HEALTH ASSESSMENT

Question 1

is an informal consideratiom of a subject by two or more health care personnel to identify a problem or establish stategies to resolve problems

Answer 1

discussion

Question 2

oral,written, or computerized- based communication intended to convey information to others

Answer 2

report

Question 3

is a formal,legal document that provides evidence of a client’s care and can be written or computer based.

Answer 3

record or chart

Question 4

also called charting used to track the application of the nursing process, making entry on a client’s chart is formal

Answer 4

documentation

Question 5

CHARACTERISTICS OF GOOD RECORDING

Answer 5

factual
accurate
complete
current
organized
confidential
client specific

Question 6

an objectiv description is the result of direct observation and measurement

Answer 6

factual

Question 7

use of exact measurement establishes accuracy

Answer 7

accurate

Question 8

report should contain appropriate and essential information

Answer 8

complete

Question 9

timely entries are essentials in the client’s ongoing care

Answer 9

current

Question 10

the nurse communicates infromation in a logical order

Answer 10

organized

Question 11

respects patient’s privacy

Answer 11

confidential

Question 12

focus on patient

Answer 12

client specific

Question 13

kept for a number of purposes including communication, planning client care, auditing health agencies

Answer 13

client record

Question 14

PURPOSES OF CLIENT RECORDS

Answer 14

communication
planning client care
auditing health agencies
research
education
legal documentation
health care analysis

Question 15

ENSURING CONFIDENTIALITY OF COMPUTER RECORDS

Answer 15

1. a personal password is recquire to enter and sign off computer file
   2.after logging on,never leave a computer terminal unattended.
   3.do not leave client information displayed on the monitor where others may see it.
   4.shred all unnedded computer-generated worksheets
   5.know the facility’s policy and procedure for correcting an entry error
   6.follow agency procedures for documenting sensitive material,such as a diagnosis of AIDS
   7.information technology personnel must install a firewall to protect the server from unauthorized access

Question 16

TYPES OF PATIENT’S RECORDS

Answer 16

source-oriented record
problem-oriented medical record
problems,interventions,evaluation model
charting by exception
computerized documentations and case management

Question 17

traditional client record, decribe as a narrative charting which is convient because care providers can easily locate forms on which to record the data

Answer 17

source-oriented record

Question 18

What is the disadvantage of soure-oriented record

Answer 18

information is scattered

Question 19

is traditonal part of source-oriented record, consist of written notes that include routine care, normal findings and client problems

Answer 19

narrative charting

Question 20

data is arranged according to the problem of the patient

Answer 20

problem-oriented medical record

Question 21

4 BASIC COMPONENTS OF PROBLEM-ORIENTED MEDICAL RECORD

Answer 21

database
problem list
plan of care
progress notes

Question 22

who established POR

Answer 22

lawrence weed 1960

Question 23

consist of all information known about the client when the client first enters the health care agencies

Answer 23

database

Question 24

it is usually kept at the front of the chart and serve as an index to the numbered entries in the progress notes

Answer 24

problem list

Question 25

made with reference to active problems

Answer 25

plan of care

Question 26

chart entry made by all health professional involved client's care, they all use the same type of sheet for notes

Answer 26

progress notes

Question 27

SOAPIER MEANS?

Answer 27

SUBJECTIVE DATA OBJECTIVE DATA ASSESSMENT PLAN INTERVENTIONS EVALUATION REVISION

Question 28

consist of information obtained from the client says

Answer 28

subjective data

Question 29

consist of information that is measured or observed by use of senses

Answer 29

objective data

Question 30

interpetation or conclusions drawn about the subjective and objective

Answer 30

assessment

Question 31

designed to resolve the stated problem

Answer 31

plan

Question 32

specific interventions that have actually been performed by the caregiver

Answer 32

interventions

Question 33

client responses to nursing interventions and medical treatments

Answer 33

evaluation

Question 34

reflects care plan modifications suggested by the evaluation

Answer 34

revision

Question 35

this system consist of client care assessement flow sheet and progress notes

Answer 35

PIE (problems,intervention,evaluation)

