Which part of the medical record can be used as evidence in court?

the care plan

the medical orders

the entire record

nursing notes

Answer and Explanation

The Correct Answer is C

A. The care plan: While important for care, the care plan alone does not provide a full picture of patient care over time.

B. The medical orders: Medical orders show physician instructions but do not capture the full scope of patient care.

C. The entire record: The entire medical record can be subpoenaed and used as legal evidence, including notes, orders, test results, and nursing documentation.

D. Nursing notes: Nursing notes are part of the medical record but do not represent the full legal documentation on their own.

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Correct Answer is A

Explanation

A. The provider’s observed data: Objective data includes what the nurse or provider directly observes and measures, such as vital signs, lab results, and physical exam findings.

B. All of the answers are correct: Only option A is correct because C and D do not define objective data.

C. The patient’s perception of provided data: The patient’s perception is subjective data, not objective.

D. The patient’s request for information: A request for information is neither assessment data nor an objective finding.

A. the patient is vulnerable to develop the problem B. there is no evidence of defining characteristics C. a condition is currently present D. it is written as a two-part statement

Correct Answer is C

Explanation

A. The patient is vulnerable to develop the problem: This describes a risk diagnosis, where the patient has the potential to develop a condition but does not currently have it.

B. There is no evidence of defining characteristics: An actual nursing diagnosis must have defining characteristics (symptoms/signs).

C. A condition is currently present: An actual nursing diagnosis means the condition is already present, with observable signs and symptoms.

D. It is written as a two-part statement: Actual nursing diagnoses use a three-part statement:

Problem (diagnosis)
Etiology (cause)
Signs and Symptoms (evidence)

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Which part of the medical record can be used as evidence in court?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To what does objective data refer when assessing a patient?

Correct Answer is A

Explanation

Compare an actual nursing diagnosis with a risk for nursing diagnosis, recognizing that in the case of the actual nursing diagnosis

Correct Answer is C

Explanation

The primary source of assessment information is:

When documenting events in a patient's chart, the nurse should chart:

Subjective data provided by the patient included complaints of intermittent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as:

The nurse is reviewing the patient's plan of care and ordered treatments. Which of the following is (are) independent nursing interventions? (select all that apply)

How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?

Select the type of assessment which is performed continuously throughout nurse-patient contact:

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin, dry mucous membranes and temperature elevation. The nurse realizes grouping this data represents: