Chapter 4

Question 1

Abbreviation

Answer 1

A shortened form of a word or phrase

Question 2

Chart

Answer 2

See ‘’ medical record ‘’

Question 3

Communication

Answer 3

The exchange of information - a message sent is received and correctly interpreted by the intended person

Question 4

Conflict

Answer 4

A clash between opposing interests or ideas

Question 5

Diagnosis

Answer 5

The term used when symptoms, signs, or reasons for a problem are identified

Question 6

Kardex

Answer 6

A type of card file that summarizes information found in the medical record - medications, treatments, diagnoses, routine care measures, equipment, and special needs

Question 7

Medical record

Answer 7

A written or electronic document of a person’s condition and response to treatment and care; often referred to as a chart or clinical record

Question 8

Prefix

Answer 8

A word element placed before a root; it changes the meaning of the word

Question 9

Progress note

Answer 9

A written description of the care given and the person’s response and progress

Question 10

Recording

Answer 10

The written account of care and observations; charting

Question 11

Reporting

Answer 11

The oral account of care and observations

Question 12

Root

Answer 12

A word element that contains the basic meaning of the word

Question 13

Suffix

Answer 13

A word element placed after a root; it changes the meaning of the word

Question 14

Word element

Answer 14

A part of the word

Question 15

Information about the person’s advance directions would be found in the

a. Admission sheet ( face sheet )
b. Graphic sheet
c. Lab results
d. Flow sheet

Answer 15

a. Admission sheet ( face sheet )

Question 16

Which of the following would not be found on the activities of the daily living ( ADL ) flow sheet?

a. Hygiene measures
b. Food and fluid intake
c. Lab results
d. Elimination

Answer 16

c. Lab results

Question 17

Under OBRA residents have the right to

a. Know the information in their medical record
b. Record in their medical record
c. Remove pages from their medical record
d. View the records of other residents

Answer 17

a. Know the information in their medical record

Question 18

OBRA requires that summaries of care ( progress notes ) be written at least

a. Every month
b. Every other month
c. Every 3 months
d. Every year

Answer 18

c. Every 3 months

Question 19

To communicate, you should do the following except

a. Use terms with many meanings
b. Be brief and concise
c. Present information logically and in sequence
d. Give facts and be specific

Answer 19

a. Use terms with many meanings

Question 20

Mr. Drake is discharged from the center. His medical record is

a. Destroyed
b. Sent home with him
c. Permanent
d. Stored on a computer

Answer 20

c. Permanent

Question 21

These statements are about medical records. Which is false?

a. These are used to communicate information about residents
b. They are a written or electronic account of illness and response to treatment
c. They can be used as evidence of the care giver
d. Anyone working in the center can read them

Answer 21

d. Anyone working in the center can read them

Question 22

A person is weighed daily. The measurement is recorded on the

a. Admission sheet
b. Kardex
c. Flow sheet
d. Progress notes

Answer 22

c. Flow sheet

Question 23

Where does the nurse describe the nursing care given?

a. Admission sheet
b. Activities of daily living flow sheet
c. Progress notes
d. Kardes

Answer 23

c. Progress notes

Question 24

When recording, you do the following except

a. Use ink
b. Include the date and time
c. Erase errors
d. Sign all entries with your name and title

Answer 24

c. Erase errors

Question 25

These statements are about recording. Which is false?

a. Use the person’s exact words when possible
b. Record only what you did and observe
c. Sign your initials to a mistaken entry
d. Chart a procedure before completing it

Answer 25

d. Chart a procedure before completing it

Question 26

In the evening the clock shows 9:26. In 24 - hour clock time this is

a. 9:25
b. 1926
c. 0926
d. 2136

Answer 26

d. 2136

Question 27

A suffix is

a. Placed at the beginning of a word
b. Placed after a root
c. A shortened form of a word or phrase
d. The main meaning of the word

Answer 27

b. Placed after a root

Question 28

Which term relates to the side of the body?

a. Anterior
b. Lateral
c. Posterior
d. Prosiminal

Answer 28

b. Lateral

Question 29

These statements are about computers in health care. Which is false?

a. Computers are used to collect, send, record, and store information
b. The person’s privacy must be protected
c. All employees have the same password
d. Computers link one department to another

Answer 29

c. All employees have the same password

Question 30

You have access to the center’s computer. Which is true?

a. Email and messages are sent only to those needing the information
b. Email is used for reports the nurse needs at once
c. You can open another person’s email
d. You can use the computer for your personal needs

Answer 30

a. Email and messages are sent only to those needing the information

Question 31

You answer a person’s phone. How should you answer?

a. ‘’ Good morning. Mrs. Parks room. ‘’
b. “ Good morning. Third floor. “
c. “ Hello “
d. “ Good morning. Tammy Brown, nursing assistant, speaking. “

Answer 31

d. “ Good morning. Tammy Brown, nursing assistant, speaking. “

Question 32

A coworker is often late for work. This means extra work for you. To resolve the conflict, you should do the following except

a. Explain the problem to your supervisor
b. Discuss the matter during the end - of - shift report
c. Give facts and specific behaviors
d. Suggest ways to solve the problem

Answer 32

b. Discuss the matter during the end - of - shift report