Foundations And Adult Health Nursing 7th
Edition 2025 Brand New|Questions and
Answers 100% Verified
_____________________________________________________________________________________
interventions were implemented to meet the patients needs
What does documentation of type of care, time of care, and signature of the person prove?
a. The person who signed the documentation did all the work noted.
b. No litigation can be brought against the person who signed.
c. Interventions were implemented to meet the patient's needs.
d. The patient's response to the intervention was positive.
Institutions are reimbursed only for patient care that is documented.
Why is documentation especially significant in managed care?
a. The hospital needs to show that employees care for patients.
b. Institutions are reimbursed only for patient care that is documented.
c. Patients might bring lawsuits if care was not given.
d. Documents may become part of a lawsuit.
CBE
The nurse charts only additional treatments done, changes in patient condition, and new
concerns. What is this system of documentation?
a. SOAP
b. Block
c. CBE
d. Focus
incident report
What form explains the lapse when events are not consistent with facility or national standards
of expected care?
a. Subjective data
b. Focus chart
c. Incident report
d. Nursing assessment
,critical pathway
The staff from all disciplines is developing integrated care plans for a projected length of stay
for patients of a specific case type. This is known as a:
a. nursing order.
b. Kardex.
c. nursing care plan.
d. critical pathway.
different health care providers need access
What makes home health care documentation unique?
a. Some charting is retained at the hospital.
b. The health care provider's office needs separate charting.
c. Different health care providers need access.
d. The health care provider is the pivotal person in the charting.
OBRA
What regulates standards for long-term care documentation?
a. OBRA
b. Title XXII
c. Patient problems
d. The care plan
have a clinical reason for reading the record
What is the nurse required to do to adhere to the concept of confidentiality for the patient's
medical record?
a. Provide information only to another nurse.
b. Provide information only to an attorney.
c. Share information only with the family.
d. Have a clinical reason for reading the record.
implementation
Documentation is necessary for the evaluation of patient care. Which of the following phases
of the nursing process is necessary for the evaluation of patient care?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
,patient problems
What does the nurse use as a basis for documentation in focus charting?
a. Problem list
b. Nursing orders
c. Patient problems
d. Evaluation
To evaluate care results against accepted standards
What is the purpose of QA (quality assurance)?
a. To screen employment applications
b. To evaluate care results against accepted standards
c. To conduct in-services for "quality documentation"
d. To report deviation from standards to the state health department
peer review
What is the process used to appraise the practice of an individual nurse known as?
a. Quality assurance
b. Incident reporting
c. OBRA
d. Peer review
problem oriented
What is the documentation format that uses the acronym SOAPE?
a. Problem-oriented
b. Focused
c. Traditional
d. Crisis
institution
Who is the legal owner of the patient's medical record?
a. Patient
b. Health care provider
c. Institution
d. State
, logging off
When using electronic (or computerized) documentation, which process should the nurse use
to ensure that no one alters the information the nurse has entered?
a. Charting in code
b. Logging off
c. Charting in privacy
d. Signing on with a password
diagnosis related groups
What is the system that classifies patients by age, diagnosis, and surgical procedure, and
produces 300 different categories used for predicting the use of hospital resources?
a. Quality assurance
b. Resource assessment
c. Quality improvement
d. Diagnosis-related groups
assessment
A nurse is using the data, action, response, education (DARE) system of charting, and is
completing the data portion. What data are the nurse's focus?
a. Planning
b. Assessment
c. Implementation
d. Patient teaching
registered nurse
A new patient is being admitted to a long-term care facility. Who has primary responsibility
for each patient's initial admission nursing history, physical assessment, and development of
the care plan based on the patient problem identified?
a. Health care provider
b. Registered nurse
c. Unlicensed assistive personnel
d. Licensed practical nurse/licensed vocational nurse
draw a single line through the error
Which of the following will the nurse implement when an error is made when documenting in
a patient's chart?
a. Scratch out the error.
