This Document Contains Chapters 8 to 9 Chapter 8 Question 1 Which of the following is least likely to require or use a longitudinal medical record? 1. Physician’s office 2. Acute care hospital 3. Dialysis center 4. Chiropractor’s office Answer: 2 Rationale 1: The client who is seen in a physician’s office is likely to require a longitudinal medical record Rationale 2: The acute care hospital is less likely to need a longitudinal medical record, as the majority of the data will pertain to the current visit Rationale 3: The client of the dialysis center is seen on a regular basis, and the records from previous visits will be reviewed Rationale 4: The client of the chiropractor is usually seen on a regular basis, and the records will be reviewed to monitor progress Question 2 What is a Problem List? 1. A compilation of all symptoms a client describes in the interview 2. A list of primary diagnoses used for billing purposes 3. An up-to-date list of a client’s diagnoses and conditions 4. A drop-down menu that allows the provider to select findings quickly Answer: 3 Rationale 1: The HPI is a compilation of all symptoms a client describes Rationale 2: The problem list may include diagnoses that are used for billing, but does not apply for billing Rationale 3: The problem list is an up to date list of the client’s diagnoses and conditions; it is used to track both acute and chronic conditions related to the care of the client Rationale 4: The problem list is not a drop down menu; it is client specific Question 3 Which of the following would not appear on a Problem List? 1. Onset date 2. Mammogram recommendations 3. Problem status 4. Vital signs data Answer: 4 Rationale 1: The onset of a problem is noted on the list Rationale 2: Wellness conditions related to health maintenance and preventive screening programs may be noted on the problem list Rationale 3: The status of the problem, such as chronic, acute, active or resolved will be noted on the list Rationale 4: Vital signs are noted elsewhere in the client record Question 4 Why would a primary care nurse practitioner choose to add a problem to a client’s Problem List automatically? 1. When the nurse wants to ensure that all possible conditions appear on the list for future reference 2. When the nurse is trying to rule out different diagnoses 3. When the nurse wants to document problems that are being treated by a specialist elsewhere 4. When the nurse has already confirmed a diagnosis for the client Answer: 4 Rationale 1: The nurse does not use the automatic addition setting for this purpose Rationale 2: The manual addition of a problem allows for further description if the condition is being ruled out Rationale 3: Manual addition of a problem is used when a specialist at another office is treating a client for a condition Rationale 4: When the diagnosis is definite, automatic addition to the problem list is appropriate Question 5 Certain wellness conditions may be included as part of the Problem List based on which of the following client information? 1. Family history 2. Gender 3. Chronic conditions 4. Client preference Answer: 2 Rationale 1: Family history of a problem does not automatically determine the existence of a problem Rationale 2: The client’s gender will automatically determine some types of wellness diagnoses Rationale 3: A chronic condition is not a wellness diagnosis Rationale 4: Client preference is not applicable to the problem list Question 6 The nurse is creating a new encounter for Mrs. Shelly, a longtime client at the medical clinic. When creating the new encounter note for this client, how should the nurse compare information from Mrs. Shelly’s previous encounters? 1. By loading the Problem List 2. By using the Search feature 3. By clicking on the Manage tab 4. By using the Care Plan tab Answer: 3 Rationale 1: The problem list does not need to be loaded Rationale 2: The Search feature is not used to locate the client’s problem list Rationale 3: By clicking on the Manage tab, the Problem List is displayed Rationale 4: The Care Plan tab displays each problem, followed by the date of each encounter that the client was seen for that problem Question 7 On what tab does the Patient Management feature automatically open? 1. Problems 2. Care Plan 3. Past Medical/Surgical History 4. Medications Answer: 1 Rationale 1: The Problem list is automatically displayed when the Manage tab is clicked Rationale 2: The Care Plan is accessed when the Care Plan tab is clicked Rationale 3: Clicking the Med/Surg tab in the Manage screen accesses the client’s Past Medical/Surgical History Rationale 4: Clicking the medication accesses the Medications Question 8 A client indicates she is using an herbal supplement to ease her menopausal symptoms. The nurse will find this information within which Patient Management section of the Student Edition software? 1. Problems 2. Care Plan 3. Medications 4. Allergies Answer: 3 Rationale 1: The Problem List displays active problems, inactive problems, and nursing assessments Rationale 2: The Care Plan displays the plan of care by problem Rationale 3: The medications tab displays medications ordered by any clinician in the practice as well as those reported by the client Rationale 4: The Allergies displays the client’s reported allergies Question 9 Which of the following statements about the Patient Management section of the Student Edition software is not correct? 