CHPT. 8 vocab and questions

Question 1

Assessment

Answer 1

collecting information about the person

Question 2

electronic health record (EHR)

Answer 2

an electronic version of a person’s medical record

Question 3

end-of-shift report

Answer 3

a report that the nurse gives at the end of the shift to the on-coming shift, change of shift report

Question 4

evaluation

Answer 4

to measure if goals in the planning step were met

Question 5

implementation

Answer 5

to perform or carry out nursing interventions in the care plan

Question 6

medical record

Answer 6

the legal account of a person’s condition and response to treatment and care, chart or clinical record

Question 7

nursing care plan

Answer 7

a written guide about the person’s nursing care, care plan

Question 8

nursing diagnosis

Answer 8

a health problem that can be treated by nursing measures

Question 9

nursing intervention

Answer 9

an action or measure taken by the nursing to help the person reach a goal, nursing action, nursing measure, nursing task

Question 10

nursing process

Answer 10

the method nurses use to plan and deliver nursing care, its 5 steps are assessment, nursing diagnosis, planning, implementation, and evaluation

Question 11

objective data

Answer 11

information that is seen, heard, felt, or smelled by an observer, signs

Question 12

observation

Answer 12

using the senses of sight, hearing touch, and smell to collect information

Question 13

progress note

Answer 13

describes the care given and the person’s response and progress

Question 14

subjective data

Answer 14

things a person tells you about that you cannot observe through your senses, symptoms

Question 15

What kind of words should you use for communication

Answer 15

words that mean the same to everyone

Question 16

what do we report when we do care

Answer 16

when there is a change from normal or a change in the person’s condition. Report these changes at once.
when the nurse asks you to do so
before leaving the unit for meals, breaks, or other reasons,
after the end-of-shift report and before reporting off duty

Question 17

what are general rules for recording

Answer 17

follow agency policies and procedures for recording. Ask for needed training, use correct grammar or make sure it makes since, accurate, concise and factual.

Question 18

you help with a person’s care. Recording on the person’s medical record violates the right to privacy.

Answer 18

False

Question 19

medical records can be used to prove the care given

Answer 19

True

Question 20

you can access all medical records in the agency

Answer 20

False

Question 21

The nursing process is the method nurses use to plan and deliver nursing care

Answer 21

True

Question 22

measures in the care plan are carried out in the assessment step of the nursing process

Answer 22

False

Question 23

when using a computer, the person’s privacy must be protected

Answer 23

True

Question 24

You can give information about the person over the phone

Answer 24

False

Question 25

you can post your username and password in your work area

Answer 25

False

Question 26

the agency can monitor your computer use

Answer 26

True

Question 27

you should leave faxes in the fax machine for the nurse to read

Answer 27

false

Question 28

to communicate well, you should

Answer 28

give facts and be specific

Question 29

A person is discharged from the agency. The medical record is

Answer 29

permanent

Question 30

where does the nurse describe the nursing care given

Answer 30

progress notes

Question 31

you need to know if a resident uses a hearing aid you should

Answer 31

read the progress notes

Question 32

you need to record a patients’ vital signs every hour. Where should you record the measurements

Answer 32

Flow sheet

Question 33

your role in the nursing process involves

Answer 33

reporting observations

Question 34

which is a symptom

Answer 34

vomiting

Question 35

which should you report at once

Answer 35

the person can no longer move a body part

Question 36

the care plan is

Answer 36

the measures to help the person

Question 37

to communicate delegated tasks to you

Answer 37

an assignment sheet

Question 38

which statement about recording is correct

Answer 38

record only what you did and observed

Question 39

you have access to the agency’s computer. Which is true

Answer 39

you should log off after making an entry

Question 40

A phone rings at the nurses’ station. Which greeting is best

Answer 40

Good morning, north hall. Joey Wilson, nursing assistant, speaking.