Jensen chapter 4 Exam Questions with Verified Answers Latest Update 2025-2026
When performing an assessment, which of the following would be most helpful in validating a
client's chief complaint?
-A genogram
-Past health history
-Objective data
-Family history data - Answers objective data
A nurse is in the elevator at the hospital. The nurse overhears another nurse laughing and
making jokes about a client. Why is this situation a breach of confidentiality?
-Other people besides the other nurse may have heard
-It is not a breach, because it is acceptable for a nurse to discuss client information with nurses
who are not involved in that client's care
-All client information is private and confidential
-It is not a breach, because both parties involved are nurses - Answers all client information is
private and confidential
A client is being discharged home. The discharge note that the nurse writes for this client
provides information for what purpose?
-Information that is only useful for an internal audit
-A summary of the medical course of the client while in the hospital
-Maintaining an accurate list of medications the client has taken
-Resources and strategies for managing the client at home - Answers resources and strategies
for managing the client at home
A client's pain has become increasingly severe, but the client has received the maximum doses
of analgesics. The nurse is receiving a new analgesic order from the health care provider. How
would the nurse best validate the new order?
-Read the order back to the health care provider for confirmation.
-Compare the order with the standard timing and dosage of the analgesic.
-Compare the order to the client's existing medication administration record (MAR).
-Have another nurse read the order that the nurse has transcribed. - Answers read the order
,back to the health care provider for confirmation
A nurse is explaining to other nurses on the unit about diagnosis-related groups (DRGs). On
what documentation do insurance companies base their payment approval/disapproval?
-Medical diagnosis
-Laboratory tests
-Diagnosis codes
-Narrative notes - Answers diagnosis codes
A nurse will be performing frequent assessment and reassessment of a client. Which form
would be most appropriate for the nurse to use?
-A screening tool that assesses specific risks
-An integrated cued checklist
-An abbreviated admission data sheet
-An assessment flow chart - Answers an assessment flow chart
The nurse is reviewing a SOAPIE note in the patient's medical record. The nurse recognizes that
"States no longer nauseous and would like something to eat" is which part of the SOAP note.
-Subjective
-Objective
-Analysis
-Plan
-Evaluation - Answers subjective
Nurses at a health care facility maintain client records using a method of documentation known
as charting by exception. Which of the following is a benefit of this method of documentation?
-It documents assessments on separate forms.
-It records progress under problems, interventions, and evaluation.
-It provides and refers to client's problem by a number.
-It provides quick access to abnormal findings. - Answers it provides quick access to abnormal
findings
, When recording data regarding the client's health record, the nurse mentions the analysis of the
subjective and objective data in addition to detailing the plan for care of the client. Which of the
following styles of documentation is the nursing implementing?
-Focus charting
-SOAP charting
-PIE charting
-Narrative charting - Answers SOAP charting
The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse
recognizes this blood pressure is abnormally low for this client. What is best response of the
nurse?
-Have the UAP retake the blood pressure
-Notify the physician
-Recheck blood pressure in 30 minutes
-Reassess blood pressure - Answers reassess blood pressure
The nurse manager is implementing walking patient rounds for the change-of-shift reports. One
benefit of this type of reporting over others is:
-It is quicker.
-It facilitates active participation of patients.
-It frees up the report room.
-It allows for exercise. - Answers It facilitates active participation of patients.
During a general survey, a 31-year-old client suddenly stands up and leaves the room quickly,
stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
-"Client visibly agitated during assessment and unwilling to continue."
-"Client became upset and terminated assessment."
-"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of
examination room."
-"During chest auscultation, client decided that she could no longer participate in assessment
and removed herself from the room." - Answers "During chest auscultation, client stated 'I'm
sorry, I just can't do this' and walked out of examination room."
When performing an assessment, which of the following would be most helpful in validating a
client's chief complaint?
-A genogram
-Past health history
-Objective data
-Family history data - Answers objective data
A nurse is in the elevator at the hospital. The nurse overhears another nurse laughing and
making jokes about a client. Why is this situation a breach of confidentiality?
-Other people besides the other nurse may have heard
-It is not a breach, because it is acceptable for a nurse to discuss client information with nurses
who are not involved in that client's care
-All client information is private and confidential
-It is not a breach, because both parties involved are nurses - Answers all client information is
private and confidential
A client is being discharged home. The discharge note that the nurse writes for this client
provides information for what purpose?
-Information that is only useful for an internal audit
-A summary of the medical course of the client while in the hospital
-Maintaining an accurate list of medications the client has taken
-Resources and strategies for managing the client at home - Answers resources and strategies
for managing the client at home
A client's pain has become increasingly severe, but the client has received the maximum doses
of analgesics. The nurse is receiving a new analgesic order from the health care provider. How
would the nurse best validate the new order?
-Read the order back to the health care provider for confirmation.
-Compare the order with the standard timing and dosage of the analgesic.
-Compare the order to the client's existing medication administration record (MAR).
-Have another nurse read the order that the nurse has transcribed. - Answers read the order
,back to the health care provider for confirmation
A nurse is explaining to other nurses on the unit about diagnosis-related groups (DRGs). On
what documentation do insurance companies base their payment approval/disapproval?
-Medical diagnosis
-Laboratory tests
-Diagnosis codes
-Narrative notes - Answers diagnosis codes
A nurse will be performing frequent assessment and reassessment of a client. Which form
would be most appropriate for the nurse to use?
-A screening tool that assesses specific risks
-An integrated cued checklist
-An abbreviated admission data sheet
-An assessment flow chart - Answers an assessment flow chart
The nurse is reviewing a SOAPIE note in the patient's medical record. The nurse recognizes that
"States no longer nauseous and would like something to eat" is which part of the SOAP note.
-Subjective
-Objective
-Analysis
-Plan
-Evaluation - Answers subjective
Nurses at a health care facility maintain client records using a method of documentation known
as charting by exception. Which of the following is a benefit of this method of documentation?
-It documents assessments on separate forms.
-It records progress under problems, interventions, and evaluation.
-It provides and refers to client's problem by a number.
-It provides quick access to abnormal findings. - Answers it provides quick access to abnormal
findings
, When recording data regarding the client's health record, the nurse mentions the analysis of the
subjective and objective data in addition to detailing the plan for care of the client. Which of the
following styles of documentation is the nursing implementing?
-Focus charting
-SOAP charting
-PIE charting
-Narrative charting - Answers SOAP charting
The nurse identifies the UAP recorded the client's blood pressure as 78/52 mm Hg. The nurse
recognizes this blood pressure is abnormally low for this client. What is best response of the
nurse?
-Have the UAP retake the blood pressure
-Notify the physician
-Recheck blood pressure in 30 minutes
-Reassess blood pressure - Answers reassess blood pressure
The nurse manager is implementing walking patient rounds for the change-of-shift reports. One
benefit of this type of reporting over others is:
-It is quicker.
-It facilitates active participation of patients.
-It frees up the report room.
-It allows for exercise. - Answers It facilitates active participation of patients.
During a general survey, a 31-year-old client suddenly stands up and leaves the room quickly,
stating, "I'm sorry, I just can't do this." How should the clinician best document this event?
-"Client visibly agitated during assessment and unwilling to continue."
-"Client became upset and terminated assessment."
-"During chest auscultation, client stated 'I'm sorry, I just can't do this' and walked out of
examination room."
-"During chest auscultation, client decided that she could no longer participate in assessment
and removed herself from the room." - Answers "During chest auscultation, client stated 'I'm
sorry, I just can't do this' and walked out of examination room."