1. The Medications tab displays medication information that has been ordered by the client’s primary care provider and no one else. 2. Information about a client’s vaccines is displayed in both the Medications tab and the Vaccines tab. 3. It is possible to add additional findings to the Care Plan tab, but this must be done manually. 4. Clicking on the Details button allows the user to view more of the Patient Management screen. Answer: 1 Rationale 1: The medications tab displays medication information that has been ordered by any clinician in the practice as well as those reported by the client Rationale 2: Information about the client’s vaccination history is displayed in both the Medications tab and the Vaccines tab Rationale 3: Additional findings may be added to the Care Plan tab manually Rationale 4: The Details button allows the user to view more of the Client Management screen Question 10 Where does the data that appears in the Med/Surg tab of the Patient Management section come from? 1. Family History 2. Problem List 3. Chief Complaint 4. Past History Answer: 4 Rationale 1: The Family History populates the data in the Family history tab Rationale 2: The data in the Problem List comes from diagnoses entered in an encounter or from the clinician manually entering the data Rationale 3: The Chief Complaint section of the encounter does not populate any other field Rationale 4: The data that populates the Med/Surg tab of the Client Management comes from data entered in the client history Question 11 The nurse understands that all of the following statements about the tabs in Patient Management are accurate except? 1. To sort data within the Vitals tab, click on the Sort button. 2. It is possible to sort any tab of Patient Management. 3. After sorting data within the Vitals tab, click on the date column. 4. When sorting data within a column, the entire row stays together. Answer: 1 Rationale 1: The Vitals tab is clicked to sort the data within the Vital tab Rationale 2: It is possible to sort any tab of the Client Management window Rationale 3: To restore the Vitals tab to its original order, the nurse clicks on the date column Rationale 4: When data is sorted by column, the entire row stays together to ensure accurate grouping of information Question 12 When using Patient Management, how would a clinician indicate that the treatment plan for a specific client problem was working? 1. The clinician would select “well controlled” from the Problem List tab drop-down list to record the status. 2. The clinician would select Clear This Problem from the Problem List tab drop-down list because it is no longer a problem. 3. The clinician would select Order a Test from the Problem List tab drop-down list to verify the treatment was working. 4. The clinician would select Order a Therapy to make sure the client has the refills he needs. Answer: 1 Rationale 1: The clinician will right-click on the Problem List screen to display a drop-down list to edit the problem, selecting well controlled from the list Rationale 2: If a problem has resolved, Clear This Problem is appropriate; a managed problem is still active Rationale 3: The results of a test previously ordered might cause the clinician to edit the problem note Rationale 4: Order a therapy would not be the action to edit the problem note Question 13 What does choosing “resolved” for a particular problem do automatically? 1. It cancels all previous orders related to that problem. 2. It discontinues all medication orders related to that problem. 3. It moves the problem to the client’s history. 4. It sets appropriate default actions related to that problem. Answer: 4 Rationale 1: Clear This Problem clears all test orders, medications, and therapy orders and sets the problem as inactive Rationale 2: Clearing a problem will discontinue all medications related to the problem Rationale 3: Resolved moves the problem to the inactive problem list Rationale 4: Resolved sets the appropriate defaults related to that problem Question 14 A nurse practitioner sees a client who is normally seen by a physician within a medical office. The client says she had a series of tests done earlier in the week, but hasn’t heard anything yet. The nurse practitioner would: 1. choose Entry Details to find out specific information on the types of tests that were ordered. 2. send an e-mail to the laboratory where the client had her tests done to see if the results are back yet. 3. click on Pending Orders in Patient Management to find out the status of the client’s tests. 4. use the Search feature to check on any recent lab test requisitions that may have been made for the client. Answer: 3 Rationale 1: Entry Details would not display tests that had been ordered Rationale 2: The clinician needs to check the EHR before contacting the lab Rationale 3: Pending Orders is selected, and will display a list of tests what have been ordered, but for which results have not yet been entered Rationale 4: The Search feature will not display the information required Question 15 The process of comparing information, such as test results, over a period of time is called: 1. Tracking 2. Graphing 3. Trending 4. Charting Answer: 3 Rationale 1: Tracking refers to being able to keep orders from getting lost, and have test results available as soon as possible Rationale 2: Graphing refers to making a visual display of test results over time Rationale 3: Trending is comparing the change of certain test components or measurements over a period of time Rationale 4: A chart is a visual display of measurements Question 16 A graph showing an individual client’s weight fluctuations over time would be least helpful when performing which of the following tasks? 