Nursing Documentation and Communication Quiz

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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?

Abnormal findings assessments Signup and view all the answers

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

The College of Nurses of Ontario Signup and view all the answers

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

To provide a chronological record of relevant symptoms and characteristics Signup and view all the answers

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

To ensure documentation is accurate, clear, and comprehensive Signup and view all the answers

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

Ensuring documentation is timely and complete Signup and view all the answers

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

Complete record of allergies, current medications, and childhood illnesses Signup and view all the answers

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

Approximately head to toe Signup and view all the answers

How do nurses safeguard client health information?

By maintaining confidentiality and following information retention policies Signup and view all the answers

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

Sign it late when they remember to do it Signup and view all the answers

What is assessed in the 'Functional assessment' section?

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

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

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

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

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

What is the difference between signs and symptoms?

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

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

When and what happened to cause the symptoms. Signup and view all the answers

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

What makes the symptoms better or worse. Signup and view all the answers

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

The location and how the symptoms are shown. Signup and view all the answers

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

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

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

To obtain information given by the patient's perspective Signup and view all the answers

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

Information about the patient, such as age, birthdate, and address 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?

Focused health history Signup and view all the answers

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

To verify key information about the patient Signup and view all the answers

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

Emergency history Signup and view all the answers

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

Legal position for making decisions on behalf of the patient Signup and view all the answers

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

'Patient's perspective' Signup and view all the answers

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

'Focused health history' 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?

'Complete health history' Signup and view all the answers

What is the purpose of the health history?

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

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

Focused health history Signup and view all the answers

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

Recent gender identity and relationship status Signup and view all the answers

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

The individual making healthcare decisions on behalf of the patient Signup and view all the answers

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

'History of current illness' 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?

'Complete health history' Signup and view all the answers

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

To collect information given by the patient Signup and view all the answers

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

Who is providing the health history and their relationship Signup and view all the answers

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

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

Nursing Documentation and Communication Quiz

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Questions and Answers

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

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

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

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

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

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

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

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

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

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

How do nurses safeguard client health information?

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

What is assessed in the 'Functional assessment' section?

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

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

What is the difference between signs and symptoms?

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

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

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

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

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

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

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

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

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

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

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

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

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

What is the purpose of the health history?

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

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

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

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

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

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

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

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

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