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Module 3 Quiz: Essential Elements

Maria Consuelo Santos


Date / Time

Student Score

Passing Score

Result

September 5, 2016
80

80

Pass

5:55 pm

Module 3 Quiz: Essential Elements


#

Question

Correct Answer

Student Answer

Result

Points
Awarded

In the case of an adverse


event, it is important that you
1
False
document what you think
happened.

True

Incorrect 0

In your client documentation,


you generally do not use
2 names of roommates or
True
visitors, as this is a breach of
their confidentiality.

True

Correct 10

Which of the following


3 documentation methods
opens up legal issues?

Block Charting

Correct 10

In which step of the nursing


4 process would you NOT
Planning
normally chart or document?

Planning

Correct 10

Which type of documentation


system records only unusual Charting by
5
findings or exceptions to
exception (CBE)
normal findings?

Charting by
exception (CBE)

Correct 10

True

Correct 10

Block Charting

6 If pages or specific forms of a True


client record are missing, this
may raise suspicion in the
legal system and may be

evidence of poor care.


Most documentation systems
7 share the nursing process as a False
framework.
8

Which of the following is an Tolerated


inaccurate descriptive phrase? procedure well

True

Incorrect 0

Awake and resting


Incorrect 0
in bed

If a client consistently refuses


a medication, it is sufficient
9
False
to record this in the progress
notes.

False

Correct 10

When your client notes are


10 completed, you should print
your signature.

False

False

Correct 10

When reporting a change in a


client's condition in the
11 progress notes to a supervisor
or physician, which of the
following is inappropriate?

Describe negative Describe negative


actions of the
actions of the
Correct 10
person you reported person you reported
to
to

You should only record the


significant details of changes
12
False
in a client's condition and
avoid excessive wordiness.

True

Incorrect 0

If you are busy caring for


clients and are having
difficulty finding time to
13
False
document, you should get a
friend to chart your care, or
you can record ahead of time.

False

Correct 10

"Client condition
satisfactory" should NOT be
14
True
used as there is no indication
that an assessment was done.

True

Correct 10

Why should you NOT leave Prevents additional Prevents additional


15 blank spaces in your notes or information being information being Correct 10
entries?
added
added
A minor client or visitor fall
16 does not have to be
documented.

False

False

Correct 10

In which step of the nursing


17 process do you document all Implementation
that you did for the client?

Implementation

Correct 10

18 You should use the term

False

Correct 10

False

"writer" while documenting


or charting in progress notes.
What is one of the most
19 common complaints about
written documentation?

Illegible or messy
handwriting

In the evaluation / outcomes


step of the nursing process
you document the client's
20
True
response to your interventions
including any unexpected
responses.

Illegible or messy
handwriting

Correct 10

True

Correct 10

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