1. Educating the client about his diet 2. Developing a care plan for the client 3. Determining if the client has a genetic predisposition to obesity 4. Tracking the success of an ongoing exercise regimen Answer: 3 Rationale 1: The graph of a client’s weight over time is helpful to the client teaching process; the results of the teaching (weight loss) will assist in engaging the clients in their own health care Rationale 2: The graphing of the weight fluctuations will help the client understand the effect of food choices on their weight Rationale 3: The genetic predisposition to obesity is not well represented by a graph Rationale 4: The graph of a client’s weight fluctuations will assist in correlating the fluctuations to the success of an exercise program Question 17 All of the following are available as options on the Graph menu except: 1. Weight 2. Body Mass Index 3. Current Finding 4. Blood pressure Answer: 4 Rationale 1: Weight is available on the Graph menu Rationale 2: BMI is available on the Graph menu Rationale 3: Current Finding is available on the graph menu Rationale 4: Blood pressure is not available on the Graph menu, but can be done manually Question 18 The nurse is preparing to label a problem. Which of the following problems would be considered “Acute Self-Limiting”? 1. Breast cancer 2. COPD 3. Allergies 4. Rhinitis Answer: 4 Rationale 1: Breast cancer is a long-term diagnosis Rationale 2: COPD is a chronic condition Rationale 3: Allergies are recurring conditions Rationale 4: Rhinitis is an acute self-limiting condition Question 19 The nurse is reviewing a client’s discharge medication orders. Before giving the client a new prescription, she or he should always check: 1. Medications and vaccines 2. Allergies and medications 3. Past Medical/Surgical History 4. Social History Answer: 2 Rationale 1: The nurse needs to be careful to check the client’s current medication list; the client’s vaccine status is unlikely to affect the choice of medication Rationale 2: The nurse should check current medications and allergies prior to giving the client the new prescriptions Rationale 3: The past medical/surgical history is unlikely to affect the choice of medications Rationale 4: The client’s social history is unlikely to have an effect on the choice of medications Question 20 The nurse is reviewing the client’s EHR and notes a lab order is marked “preliminary;” this means that the: 1. order has been sent, but no results are available yet. 2. results show an early indication of the test, but they are not verified. 3. test results have been verified and are ready for the clinician. 4. test has been repeated because results are inconclusive. Answer: 2 Rationale 1: Pending would indicate that the results are not available yet Rationale 2: Preliminary results are early results, but have not been verified Rationale 3: Final results have been verified and are ready for review Rationale 4: Corrected results have been repeated and a change has occurred Question 21 The nurse is reviewing an obstetric client’s EHR prior to the office visit. The quickest way for the nurse to review the previous encounters is to: 1. click on Search 2. click on Encounter Details 3. click on Manage 4. click on details Answer: 3 Rationale 1: Clicking on search will not be the quickest way to review the client’s record Rationale 2: Encounter details is not the quickest way to review the client’s EHR Rationale 3: Clicking on Manage will allow the nurse to review the information from previous encounters without having to open and read each one individually Rationale 4: Details will not display the information the nurse wishes to review Question 22 The nurse is preparing to assess a client who is returning for a follow-up visit after a sinus infection. After clicking on the Manage tab, the nurse clicks the Problem List. An appropriate next action would be to: 1. select order a test. 2. select order a medication. 3. select Nursing to enter the nursing diagnosis 4. select Quick H&P Answer: 4 Rationale 1: The nurse does not need to order a test at this time Rationale 2: The nurse does not order medications Rationale 3: The nurse needs to do an assessment prior to entering a nursing diagnosis Rationale 4: A quick H&P that is focused on the HEENT system is an appropriate action Question 23 The client reports that the sinus infection has resolved. The nurse clicks on resolved from the menu available. The following action will occur: 1. the problem will be deleted. 2. the problem will remain in the Active Problems list until manually removed. 3. the previous orders will automatically be cancelled. 4. the nurse will then document in the current encounter that the previous orders. can be canceled Answer: 3 Rationale 1: The problem is not deleted Rationale 2: The problem does not remain in the Active list; it will move to the inactive list Rationale 3: The previous orders will automatically be cancelled; the nurse will need to confirm this action Rationale 4: The nurse does not need to document the resolution of the problem separately Question 24 The nurse is reviewing a client’s lab results. In order to see the tests that have been ordered, the nurse: Standard Text: Select all that apply. 1. clicks Manage. 2. clicks Tx . 