Edition 2025 Brand New|Questions and
Answers 100% Verified
_____________________________________________________________________________________
interventions were implemented to meet the patients needs
What does documentation of type of care, time of care, and signature of the person prove?
a. The person who signed the documentation did all the work noted.
b. No litigation can be brought against the person who signed.
c. Interventions were implemented to meet the patient's needs.
d. The patient's response to the intervention was positive.
Institutions are reimbursed only for patient care that is documented.
Why is documentation especially significant in managed care?
a. The hospital needs to show that employees care for patients.
b. Institutions are reimbursed only for patient care that is documented.
c. Patients might bring lawsuits if care was not given.
d. Documents may become part of a lawsuit.
CBE
The nurse charts only additional treatments done, changes in patient condition, and new
concerns. What is this system of documentation?
a. SOAP
b. Block
c. CBE
d. Focus
incident report
What form explains the lapse when events are not consistent with facility or national standards
of expected care?
a. Subjective data
b. Focus chart
c. Incident report
d. Nursing assessment
,critical pathway
The staff from all disciplines is developing integrated care plans for a projected length of stay
for patients of a specific case type. This is known as a:
a. nursing order.
b. Kardex.
c. nursing care plan.
d. critical pathway.
different health care providers need access
What makes home health care documentation unique?
a. Some charting is retained at the hospital.
b. The health care provider's office needs separate charting.
c. Different health care providers need access.
d. The health care provider is the pivotal person in the charting.
OBRA
What regulates standards for long-term care documentation?
a. OBRA
b. Title XXII
c. Patient problems
d. The care plan
have a clinical reason for reading the record
What is the nurse required to do to adhere to the concept of confidentiality for the patient's
medical record?
a. Provide information only to another nurse.
b. Provide information only to an attorney.
c. Share information only with the family.
d. Have a clinical reason for reading the record.
implementation
Documentation is necessary for the evaluation of patient care. Which of the following phases
of the nursing process is necessary for the evaluation of patient care?
a. Assessment
b. Planning
c. Implementation
d. Evaluation
,patient problems
What does the nurse use as a basis for documentation in focus charting?
a. Problem list
b. Nursing orders
c. Patient problems
d. Evaluation
To evaluate care results against accepted standards
What is the purpose of QA (quality assurance)?
a. To screen employment applications
b. To evaluate care results against accepted standards
c. To conduct in-services for "quality documentation"
d. To report deviation from standards to the state health department
peer review
What is the process used to appraise the practice of an individual nurse known as?
a. Quality assurance
b. Incident reporting
c. OBRA
d. Peer review
problem oriented
What is the documentation format that uses the acronym SOAPE?
a. Problem-oriented
b. Focused
c. Traditional
d. Crisis
institution
Who is the legal owner of the patient's medical record?
a. Patient
b. Health care provider
c. Institution
d. State
, logging off
When using electronic (or computerized) documentation, which process should the nurse use
to ensure that no one alters the information the nurse has entered?
a. Charting in code
b. Logging off
c. Charting in privacy
d. Signing on with a password
diagnosis related groups
What is the system that classifies patients by age, diagnosis, and surgical procedure, and
produces 300 different categories used for predicting the use of hospital resources?
a. Quality assurance
b. Resource assessment
c. Quality improvement
d. Diagnosis-related groups
assessment
A nurse is using the data, action, response, education (DARE) system of charting, and is
completing the data portion. What data are the nurse's focus?
a. Planning
b. Assessment
c. Implementation
d. Patient teaching
registered nurse
A new patient is being admitted to a long-term care facility. Who has primary responsibility
for each patient's initial admission nursing history, physical assessment, and development of
the care plan based on the patient problem identified?
a. Health care provider
b. Registered nurse
c. Unlicensed assistive personnel
d. Licensed practical nurse/licensed vocational nurse
draw a single line through the error
Which of the following will the nurse implement when an error is made when documenting in
a patient's chart?
a. Scratch out the error.
