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Electronic Health Records And Nursing by Gartee _ beal – Test Bank

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Electronic Health Records And Nursing by Gartee _ beal – Test Bank

Gartee, Electronic Health Records and Nursing, 1e
Chapter 8
Question 1
Type: MCSA
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
Correct 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
Global Rationale:

Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:

Question 2
Type: MCSA
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
Correct 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
Global Rationale:

Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:

Question 3
Type: MCSA
Which of the following would not appear on a Problem List?
1. Onset date
2. Mammogram recommendations
3. Problem status
4. Vital signs data
Correct 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
Global Rationale:

Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:

Question 4
Type: MCSA
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
Correct 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
Global Rationale:

Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:

Question 5
Type: MCSA
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
Correct 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
Global Rationale:

Cognitive Level: Understanding
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome:

Question 6
Type: MCSA
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
Correct 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
Global Rationale:

Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome:

Question 7
Type: MCSA
On what tab does the Patient Management feature automatically open?
1. Problems
2. Care Plan
3. Past Medical/Surgical History
4. Medications
Correct 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
Global Rationale:

Cognitive Level: Knowing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome:

 

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