3. clicks Problem list. 4. clicks Select on the Menu bar. 5. clicks existing encounter. Answer: 1, 3, 5 Rationale 1: Clicking on Manage will open the Client Management display Rationale 2: Clicking on Tx will reveal tests that were ordered, but will not identify quickly the tests that are not final Rationale 3: Clicking on the Problem list will display Active problems and tests ordered Rationale 4: Clicking on Select on the Menu bar will open a drop down menu that includes Pending Orders as an option Rationale 5: Clicking on Existing encounter will not display pending orders Question 25 In order to review the blood work results of a client, the nurse will open the 1. Problem List. 2. Care Plan. 3. Chief. 4. History. Answer: 1 Rationale 1: The Problem list will open with the active problems displayed Rationale 2: Selecting Care Plan will not display tests that have been ordered Rationale 3: Selecting Chief will not display tests that have been ordered Rationale 4: Selecting History will display the client’s history Question 26 The nurse will quickly know which tests have results entered in the EHR by 1. The test names that are flashing have results in the system 2. The test names that are highlighted in red have abnormal results in the system 3. The test results that are highlighted in yellow have results in the system 4. The test names that are in bold indicate those that have results in the system Answer: 4 Rationale 1: Test names will not be flashing Rationale 2: Test names will not be highlighted in red Rationale 3: Test results will not be highlighted in yellow Rationale 4: The test names in bold type indicate those that have results in the system Question 27 In order to see the results of ordered Tests, the nurse will 1. right click on the bold typed test name. 2. right click in the column heading. 3. left click on Nursing assessment. 4. select ROS. Answer: 1 Rationale 1: Right clicking on the bold typed test will display a drop down menu; from that menu the nurse can select show results Rationale 2: Right clicking on the column name will not display the test results Rationale 3: Left clicking on Nursing assessment will not display test results Question 28 The nurse is caring for a client who has been bleeding from a duodenal ulcer, and has received several blood transfusions. The provider has been ordering a daily CBC to follow the client’s progress. The nurse will select CBC and then: 1. select enter from the tool bar. 2. select Options from the tool bar. 3. select graph from the tool bar. 4. select Tx from the tool bar. Answer: 3 Rationale 1: Selecting Enter will not graph the lab results Rationale 2: Selecting Options from the Tool bar will not graph the client’s lab results Rationale 3: Selecting Graph and Current finding will display the results in a graph Rationale 4: Selecting Tx will not display the results as a graph Question 29 The client is caring for a client with chronic hypertension. After the physician visit and prior to a teaching session, the nurse prepares a graph of the client’s previous blood pressure measurements. In order to locate the results, the nurse will first 1. select the client’s blood pressure from the encounter. 2. select the client’s vital signs after clicking History. 3. select Hx from the Encounter view. 4. select Px from the Encounter view. Answer: 1 Rationale 1: Selecting blood pressure from the encounter and then Graph Current Finding will create the desired graph Rationale 2: Selecting History and Vital signs is not the appropriate action Rationale 3: Selecting Hx from the Encounter view will not lead the nurse quickly towards the appropriate result Rationale 4: Selecting Px from the Encounter will not lead the nurse quickly towards the appropriate result Question 30 The client requests a graph of her weight measurements. The nurse is able to provide this most quickly by: Standard Text: Select all that apply. 1. clicking on Graph from the tool bar. 2. clicking on weight in the current encounter. 3. clicking on the problem list from the Manage view. 4. clicking on weight from the encounter and then Select. 5. clicking on Weight from the drop down menu. Answer: 1, 5 Rationale 1: Clicking Graph will display a drop down menu Rationale 2: Clicking on weight from the current encounter is not the quickest procedure Rationale 3: Clicking on weight from the problem list is not the most efficient way to get to the weight graphed Rationale 4: Clicking on Weight from the encounter and then Select is not the most efficient way to get the desired graph Rationale 5: Clicking on Weight from the Graph drop down menu will graph the weight results Chapter 9 Question 1 What is a flow sheet? 1. A feature of the software that displays a desired group of findings in a presentation that allows for quick entry of not only the selected findings, but of any entry details as well. 2. A feature of the software that presents data from multiple encounters in column format that resembles a spreadsheet. 3. A feature of the software that provides a list of the medications that the client currently is taking. 4. A feature of the software that displays all of the standard plans of therapy used to treat common diseases or conditions. Answer: 2 Rationale 1: Entry details are not added quickly in the flow sheet Rationale 2: Flow sheets present data in a format that allows for side-by-side comparison of findings over a period of time Rationale 3: The medication list would display the medications that the client is currently taking Rationale 4: Protocols are standard plans of therapy used to treat common diseases or conditions Question 2 Which of the following does the nurse consider an advantage of a flow sheet? 