FUNDAMENTALS EXAM REVIEW 2 STUDY
GUIDE GALLEN COLLEGE OF NURSING 2026 .
,Section 1: Documentation & Legal/Ethical Issues (Q1–Q10)
1. A nurse documents: "Patient is angry and uncooperative today." This is an
example of:
• A. Objective data
• B. Subjective data
• C. Factual data
, • D. Interpretive data
Answer: D. Interpretive data
Rationale: "Angry and uncooperative" are interpretations, not factual
observations. Objective data would be specific behaviors (e.g., "Patient crossed
arms, turned away, and stated 'Leave me alone'"). Interpretive language should be
avoided in documentation.
2. A nurse threatens to restrain a patient who refuses to stay in bed. This is an
example of:
• A. Battery
• B. Assault
• C. Malpractice
• D. Negligence
Answer: B. Assault
Rationale: Assault is a threat or attempt to make bodily contact without consent.
Battery is the actual contact. No contact occurred here, so it is assault.
3. A nurse accidentally administers the wrong medication to a patient who
suffers no harm. This is:
• A. Malpractice
• B. Negligence
• C. Assault
• D. No legal concern because no harm occurred
Answer: B. Negligence
Rationale: Negligence is failure to act as a reasonably prudent person would
(giving wrong medication). Malpractice requires actual injury/damages. Even
without harm, the error must be reported and documented.
4. A nurse receives a call from a family member asking about a patient's
diagnosis. The nurse should:
, • A. Provide the information if the family member sounds concerned
• B. Ask the patient's permission before sharing information
• C. Refuse to provide any information without a signed release
• D. Give only limited information without the patient's name
Answer: C. Refuse to provide any information without a signed release
Rationale: HIPAA requires patient authorization (signed release) before disclosing
protected health information to family members unless the patient is present and
agrees or has designated the family member in advance.
5. A 17-year-old patient who is married requires surgery. Who must sign the
informed consent?
• A. The patient's parent
• B. The patient alone
• C. The patient's spouse
• D. The patient's provider
Answer: B. The patient alone
Rationale: Emancipated minors (including married minors) can legally consent for
their own medical treatment. No parent or guardian signature is required.
6. A nurse makes a factual error in a patient's chart. The correct way to correct
the error is:
• A. Use white-out to cover the error
• B. Erase the error completely
• C. Draw a single line through the error, write "error," initial and date
• D. Black out the error with permanent marker
Answer: C. Draw a single line through the error, write "error," initial and date
Rationale: The original entry must remain legible. Draw a single line, write "error"
(or "mistaken entry"), initial, and date. Never use white-out, eraser, or blackout.
GUIDE GALLEN COLLEGE OF NURSING 2026 .
,Section 1: Documentation & Legal/Ethical Issues (Q1–Q10)
1. A nurse documents: "Patient is angry and uncooperative today." This is an
example of:
• A. Objective data
• B. Subjective data
• C. Factual data
, • D. Interpretive data
Answer: D. Interpretive data
Rationale: "Angry and uncooperative" are interpretations, not factual
observations. Objective data would be specific behaviors (e.g., "Patient crossed
arms, turned away, and stated 'Leave me alone'"). Interpretive language should be
avoided in documentation.
2. A nurse threatens to restrain a patient who refuses to stay in bed. This is an
example of:
• A. Battery
• B. Assault
• C. Malpractice
• D. Negligence
Answer: B. Assault
Rationale: Assault is a threat or attempt to make bodily contact without consent.
Battery is the actual contact. No contact occurred here, so it is assault.
3. A nurse accidentally administers the wrong medication to a patient who
suffers no harm. This is:
• A. Malpractice
• B. Negligence
• C. Assault
• D. No legal concern because no harm occurred
Answer: B. Negligence
Rationale: Negligence is failure to act as a reasonably prudent person would
(giving wrong medication). Malpractice requires actual injury/damages. Even
without harm, the error must be reported and documented.
4. A nurse receives a call from a family member asking about a patient's
diagnosis. The nurse should:
, • A. Provide the information if the family member sounds concerned
• B. Ask the patient's permission before sharing information
• C. Refuse to provide any information without a signed release
• D. Give only limited information without the patient's name
Answer: C. Refuse to provide any information without a signed release
Rationale: HIPAA requires patient authorization (signed release) before disclosing
protected health information to family members unless the patient is present and
agrees or has designated the family member in advance.
5. A 17-year-old patient who is married requires surgery. Who must sign the
informed consent?
• A. The patient's parent
• B. The patient alone
• C. The patient's spouse
• D. The patient's provider
Answer: B. The patient alone
Rationale: Emancipated minors (including married minors) can legally consent for
their own medical treatment. No parent or guardian signature is required.
6. A nurse makes a factual error in a patient's chart. The correct way to correct
the error is:
• A. Use white-out to cover the error
• B. Erase the error completely
• C. Draw a single line through the error, write "error," initial and date
• D. Black out the error with permanent marker
Answer: C. Draw a single line through the error, write "error," initial and date
Rationale: The original entry must remain legible. Draw a single line, write "error"
(or "mistaken entry"), initial, and date. Never use white-out, eraser, or blackout.
