NRSE 260 EXAM 4 QUESTIONS ANSWERED CORRECTLY LATEST UPDATE 2026
Information regarding a patient's health status may not be released to non-health care team
members because:
A. legal and ethical obligations require health care providers to keep information strictly confidential.
B. regulations require health care institutions to document evidence of physical and emotional well-
being.
C. reimbursement issues related to patient care and procedures may be of concern.
D. fragmentation of nursing and medical care procedures may be identified. - Answers A- Rationale:
Under HIPAA laws, a patient's medical information can only be released to team members, unless
express written consent is given by the patient.
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When
completing the admission paper work, the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entry using lay terminology.
D. abbreviations familiar to the nurse. - Answers B- Rationale: Objective data are part of the
assessment portion of the nursing process. All data collected during the nursing process should be
documented.
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an
example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception. - Answers C- Rationale: Writing subjective data, which includes the
information the patient verbalizes, is written in narrative charting.
A patient you are assisting has fallen in the shower. You must complete an incident report. The
purpose of an incident report is to:
A. exchange information among health care members.
B. provide information about patients from one unit to another unit.
C. ensure proper care for the patient.
D. aid in the hospital's quality improvement program. - Answers D- Rationale: Any deviation from the
norm, such as a patient fall, can be used to improve quality. Incidents are gathered and assessed to
see if there is a way to prevent it from happening again.
What does EHR stand for? - Answers Electronic Health Record:
- digital record of health info
- streamlined sharing of updated info
- allows patients medical info to move with them
-access to tools that providers can use for decision making
What does EMR stand for? - Answers Electric Medical Record:
- digital version of the chart
-not designated to be shared outside the individual practice
- patient record does not easily travel outside of practice
- mainly used by providers for diagnosis and treatment
What is HIPPA? - Answers the privacy rule requires that nurses protect all written and verbal
communication about patients
Information Security Protocols - Answers • Log off from the computer before leaving the workstation
to ensure that others cannot view protected health information on the monitor
• Never share a user ID or password with anyone
• Never leave a medical record or other printed or written PHI where others can access it.
• Shred any printed or written patient information for reporting or patient care after use.
Handling and Disposing of Information - Answers • You must safeguard any information that is
printed from the record or extracted for report purposes
, • Destroy anything that is printed when the information is no longer needed
• De-identify all patient data
• Special considerations for faxing
5 guidelines for Quality Documentation - Answers • Factual
• Accurate
• Complete
• Current
• Organized
What does POMR stand for? - Answers Problem-oriented Medical Record
What does SOAP stand for? - Answers Subjective
Objective
Assessment
Plan
What does SOAPIE stand for? - Answers Subjective
Objective
Assessment
Plan
Intervention
Evaluation
What does DAR stand for? - Answers Data
Action
Response
-used for focused charting
What are flow charts? - Answers Show trends in vital signs, blood glucose levels, pain level, and other
frequent assessments
What does CBE stand for / mean? - Answers Charting By Exception
o Uses standardized forms that identify norms and allows selective documentation of deviations from
those norms
o Focuses on documenting deviations
o WNL or WDL
What are the levels of Communication? - Answers Intrapersonal
Interpersonal
Small Group
Public
Electronic
What is Intrapersonal Communication? - Answers Self-talk influences perceptions, feelings, behavior,
and self-esteem
Intrapersonal communication is a powerful form of communication that you use as a professional
nurse. This level of communication is also called self-talk. People's thoughts and inner
communications strongly influence perceptions, feelings, behavior, and self-esteem.
Nurses use intrapersonal communication to develop self-awareness and a positive self-esteem that
enhances appropriate self-expression.
What is Interpersonal Communication? - Answers one-on-one interaction between a nurse and
another person that often occurs face to face
Interpersonal communication is one-on-one interaction between a nurse and another person that
often occurs face to face. It is the level most frequently used in nursing situations and lies at the heart
of nursing practice.
