What is a common physiological change in aging?
A. Increased muscle mass
B. Slower metabolism and decreased skin elasticity
C. Faster reflexes
D. Increased lung capacity
B. Slower metabolism and decreased skin elasticity
Which technique involves using hands to assess temperature, swelling, or pain?
A. Inspection
B. Palpation
C. Percussion
D. Ausculation
B. Palpation
What is the primary purpose of documenting patient care in a medical record?
A) To provide legal protection for the healthcare provider
B) To serve as a memory tool for patients
C) To track the financial status of the patient
D) To communicate with the insurance company
To provide legal protection for the healthcare provider
Which of the following is an example of non-verbal communication?
A) Speaking directly to the person
B) Sending a text message
C) Making eye contact with someone
D) Giving someone a phone call
C) Making eye contact with someone
Why is documentation important in nursing?
A. it provides a legal record
B. It helps with patient care continuity
C. it communicates findings to other healthcare professionals
D. All of the above
D. All of the above
Which factor increases fall risk in older adults?
A. Improved balance
B. Reduced bone density and muscle strength
C. Enhanced vision
D. Increased sense of smell
B. Reduced bone density and muscle strength
Which type of documentation is used for ongoing patient status updates?
A. Narrative charting
B. Incident reports
C. Shift report notes
D. insurance claims
C. Shift report notes
A home health nurse receives a referral to provide care to a client in their home. According to the Center for Medicare and Medicaid Services, what should the nurse document in the client’s medical record? (Select all that apply.)
A) A comprehensive assessment of the client’s health status
B) A detailed list of medications prescribed to the client
C) Documentation of the client’s consent for home health care services
D) A care plan that includes measurable outcomes and interventions
E) A record of the nurse's personal observations during the visit
A) A comprehensive assessment of the client’s health status
C) Documentation of the client’s consent for home health care services
D) A care plan that includes measurable outcomes and interventions
What is active listening in communication?
A) Hearing only the speaker's main points
B) Interrupting the speaker to provide feedback
C) Fully concentrating and responding to the speaker's message
D) Avoiding distractions while the speaker talks
C. Fully concentrating and responding to the speaker's message
Which of the following is true about documenting patient care?
A) Documentation should be written in pencil for easy changes
B) Documentation should be completed immediately after care is provided
C) Documentation can include personal opinions of the healthcare provider
D) Documentation is not necessary for minor procedures
Documentation should be completed immediately after care is provided
Which dietary change is recommended for older adults?
A. More processed foods
B. Increased sodium intake
C. More fiber and hydration
D. High caffeine intake
C. More fiber and hydration
During a health assessment, what part of the physical examination would include checking the patient's heart rate and rhythm?
A) Inspection
B) Palpation
C) Percussion
D) Auscultation
B) Palpation
What type of documentation format organizes patient data based on subjective and objective findings, along with an assessment and plan?
A) PIE
B) SOAP
C) CBE
D) FACT
B) SOAP
Which of the following is an example of assertive communication?
A) Avoiding confrontation and staying silent
B) Expressing your needs and feelings honestly and respectfully
C) Interrupting others to get your point across
D) Yelling to make your opinion heard
B) Expressing your needs and feelings honestly and respectfully
Which dietary change is recommended for older adults?
A. More processed foods
B. Increased sodium intake
C. More fiber and hydration
D. High caffeine intake
C. More fiber and hydration
Which of the following is NOT a normal age-related cognitive change?
A. Slower recall
B. Occasional forgetfulness
C. Dementia
D. Reduced multitasking ability
C. Dementia
What is the term for the process of systematically gathering data through the senses (touch, sight, hearing, and smell) during a health assessment?
A) Documentation
B) Evaluation
C) Observation
D) Interviewing
C) Observation
In charting by exception (CBE), what is documented?
A) Only unusual or abnormal findings
B) Every single detail, including routine observations
C) Patient’s family history
D) Only positive test results
A) Only unusual or abnormal findings
In communication, what is feedback?
A) The time it takes for a message to be sent
B) The sender’s emotional response
C) A verbal or non-verbal response to a message received
D) The speaker’s body language
C) A verbal or non-verbal response to a message received
When documenting patient care, what should always be avoided?
A) Writing in clear, legible handwriting
B) Using abbreviations that are not universally recognized
C) Including the date and time of each entry
D) Using objective language
B) Using abbreviations that are not universally recognized
Which intervention helps prevent skin breakdown in older adults?
A. Frequent repositioning
B. Keeping skin constantly dry
C. Massaging pressure ulcers
D. Restricting movement
A Frequent repositioning
Calculating the body mass index (BMI) is typically part of a physical assessment. For which types of clients is the BMI not helpful? (Select all that apply)
A. Pregnant women
B. Bodybuilders
C. Older adults with muscle loss
D. Adolescents going through puberty
According to the Health Insurance Portability and Accountability Act (HIPAA), how should a nurse handle patient information in an electronic medical record?
A) Share it freely with other providers
B) Secure it with a username and password
C) Leave it open on the screen for easy access
D) Print it for hard copy storage
B) Secure it with a username and password
Which communication technique involves paraphrasing what the other person has said to ensure understanding?
A) Reflective listening
B) Passive communication
C) Open-ended questioning
D) Closed-ended questioning
A) Reflective listening
What is the purpose of an SBAR report in healthcare?
A) To organize patient documentation for insurance purposes
B) To provide a quick, structured method for communicating critical information between healthcare providers
C) To track the patient’s personal medical history
D) To inform patients about their rights
B) To provide a quick, structured method for communicating critical information between healthcare providers