Question 1

A 75-year-old adult has been admitted to the surgical unit.You are not assigned to admit the older person; however, you overhear two nurses standing beside the mobile computer in the hallway discussing the admission.Which one of the following outlines rules ensuring privacy for this older person?
A)The Continuing Care Reporting System (CCRS)
B)Personal Health Information Protection Act (PHIPA)
C)Health Insurance Portability and Accountability Act (HIPAA)
D)The Canadian Nurses Association's Code of Ethics

Accepted Answer

The Personal Health Information Protection Act (PHIPA) is a law in Ontario, Canada that outlines rules for protecting the privacy of personal health information. As the scenario mentions the patient being admitted to a surgical unit, it can be assumed that this is taking place in Ontario, making PHIPA the most relevant answer. The Continuing Care Reporting System (CCRS) is a reporting system for healthcare data in Canada, not related to privacy. The Health Insurance Portability and Accountability Act (HIPAA) is a law in the United States, not applicable in Canada. The Canadian Nurses Association's Code of Ethics outlines ethical principles for nurses, but does not specifically address privacy for older adults in this scenario.

Question 2

The same nursing documentation record is used in every unit of a hospital.Why does a hospital use a standardized form for nursing documentation?
A)Standardized documentation helps to provide continuity of care.
B)Standardized documentation assists in maintaining confidentiality.
C)Standardized documentation reduces the number of medication errors.
D)Standardized documentation guarantees excellence of care between units.

Accepted Answer

Standardized documentation helps to provide continuity of care, which is essential for ensuring that all healthcare professionals involved in a patient's care have access to the same up-to-date information. This can improve communication, enhance patient safety, and ensure that patients receive consistent and appropriate care. Standardized documentation is also often used to facilitate data collection and analysis for quality improvement purposes. While standardized documentation may assist in maintaining confidentiality and reducing medication errors, these are not the primary reasons for its use. Standardized documentation also does not guarantee excellence of care between units, as many other factors can impact care quality.

Question 3

In Canada, advance directives (advanced care planning) falls under which jurisdiction?
A)Federal
B)Provincial/territorial
C)Municipal
D)Health care agency/provider

Accepted Answer

Advance directives (advanced care planning) fall under provincial/territorial jurisdiction in Canada. Each province/territory has its own laws and regulations regarding advanced care planning, and individuals should familiarize themselves with the specific rules in their region. However, there may also be some federal laws or guidelines related to advanced care planning, such as the Criminal Code of Canada's provisions on assisted dying.

Question 4

Which of the following is a primary reason that documentation is important when caring for an older person?
A)Documentation enables the team to provide care to meet the older person's individual needs.
B)Documentation helps defend the nurse in the event of a possible lawsuit.
C)Documentation enables the older person to access valuable information about the care he is receiving.
D)Documentation is the basis for reimbursement to the older person after discharge home.

Accepted Answer

Documentation is important because it helps the team provide care to meet the older person's individual needs. It ensures that the care provided is well-documented and that all members of the team are aware of the care plan. By documenting vital information such as vital signs, medication administration, and overall health and medical history, the team can work together to ensure that the older person receives the high-quality care they need.

Question 5

Which documentation tool does the nurse use in extended care and long-term care settings to gather definitive information on the resident's functioning?
A)Narrative patient progress notes
B)Problem-oriented documentation
C)Resource Utilization Group (RUG)
D)Resident Assessment Instrument (RAI)

Accepted Answer

The Resident Assessment Instrument (RAI) is the documentation tool used in extended care and long-term care settings to gather definitive information on the resident's functioning. It includes a comprehensive assessment of the resident's physical, cognitive, emotional, and social functioning, and is used to develop an individualized care plan for each resident. The RAI is mandated by the Centers for Medicare and Medicaid Services (CMS) for use in all nursing homes and is considered the standard for assessing and documenting resident care in these settings.