Information regarding a patient's health status may not be released to non-health care team
members because:
A. legal and ethical obligations require health care providers to keep information strictly confidential.
B. regulations require health care institutions to document evidence of physical and emotional well-
being.
C. reimbursement issues related to patient care and procedures may be of concern.
D. fragmentation of nursing and medical care procedures may be identified. - Answers A- Rationale:
Under HIPAA laws, a patient's medical information can only be released to team members, unless
express written consent is given by the patient.
A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When
completing the admission paper work, the nurse needs to record:
A. an interpretation of patient behavior.
B. objective data that are observed.
C. lengthy entry using lay terminology.
D. abbreviations familiar to the nurse. - Answers B- Rationale: Objective data are part of the
assessment portion of the nursing process. All data collected during the nursing process should be
documented.
A nurse records that the patient stated his abdominal pain is worse now than last night. This is an
example of:
A. PIE documentation.
B. SOAP documentation.
C. narrative charting.
D. charting by exception. - Answers C- Rationale: Writing subjective data, which includes the
information the patient verbalizes, is written in narrative charting.
A patient you are assisting has fallen in the shower. You must complete an incident report. The
purpose of an incident report is to:
A. exchange information among health care members.
B. provide information about patients from one unit to another unit.
C. ensure proper care for the patient.
D. aid in the hospital's quality improvement program. - Answers D- Rationale: Any deviation from the
norm, such as a patient fall, can be used to improve quality. Incidents are gathered and assessed to
see if there is a way to prevent it from happening again.
What does EHR stand for? - Answers Electronic Health Record:
- digital record of health info
- streamlined sharing of updated info
- allows patients medical info to move with them
-access to tools that providers can use for decision making
What does EMR stand for? - Answers Electric Medical Record:
- digital version of the chart
-not designated to be shared outside the individual practice
- patient record does not easily travel outside of practice
- mainly used by providers for diagnosis and treatment
What is HIPPA? - Answers the privacy rule requires that nurses protect all written and verbal
communication about patients
Information Security Protocols - Answers • Log off from the computer before leaving the workstation
to ensure that others cannot view protected health information on the monitor
• Never share a user ID or password with anyone
• Never leave a medical record or other printed or written PHI where others can access it.
• Shred any printed or written patient information for reporting or patient care after use.
Handling and Disposing of Information - Answers • You must safeguard any information that is
printed from the record or extracted for report purposes
, • Destroy anything that is printed when the information is no longer needed
• De-identify all patient data
• Special considerations for faxing
5 guidelines for Quality Documentation - Answers • Factual
• Accurate
• Complete
• Current
• Organized
What does POMR stand for? - Answers Problem-oriented Medical Record
What does SOAP stand for? - Answers Subjective
Objective
Assessment
Plan
What does SOAPIE stand for? - Answers Subjective
Objective
Assessment
Plan
Intervention
Evaluation
What does DAR stand for? - Answers Data
Action
Response
-used for focused charting
What are flow charts? - Answers Show trends in vital signs, blood glucose levels, pain level, and other
frequent assessments
What does CBE stand for / mean? - Answers Charting By Exception
o Uses standardized forms that identify norms and allows selective documentation of deviations from
those norms
o Focuses on documenting deviations
o WNL or WDL
What are the levels of Communication? - Answers Intrapersonal
Interpersonal
Small Group
Public
Electronic
What is Intrapersonal Communication? - Answers Self-talk influences perceptions, feelings, behavior,
and self-esteem
Intrapersonal communication is a powerful form of communication that you use as a professional
nurse. This level of communication is also called self-talk. People's thoughts and inner
communications strongly influence perceptions, feelings, behavior, and self-esteem.
Nurses use intrapersonal communication to develop self-awareness and a positive self-esteem that
enhances appropriate self-expression.
What is Interpersonal Communication? - Answers one-on-one interaction between a nurse and
another person that often occurs face to face
Interpersonal communication is one-on-one interaction between a nurse and another person that
often occurs face to face. It is the level most frequently used in nursing situations and lies at the heart
of nursing practice.