1. It allows findings from any previous encounter to be cited into the current note. 2. It allows the provider to enter selected findings quickly. 3. It allows a nurse to link an annotated drawing to a relevant finding. 4. It simplifies information about combinations of multiple diseases. Answer: 1 Rationale 1: The flow sheet allows entry of common findings to be cited in the current note Rationale 2: Forms allow for quick entry of findings Rationale 3: Annotated drawings are not part of a flow sheet Rationale 4: The flow sheet does displays information in columns for simplified comparison Question 3 Which of the following statements about flow sheet is correct? 1. Flow sheets typically display data from the current encounter only. 2. Flow sheets are generally limited to lab results or vital signs. 3. Single flow sheets are generally less useful for clients who have a chronic disease. 4. EHR systems will vary on how they implement flow sheets. Answer: 4 Rationale 1: Flow sheets typically display data from multiple encounters Rationale 2: Flow sheets may include ROS information, depending on selection Rationale 3: Flow sheets are very useful in the client with a chronic disease; data over time is easily reviewed Rationale 4: EHR systems vary on how they implement flow sheets; this can be customized to the facility Question 4 Jared Peters has type 2 diabetes, hypertension, and a new diagnosis of macular degeneration. When the nurse sees Jared during an encounter, which of the following is the most likely scenario? 1. The nurse will use one flow sheet for Jared that includes all of his current chronic diseases. 2. The nurse will use separate flow sheets for each of Jared’s chronic conditions, but will need to enter the same findings more than once. 3. The nurse will use flow sheets for Jared’s diabetes, but not for his other chronic conditions. 4. The macular degeneration flow sheet will not have columns for previous encounters. Answer: 4 Rationale 1: The nurse will use separate flow sheets for each condition Rationale 2: The nurse will need to enter the findings only once, and they will appear as appropriate in all flow sheets Rationale 3: The nurse will use flow sheets for all of his chronic conditions Rationale 4: The macular degeneration flow sheet is being added as a new condition at this encounter; future encounters will have columns for previous encounters Question 5 The nurse has invoked a flow sheet using the Student Edition software from a form; what does this mean? 1. The first column of the flow sheet is populated by findings pertinent to the selected Form. 2. The findings that appear in the first column of the flow sheet display the dates of the client’s previous visits. 3. The Ellipsis button, which opens the Data Details window, is disabled. 4. The flow sheet displays all findings in the current encounter. Answer: 1 Rationale 1: The first column is populated by findings pertinent to the selected Form; for example, if a form for hypertension has been selected, information on the form will be related to hypertension, and not any other condition Rationale 2: The findings in the first column are related to the current visit, with previous visits’ data displayed to the right Rationale 3: The Ellipsis button indicates additional data available for the entry Rationale 4: The flow sheet will only display findings from the current encounter that are related to the information on the form Question 6 The nurse is viewing a flow sheet for a client and wishes to see details from a previous encounter. How does she do this? 1. By clicking on the date of the previous encounter 2. By clicking on the Details button 3. By clicking anywhere in the column beneath a date 4. By clicking on the Narrative window button Answer: 1 Rationale 1: The nurse will click on the date of the previous encounter located at the top of the flow sheet; this will be displayed in narrative form Rationale 2: The details button will not display the details from previous encounters Rationale 3: Clicking beneath the date will display the information from that cell Rationale 4: The narrative window is displayed by clicking on the date of the previous encounter Question 7 What does the Cite feature do? 1. It provides a view of the plan from each previous encounter in a problem-oriented view. 2. It brings forward findings from a previous encounter into the current encounter. 3. It reminds the nurse about certain actions that must be taken. 4. It generates a list of findings that are clinically related to the finding currently highlighted. Answer: 2 Rationale 1: The Cite feature provides a view of the findings from the previous encounter in a list view Rationale 2: The Cite feature brings forward findings from a previous encounter that can be easily entered into the current encounter Rationale 3: The Cite feature allows the nurse to cite similar information into the current encounter Rationale 4: The Cite feature only displays findings that have been previously noted Question 8 When the nurse is working with a flow sheet, how do he know that the Cite button is on? 1. The Cite button will disappear. 2. The mouse pointer will change to a large question mark. 3. The Ellipsis button turns orange. 