Nursing Documentation and Communication Quiz
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Questions and Answers

What is the acceptable format for recording assessments according to the text?

  • Verbal report to the team
  • Pictorial or graphs only
  • Electronic or paper form (correct)
  • Narrative only

    • Who may need to be verbally reported to in case of abnormal findings?

  • The health care team (correct)
  • The police
  • The administrative assistant
  • The social worker

    • What is the most responsible provider to whom abnormal findings may need to be reported?

  • Social worker
  • Pharmacist
  • Children's Aid Services (CAS)
  • Physician or Nurse Practitioner (correct)

    • Which type of assessments may involve reporting to the police according to the text?

    <p>Abnormal findings assessments</p> Signup and view all the answers

    Who determines the set of rules on documentation according to the text?

    <p>The College of Nurses of Ontario</p> Signup and view all the answers

    What is the purpose of the 'History of current illness' section?

    <p>To provide a chronological record of relevant symptoms and characteristics</p> Signup and view all the answers

    What is the nurses' responsibility regarding documentation of client care?

    <p>To ensure documentation is accurate, clear, and comprehensive</p> Signup and view all the answers

    What is an important aspect of nurses' accountability for documentation?

    <p>Ensuring documentation is timely and complete</p> Signup and view all the answers

    What is included in the 'Past health history' section?

    <p>Complete record of allergies, current medications, and childhood illnesses</p> Signup and view all the answers

    What is the order of the examination of body systems in the 'Review of systems' section?

    <p>Approximately head to toe</p> Signup and view all the answers

    How do nurses safeguard client health information?

    <p>By maintaining confidentiality and following information retention policies</p> Signup and view all the answers

    What should nurses do if they forget to document at the right time?

    <p>Sign it late when they remember to do it</p> Signup and view all the answers

    What is assessed in the 'Functional assessment' section?

    <p>Patients' self-care ability and activities of daily living</p> Signup and view all the answers

    What is the purpose of using appropriate abbreviations and symbols in documentation?

    <p>To ensure each has a distinct interpretation and appears in a list with full explanations</p> Signup and view all the answers

    What kind of information is included in the 'Family history' section?

    <p>Ages and health of family members, date and cause of death, and relevant-shared illness related to RSC</p> Signup and view all the answers

    What is the difference between signs and symptoms?

    <p>Signs are objective observations, while symptoms are subjective sensations.</p> Signup and view all the answers

    What does the 'onset' relate to when gathering information from the patient?

    <p>When and what happened to cause the symptoms.</p> Signup and view all the answers

    What is meant by 'palliative and provocative' in the context of reporting to the healthcare team?

    <p>What makes the symptoms better or worse.</p> Signup and view all the answers

    What does 'radiation and region' refer to in reporting the patient's condition?

    <p>The location and how the symptoms are shown.</p> Signup and view all the answers

    Why is it important to understand the 'associated signs and symptoms' when reporting to the healthcare team?

    <p>To identify other symptoms related to the patient's condition.</p> Signup and view all the answers

    What is the purpose of collecting subjective data in health history?

    <p>To obtain information given by the patient's perspective</p> Signup and view all the answers

    What does the term 'biographical data' in health history refer to?

    <p>Information about the patient, such as age, birthdate, and address</p> Signup and view all the answers

    In which type of health history does the nurse focus on only what the patient complains about or reason for seeking care?

    <p>Focused health history</p> Signup and view all the answers

    What is the role of the nurse in obtaining the health history 'source of Hx'?

    <p>To verify key information about the patient</p> Signup and view all the answers

    What type of health history uses only yes/no answers and is considered urgent?

    <p>Emergency history</p> Signup and view all the answers

    What does the term 'substitute decision maker' refer to in the context of health history?

    <p>Legal position for making decisions on behalf of the patient</p> Signup and view all the answers

    What category of subjective data includes information given by the patient?

    <p>'Patient's perspective'</p> Signup and view all the answers

    Where does a nurse focus solely on what the patient complains about or reason for seeking care?

    <p>'Focused health history'</p> Signup and view all the answers

    In which type of health history does a person new to a hospital have to provide data in every single 12 categories?

    <p>'Complete health history'</p> Signup and view all the answers

    What is the purpose of the health history?

    <p>To collect subjective data: what the patient says about himself, herself, or themselves</p> Signup and view all the answers

    Which type of health history focuses on only what the patient complains about or reason for seeking care?

    <p>Focused health history</p> Signup and view all the answers

    What is included in the 'Biographical data' category of the health history?

    <p>Recent gender identity and relationship status</p> Signup and view all the answers

    What does the term 'Substitute Decision Maker' refer to in the context of health history?

    <p>The individual making healthcare decisions on behalf of the patient</p> Signup and view all the answers

    What category of subjective data includes information given by the patient?

    <p>'History of current illness'</p> Signup and view all the answers

    In which type of health history does a person new to a hospital have to provide data in every single 12 categories?

    <p>'Complete health history'</p> Signup and view all the answers

    What is the purpose of collecting subjective data in health history?

    <p>To collect information given by the patient</p> Signup and view all the answers

    What does 'Source of Hx' refer to in the context of health history?

    <p>Who is providing the health history and their relationship</p> Signup and view all the answers

    What is focused on in the 'Emergency history' type of health history?

    <p>Uses only yes/no answers. Urgent</p> Signup and view all the answers

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