B
Improve-clarity-and-reduce-misinterpretation.
Rationale:-Standardized-abbreviations-reduce-ambiguity-and-improve-patient-safety.
Q8.-In-documentation,-the-primary-purpose-of-using-approved-abbreviations-is-to:
A.-Save-time,-even-if-terms-are-unclear.
B.-Improve-clarity-and-reduce-misinterpretation.
C.-Allow-each-nurse-to-use-personal-shorthand.
D.-Avoid-documenting-patient-quotes.
A8.-Correct:-B
Improve-clarity-and-reduce-misinterpretation.
Rationale:-Standardized-abbreviations-reduce-ambiguity-and-improve-patient-safety.
Q9.-In-documentation,-the-primary-purpose-of-using-approved-abbreviations-is-to:
A.-Save-time,-even-if-terms-are-unclear.
B.-Improve-clarity-and-reduce-misinterpretation.
C.-Allow-each-nurse-to-use-personal-shorthand.
D.-Avoid-documenting-patient-quotes.
(7th-Edition)
Unit-III:-Communication-in-Nursing
Study-Question-Bank-(Original)
Author:-Patricia-A.-Williams,-MSN,-RN,-CCRN-(textbook-author)
Contents
1.-Chapter-7:-Documentation-of-Nursing-Care
2.-Communication-and-the-Nurse-Patient-Relationship
3.-Patient-Education-and-Health-Promotion
4.-Leadership-and-Management
,Chapter-7:-Documentation-of-Nursing-Care
Quick-reminders
Focus Key-point
1 Chart-promptly,-objectively,-and-professionally.
2 Include-date/time-and-your-signature/ID-for-
every-entry.
3 Document-assessments,-interventions,-patient-
response,-and-follow-up.
Example:-SOAP-Note-Structure-(summary)
S-(Subjective) O-(Objective) A-(Assessment) P-(Plan)
Patient-reports-pain- RR-18,-BP-128/76,- Acute-post-op-pain. Administer-analgesic;-
8/10. guarding-noted. reassess-in-30–60-min.
,Questions-and-Answers
Q1.-Which-documentation-entry-best-demonstrates-objectivity?
A.-Patient-seems-anxious-and-annoying.
B.-Patient-reports-'I-feel-nervous'-and-is-pacing-in-the-room.
C.-Patient-is-manipulative-and-refuses-care.
D.-Patient-is-stable-and-doing-fine.
A1.-Correct:-B
Patient-reports-'I-feel-nervous'-and-is-pacing-in-the-room.
Rationale:-Objective-charting-uses-observable-behaviors-and-the-patient's-exact-words-rather-than-
labels-or-judgments.
Q2.-When-correcting-an-error-in-a-paper-record,-the-nurse-should:
A.-Erase-it-completely-and-rewrite.
B.-Use-correction-fluid-and-initial-later.
C.-Draw-a-single-line-through-the-error,-write-'error',-initial,-and-date/time.
D.-Tear-out-the-page-and-replace-it.
A2.-Correct:-C
Draw-a-single-line-through-the-error,-write-'error',-initial,-and-date/time.
Rationale:-Records-must-preserve-the-original-entry;-a-single-line-keeps-it-readable-and-maintains-
integrity.
Q3.-A-late-entry-should-include:
A.-Only-the-new-information,-without-noting-it-is-late.
B.-The-time-the-event-occurred-and-the-current-date/time-of-the-documentation,-labeled-as-a-late-
entry.
C.-A-new-progress-note-dated-yesterday.
D.-Nothing;-late-entries-are-prohibited.
A3.-Correct:-B
The-time-the-event-occurred-and-the-current-date/time-of-the-documentation,-labeled-as-a-late-
entry.
Rationale:-Late-entries-are-acceptable-when-clearly-labeled-and-time-stamped-with-both-the-event-
time-and-the-entry-time.
Q4.-Which-statement-about-incident-reports-is-correct?
A.-They-are-part-of-the-patient's-medical-record.
B.-They-document-unusual-events-for-risk-management-and-quality-improvement.
C.-They-should-include-blame-statements.
D.-They-replace-charting-about-the-event.
A4.-Correct:-B
They-document-unusual-events-for-risk-management-and-quality-improvement.
Rationale:-Incident-reports-are-internal-tools;-document-the-patient's-assessment-and-care-in-the-
chart-separately.
, Q5.-Charting-by-exception-is-most-appropriate-when:
A.-The-unit-uses-standardized-normal-findings-and-the-nurse-documents-only-deviations.
B.-The-nurse-wants-to-reduce-documentation-for-legal-safety.
C.-The-patient-is-unstable-and-needs-frequent-narrative-notes.
D.-The-nurse-is-unfamiliar-with-the-EHR.
A5.-Correct:-A
The-unit-uses-standardized-normal-findings-and-the-nurse-documents-only-deviations.
Rationale:-Charting-by-exception-relies-on-defined-norms;-deviations-and-significant-events-must-
still-be-documented-in-detail.
Q6.-In-documentation,-the-primary-purpose-of-using-approved-abbreviations-is-to:
A.-Save-time,-even-if-terms-are-unclear.
B.-Improve-clarity-and-reduce-misinterpretation.
C.-Allow-each-nurse-to-use-personal-shorthand.
D.-Avoid-documenting-patient-quotes.
A6.-Correct:-B
Improve-clarity-and-reduce-misinterpretation.
Rationale:-Standardized-abbreviations-reduce-ambiguity-and-improve-patient-safety.
Q7.-In-documentation,-the-primary-purpose-of-using-approved-abbreviations-is-to:
A.-Save-time,-even-if-terms-are-unclear.
B.-Improve-clarity-and-reduce-misinterpretation.
C.-Allow-each-nurse-to-use-personal-shorthand.
D.-Avoid-documenting-patient-quotes.
A7.-Correct:-B
Improve-clarity-and-reduce-misinterpretation.
Rationale:-Standardized-abbreviations-reduce-ambiguity-and-improve-patient-safety.
Q8.-In-documentation,-the-primary-purpose-of-using-approved-abbreviations-is-to:
A.-Save-time,-even-if-terms-are-unclear.
B.-Improve-clarity-and-reduce-misinterpretation.
C.-Allow-each-nurse-to-use-personal-shorthand.
D.-Avoid-documenting-patient-quotes.
A8.-Correct:-B
Improve-clarity-and-reduce-misinterpretation.
Rationale:-Standardized-abbreviations-reduce-ambiguity-and-improve-patient-safety.
Q9.-In-documentation,-the-primary-purpose-of-using-approved-abbreviations-is-to:
A.-Save-time,-even-if-terms-are-unclear.
B.-Improve-clarity-and-reduce-misinterpretation.
C.-Allow-each-nurse-to-use-personal-shorthand.
D.-Avoid-documenting-patient-quotes.