4. The mouse pointer changes into a teal check mark. Answer: 2 Rationale 1: The cite button does not disappear when on or off Rationale 2: The mouse pointer does not change Rationale 3: The Ellipsis button does not change when the Cite button is on Rationale 4: The mouse pointer does not change when the Cite feature is in use Question 9 A client has had a new cholesterol test result, and the nurse is using the Cite window to record this finding. The nurse should remember that: 1. the data you enter will post to the current client encounter. 2. you need to use the Clear button first before entering new findings. 3. unless you are careful, you may inadvertently change a previous encounter. 4. to cite an individual finding, you need to use the cite review window. Answer: 1 Rationale 1: The data will be posted to the new encounter Rationale 2: The clear button is not necessary; typing in the new entry can be done easily Rationale 3: The previous encounter will not be changed Rationale 4: To cite an individual finding, you click on the finding; highlight it Question 10 The nurse needs to review the narrative of a previous encounter while viewing a flow sheet of a client’s hypertension findings. In which of the following positions should the buttons be in if you wish to view the narrative of an encounter from within a flow sheet? 1. FS Flow Off 2. Cite Off 3. Cite On 4. ROS On Answer: 2 Rationale 1: To view the narrative form within the flow sheet, the FS Form button should be on Rationale 2: To view the narrative of an encounter from a flow sheet, the FS Form needs to be on and Cite buttons need to be off Rationale 3: To cite findings from a previous encounter, the Cite button needs to be on Rationale 4: To cite findings related to a previous encounter’s ROS from a flow sheet, the ROS, FS Form and Cite buttons need to be on Question 11 A pediatric clinic would be least likely to use a flow sheet for which of the following? 1. Diabetes 2. Vitals 3. Pregnancy 4. Otitis media Answer: 3 Rationale 1: A pediatric diabetic client will have ongoing repeated findings to review Rationale 2: A pediatric client will have changing vital signs, and measurements that the nurse will need to review for trends Rationale 3: It is unlikely for a pregnant pediatric client to be seen in the pediatric office; this client will likely be seen for the pregnancy in an obstetric clinic Rationale 4: A flow sheet view of otitis media will be useful in tracking measurements and recurrences of the disorder Question 12 Which of the following is true about a form-based flow sheet? 1. It displays all of the details from previous encounters. 2. It displays new findings that may be related to the client’s condition. 3. It displays all of the findings that match a Problem List. 4. It displays all of the findings that match the form. Answer: 4 Rationale 1: The form-based flow sheet displays the findings that match the form from previous encounters, but not all of the details Rationale 2: New findings not included in the form are not included in the form-based flow sheet Rationale 3: A flow sheet invoked from the client’s Problem List will display the findings pertinent to the problem selected on the Problem List Rationale 4: The form-based flow sheet will be populated with the findings that match the form from previous encounters Question 13 The nurse wants to create a flow sheet that is based on a specific problem. To accomplish this task, what do the nurse need to do first? 1. Click on the Problem List tab. 2. Click on the Details button. 3. Click on the Manage tab. 4. Click on the Flow sheet button. Answer: 3 Rationale 1: The Problem List tab is opened by default when the Manage tab is clicked Rationale 2: Clicking on the Details button will open the Entry Details section over the bottom of the form Rationale 3: Clicking the Manage tab will display the current Problem list for the client Rationale 4: Clicking on the Flow sheet button is the second action Question 14 A problem-oriented flow sheet would not include which of the following? 1. All findings that are related to a specific problem 2. Findings from previous client encounters 3. Findings that related to individual body systems 4. Findings that are related to the client’s other problems Answer: 4 Rationale 1: A problem-oriented flow sheet will include all findings related to the specific problem Rationale 2: The problem-oriented flow sheet will include all findings related to the specific problem from all previous client encounters Rationale 3: A problem-oriented flow sheet will display findings related to a specific problem in a ROS format Rationale 4: The problem-oriented flow sheet will not display findings specific to other problems the client has Question 15 On which of the following devices is an anatomical drawing the easiest to utilize and navigate? 1. Laptop computer 2. Tablet PC 3. Computer workstation 4. Cellular phone Answer: 2 Rationale 1: Annotated drawings can be utilized on a laptop, using the mouse or track pad, but not as easily as with a Tablet PC Rationale 2: The Tablet PC allows the nurse to navigate or annotate anatomical drawings easily Rationale 3: A workstation computer can navigate anatomical drawings using a mouse; this is not as easily done as with a Tablet PC Rationale 4: The size of the cellular phone screen limits its usefulness in this area Question 16 Why would an EHR system that allows a nurse to select findings related to a sprained ankle by viewing an anatomic illustration of the foot be useful? 