Question 6

Mrs.Smadu, who is 80 years of age, was recently admitted to a long-term care setting.Over the past month, Mrs.Smadu appears to be deteriorating.She does not wish to eat, sleeps all the time, and is not able to participate in any of her activities of daily living.Which of the following assessment tools will help inform and guide comprehensive care and planning for this older person?
A)Clinical Assessment Protocols (CAPs)
B)Continuing Care Reporting System (CCRS)
C)Resident Assessment Instrument (RAI)
D)Utilization Guide (UG)

Accepted Answer

The Resident Assessment Instrument (RAI) is a comprehensive tool used in long-term care settings to assess the resident's physical, cognitive, and psychosocial functioning. It is used to develop an individualized care plan and monitor the resident's progress or decline. The other options, Clinical Assessment Protocols (CAPs), Continuing Care Reporting System (CCRS), and Utilization Guide (UG), may have their uses in long-term care settings, but they do not provide the same level of comprehensive assessment and care planning as the RAI.

Question 7

Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger from the Minimum Data Set (MDS) for an older person in a nursing home who requires an indwelling urinary catheter.Which should the nurse do next?
A)The nurse should develop a patient-centred plan of care.
B)The nurse should assign suitable nursing interventions.
C)The nurse should use the Resident Assessment Protocols (RAPs).
D)The nurse should institute agency-approved catheter care.

Accepted Answer

After identifying a trigger from the MDS, the next step is to use the Resident Assessment Protocols (RAPs) to further assess and determine the appropriate interventions.

Question 8

The nurse must inform an older person whose first language is French and who does not speak any English about patient rights.The nurse also has to have the older person sign the document about information access.Which intervention should the nurse use to maintain the confidentiality of this older person?
A)The nurse should present the older person with a French version of the information access document.
B)The nurse should have an English-speaking family member explain the document to the older person.
C)The nurse should explain the document to the older person using an interpreter to ensure understanding.
D)The nurse should instruct an interpreter to read the information access document to the older person privately.

Accepted Answer

Using an interpreter ensures that the older person understands the document while maintaining confidentiality, as the interpreter is bound by confidentiality agreements.

Question 9

Which of the following is a true statement about documentation?
A)Nurses should keep records of patients' wishes.
B)Patients do not have access to their own medical records.
C)The DARE approach is a complete record of the health status of a patient.
D)The nurse is responsible for completing all of the Minimum Data Set (MDS).

Accepted Answer

Nurses have the responsibility of making notes about patients' wishes, preferences, and decision-making abilities. This is known as documentation, which should not only include the patient's medical status but also their psychological and social needs.

Question 10

What is a SOAP note?
A)This is a record of supplies used in patient hygiene.
B)This is a record of an event during a patient's stay, formatted according to the Simple Object Access Protocol (SOAP), so that it can be easily transmitted between computers.
C)This is a form of bar code.
D)This is a record of patient data listing the patient's subjective complaint, objective data recorded by the nurse, the nurse's assessment of the situation, and the nurse's plan of action.

Accepted Answer

A SOAP note is a type of documentation used in healthcare settings to record a patient's subjective complaints, objective data recorded by the nurse (such as vital signs), the nurse's assessment of the situation, and the nurse's plan of action. It is a standard format that allows healthcare professionals to share information about a patient's care in a consistent and organized way.

Quiz 5: Nursing Documentation

A 75-year-old adult has been admitted to the surgical unit.You are not assigned to admit the older person; however, you overhear two nurses standing beside the mobile computer in the hallway discussing the admission.Which one of the following outlines rules ensuring privacy for this older person?

The same nursing documentation record is used in every unit of a hospital.Why does a hospital use a standardized form for nursing documentation?

In Canada, advance directives (advanced care planning) falls under which jurisdiction?

Which of the following is a primary reason that documentation is important when caring for an older person?

Which documentation tool does the nurse use in extended care and long-term care settings to gather definitive information on the resident's functioning?

Using the Resident Assessment Instrument (RAI) , the nurse identifies a trigger from the Minimum Data Set (MDS) for an older person in a nursing home who requires an indwelling urinary catheter.Which should the nurse do next?

Which of the following is a true statement about documentation?

What is a SOAP note?