PNC Patient Assessment & Documentation 3 — Questions and Answers
Question 1: A parish nurse documents that a parishioner is 'SOB on exertion.' What does SOB stand for in clinical documentation?
- Shortness of breath (Correct answer)
- Signs of bleeding
- Sudden onset of bruising
- Severity of burden
Correct answer: Shortness of breath
SOB is a standard clinical abbreviation for shortness of breath, commonly documented during respiratory assessments.
Question 2: Which element is essential when a parish nurse documents a referral made on behalf of a parishioner?
- Date, reason for referral, provider referred to, and parishioner's consent (Correct answer)
- Only the provider's name and phone number
- The parishioner's insurance information exclusively
- The referral must be documented by the receiving provider only
Correct answer: Date, reason for referral, provider referred to, and parishioner's consent
Complete referral documentation includes date, clinical rationale, destination provider, and confirmation that the parishioner gave informed consent.
Question 3: When using the MoCA (Montreal Cognitive Assessment) tool, a score below which threshold indicates possible cognitive impairment?
- 26 out of 30 (Correct answer)
- 20 out of 30
- 15 out of 30
- 10 out of 30
Correct answer: 26 out of 30
A MoCA score below 26/30 is the standard cutoff indicating possible mild cognitive impairment warranting further evaluation.
Question 4: A parish nurse is assessing hydration status in an elderly congregant. Which clinical sign is MOST reliable for detecting dehydration in older adults?
- Decreased skin turgor on the forehead or sternum (Correct answer)
- Dry lips alone
- Feeling thirsty
- Absence of sweating
Correct answer: Decreased skin turgor on the forehead or sternum
Skin turgor assessed at the forehead or sternum is more reliable in older adults because skin on the hand loses elasticity with age regardless of hydration.
Question 5: During a home health assessment, the parish nurse notes a Stage 2 pressure injury on a parishioner's sacrum. How is a Stage 2 pressure injury best described?
- Partial thickness skin loss with exposed dermis, moist and pink/red wound bed (Correct answer)
- Full thickness skin loss with visible bone
- Intact skin with non-blanchable redness
- Deep tissue injury with purple discoloration
Correct answer: Partial thickness skin loss with exposed dermis, moist and pink/red wound bed
Stage 2 pressure injuries involve partial thickness skin loss with exposed dermis that appears pink/red and moist, without slough or eschar.
Question 6: Which documentation practice best protects a parish nurse legally when a parishioner declines a recommended health intervention?
- Document the parishioner's informed refusal, the risks explained, and have them sign a refusal form if possible (Correct answer)
- Simply note 'patient non-compliant' in the record
- Omit the incident from documentation to avoid liability
- Contact the family without the parishioner's consent to override the refusal
Correct answer: Document the parishioner's informed refusal, the risks explained, and have them sign a refusal form if possible
Documenting informed refusal with risks explained and a signed refusal form (when possible) provides legal protection and respects patient autonomy.
Question 7: A parish nurse uses the CAGE questionnaire. This tool screens for problems related to which health issue?
- Alcohol use disorder (Correct answer)
- Caregiver burnout
- Cognitive aging
- Chronic pain management
Correct answer: Alcohol use disorder
The CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener) is a validated four-question tool for screening alcohol use disorder.
PNC Patient Assessment & Documentation 3
A parish nurse documents that a parishioner is 'SOB on exertion.' What does SOB stand for in clinical documentation?