1. Because the EHR system adds both the findings and the illustration to the encounter note 2. Because it allows the nurse to zero in on the appropriate findings quickly 3. Because it allows both the nurse and the client to communicate more effectively about a problem 4. Because the illustration of the ankle may be printed at the end of the encounter for client education materials Answer: 2 Rationale 1: The EHR does not add the picture to the client note Rationale 2: The anatomic illustration allows the nurse to search with pictures rather than words Rationale 3: The client can show the nurse on the ankle exactly where the problem is Rationale 4: The drawing is being used for documentation in the encounter note; the client knows where the problem is Question 17 The nurse in which of the following medical specialty clinics would be least likely to include annotated drawings as part of encounter notes? 1. Dermatology 2. Cardiology 3. Behavioral 4. Ophthalmology Answer: 3 Rationale 1: The dermatology clinic will use annotated drawings to document the location of lesions Rationale 2: The cardiology clinic may use the annotated drawing to document location of pain, pulses, medication sites Rationale 3: The behavioral clinic is unlikely to use the drawing feature; teaching is not usually related to visible issues Rationale 4: The ophthalmology clinic may use annotated drawings for noting lesions on the eye Question 18 What happens to a handwritten note that a nurse adds to an annotated anatomical drawing? 1. The note becomes codified data. 2. The note is not saved by the EHR. 3. The note is not searchable by the EHR. 4. The note may then be used to locate the image later. Answer: 3 Rationale 1: Free text is not codified data Rationale 2: The free text note is added to the EHR Rationale 3: The free text not is not codified, and therefore not searchable Rationale 4: The note is not searchable Question 19 The nursing student is selecting an anatomical drawing for annotation within the Student Edition software. This means the student may need to select all of the following except: 1. The body system they wish to show 2. The gender of the image 3. The view of the image 4. The region they wish to show Answer: 2 Rationale 1: The selection after selecting the Context option will open a navigational bar with selections to make Rationale 2: The gender of the image, as well as the age range of the image is automatically determined by the demographics of the current client Rationale 3: The view of the image may need to be selected, such as the front, back, etc. Rationale 4: The region of the image within the body system selected will need to be selected Question 20 The Line drawing tool would be most useful to accomplish which of the following when annotating a drawing within the EHR? 1. To emphasize a body region 2. To make a box on the drawing 3. To connect elements on the drawing 4. To create a free-hand drawing Answer: 3 Rationale 1: Shading will emphasize a body region Rationale 2: Selecting a shape from the Select tool button will be useful in making a box on the drawing Rationale 3: The Line drawing tool will be the most useful in connecting elements on a drawing Rationale 4: The pencil or brush tool will be the most useful in creating a free hand drawing Question 21 The nurse who works in a cardiovascular clinic is likely to use a flow sheet to monitor Standard Text: Select all that apply. 1. Weight 2. Height 3. Edema 4. Pulse 5. Blood pressure Answer: 1, 3, 4, 5 Rationale 1: The client’s weight may change based on fluid retention, or effects of medication, and is important to track Rationale 2: The client’s height is unlikely to change Rationale 3: The client’s finding of edema may change based on medications, and is important to track Rationale 4: The pulse of a cardiovascular client is an important finding to track from encounter to encounter Rationale 5: The client in the cardiovascular clinic will have his or her blood pressure measured at each encounter Question 22 The nurse in the pediatric endocrinology clinic uses a form to enter the routine follow-up visit information. In order to see this information in flow sheet format, the nurse needs to: 1. Search for Flow Sheets 2. Click Select on the tool bar 3. Click Lists on the tool bar 4. Click FS Form on the tool bar Answer: 4 Rationale 1: The Search function will not lead to the Flow sheet format Rationale 2: Select does not display a flow sheet option Rationale 3: Lists will not display a flow sheet option Rationale 4: FS Form will change the display to a Flow sheet Question 23 The nurse notes that the current blood pressure reading is significantly lower than on a previous encounter. In order to quickly see the details of that previous encounter, the nurse will: 1. Click the date at the top of the column 2. Click on the Ellipsis button next to the blood pressure finding 3. Click on Select and choose previous encounter 4. Select search and enter the date Answer: 1 Rationale 1: Clicking on the date at the top of the column will display the narrative form of the encounter note Rationale 2: Clicking on the Ellipsis button next to the blood pressure finding will display normal parameters for the blood pressure Rationale 3: Clicking on Select and previous encounter will not display the information quickly Rationale 4: Selecting search and entering the date is not the quickest way to display the information Question 24 The nurse in the long-term care facility is reviewing the client’s problem list. In order to view the client’s progress towards weight gain, the most efficient choice is to: 1. Click Manage > Highlight the Undernutrition problem > List 2. Click Manage > highlight the Undernutrition problem > Details 3. Click Manage > highlight the Undernutrition problem > Flow sheet 4. Click Manage > highlight the Undernutrition problem > Select Answer: 3 Rationale 1: Clicking Manage > Highlight the Undernutrition problem > List will not display a flow sheet related to the problem Rationale 2: Clicking Manage > highlight the Undernutrition problem > Details will either hide or display the Encounter details portion of the window Rationale 3: Clicking Manage > highlight the Undernutrition problem > Flow sheet will display a flow sheet with a historical view of the client’s data pertinent to this problem Rationale 4: Clicking Manage > highlight the Undernutrition problem > Select will not display the data the nurse wants to review Question 25 The nurse is reviewing the inpatient’s plan of care. The flow sheet format for Nursing Diagnoses is different than the Problem based flow sheet in the following ways: 1. The Plan of care flow sheet has no columns with dates 2. Nursing Diagnosis flow sheet includes all nursing diagnoses 3. The Nursing Diagnosis flow sheet allow the nurse to view the narrative note by clicking on the date 4. The Problem based flow sheet displays all active problems 5. The Nursing Diagnosis flow sheet does not allow for use of the Cite feature Answer: 2 Rationale 1: The plan of care flow sheet has dated columns Rationale 2: The Nursing Diagnosis flow sheet includes all nursing diagnoses Rationale 3: The Nursing Diagnosis flow sheet is similar to the Problem oriented flow sheet in that both allow viewing the narrative note for a finding by clicking on the date at the top of the column Rationale 4: The Problem based flow sheet does not display all active problems; it displays each problem separately when selected Rationale 5: The Nursing Diagnosis flow sheet allows the use of the Cite feature Question 26 When using the Cite feature in a Nursing Diagnosis flow sheet, the nurse uses which button to add free text to an entry? 1. The nurse cannot enter free text in this view 2. The nurse will use the Details button 3. The nurse will click on Encounter 4. The nurse will click on Select Answer: 2 Rationale 1: The nurse is able to enter free text in this view, as well as vital signs or other values Rationale 2: The nurse will use the Details button to redisplay the Entry Details fields Rationale 3: The Nurse will not be able to enter free text in this window Rationale 4: The Nurse does not click Select to enter free text Question 27 The nurse is able to document using the Plan of Care flow sheet by using the: 1. Grid button 2. ROS button 3. Cite button 4. Forms button Answer: 3 Rationale 1: The grid button is not used to enter new findings from a flow sheet Rationale 2: The ROS button will not enable the nurse to enter new findings from a flow sheet Rationale 3: The Cite button is used to enter new findings from the flow sheet view Rationale 4: The forms button is not used to cite new findings from the flow sheet view Question 28 The nurse is explaining a flow sheet to a client. An accurate comparison would be: 1. it is similar to a word processing document. 2. it is similar to a list document. 3. it is similar to a picture. 4. it is similar to a spreadsheet. Answer: 4 Rationale 1: The flow sheet is not similar to a word processing document Rationale 2: The flow sheet has some list characteristics, but this is not the best answer Rationale 3: The flow sheet is visual, but not as a picture Rationale 4: The flow sheet is similar to a spread sheet, and displays data in an easy to use format Question 29 The nurse is reviewing the client’s plan of care. The methods of recording data in the flow sheet view of the care plan include: Standard Text: Select all that apply. 1. Using the Search button 2. Using the Cite feature 3. Using the Red and Blue buttons in the flow sheet 4. Using the Prompt feature 5. Using the Graph feature Answer: 2, 3 Rationale 1: The Search button is not used to enter data in the flow sheet view of the care plan Rationale 2: The Cite feature can be used to enter data in the flow sheet view of the care plan Rationale 3: With the Cite button off, the red and blue buttons can be used to enter data in the flow sheet view of the care plan Rationale 4: The Prompt feature is not used to enter data in the flow sheet view of the care plan Rationale 5: The Graph feature is not used to enter data in the flow sheet view Question 30 The Student Edition software allows creation of flow sheets based on: Standard Text: Select all that apply. 1. Lists 2. Problems 3. Forms 4. Nursing plan of care 5. ROS Answer: 1, 2, 3, 4 Rationale 1: Lists can be used to create a flow sheet; the first column of the flow sheet is populated with findings pertinent to the list Rationale 2: The client’s Problem list can be used to invoke a flow sheet; the first column is populate with findings pertinent to the problem selected Rationale 3: Flow sheets can be invoked using a form; the first column is populated with the data elements on the form Rationale 4: The Nursing Plan of Care can be used to invoke a flow sheet; the first column is populated with findings pertinent to the nursing diagnosis, nursing interventions and nursing actions, as well as symptoms or physical findings in lists relate to those nursing CCC codes Rationale 5: The ROS button is not used to invoke a flow sheet Test Bank for Electronic Health Records and Nursing Richard Gartee, Sharyl Beal 9780131383722, 9780132885522
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