Question 36

is intended to make the client concerns and strength the focus of care

Answer 36

focus charting

Question 37

is a documentation system in which only abonormal or significant findings or exceptions to nors are recorded

Answer 37

charting by exception

Question 38

CBE INCOPERATES THREE KEY ELEMENTS

Answer 38

FLOW SHEETS STANDARDS OF NURSING CARE BESIDE ACCESS TO CHART FORMS

Question 39

used to manage a huge volume of information required in contemporary health care

Answer 39

computerized documentations and case management

Question 40

enables nurses to record nursing data quickly and concisely and provides an easy to read record of the client's conditiom over time

Answer 40

flow sheets

Question 41

this record typically indicates body temperature,pulse, respiratory rate,blood pressures,weight

Answer 41

graphic record

Question 42

all routes of fluid intake and all routes of fluid loss or output are measured and recorded on this form

Answer 42

intake and output record

Question 43

designated areas for the date of the medication order, the expiration date, medication name and dose, frequency of administration and route

Answer 43

medication administration

Question 44

often recorded on a flow sheet, categories related to stage of skin injury

Answer 44

skin assessment record

Question 45

made by nurse provide information about the progress a client is making toward achieving outcomes

Answer 45

progress notes

Question 46

widely use,concise method of organizing and recording data about a client,making information quickly accessible to all health professionals

Answer 46

kardexes

Question 47

completed when the client is been discharged and transferred to another insituitons or to a home setting

Answer 47

nursing discharge

Question 48

GENERAL GUIDELINES FOR RECORDING

Answer 48

DATA AND TIMR TIMING LEGIBILITY PERMANENCE ACCEPTED TECHNOLOGY CORRECT SPELLING ACCURACY APPRIATENESS COMPLETENESS CONCISENESS

Question 49

communicate specific information to a person or a group of people

Answer 49

reporting

Question 50

health professionals frequenly report about a client by telephone

Answer 50

telephone reports

Question 51

ofter order a therapy for a client by telephone

Answer 51

telephone orders

Question 52

GUDELINES FOR TELEPHONE AND VERBAL ORDERS

Answer 52

1. know the state nursing board's position on who can give and accept verbal and phone orders 2. know the agency's policy regarding phone orders 3.ask the prescriber to speak slowly and clearly 4.ask the prescriber to spell out the medication if you are not familiar with it. 5.question the drug,dosage,or changes if thery seem inappropriate for this client 6. write the order down or enter into a computer on the physician's order form 7.read the order back to the prescriber. 8.have the prescriber verbally acknowledge the read back 9.record date and time and indicate it was telephone order. 10.when writing dosage always put a number before a decimal but never after a decimal. 11.write out units 12.transcribe the order 13.follow the agency protocol about the prescriber's protocol for signing telephone orders

Question 53

meeting of a group of nurses to discuss possible solutions to certain problems of a cliet

Answer 53

care plan conference

Question 54

are procedures in which two or more nurses visit slected client at each clieant's bedside to

Answer 54

nursing rounds

Question 55

any event not consistent with the routine operation or care of patient

Answer 55

incident reports

Question 56

H,HR

Answer 56

HOUR

Question 57

HS

Answer 57

AT BEDTIME

Question 58

IM

Answer 58

INTRAMUSCULAR

Question 59

INJ.

Answer 59

INJECTION

Question 60

IV

Answer 60

INTRAVENOUS

Question 61

IVP

Answer 61

IV PUSH

Question 62

IVPS

Answer 62

IV PIGGY BACK

Question 63

NOCT.

Answer 63

NIGHT

Question 64

OD

Answer 64

RIGHT EYE

Question 65

OS

Answer 65

LEFT EYE

Question 66

OU

Answer 66

BOTH EYES

Question 67

AC

Answer 67

BEFORE MEALS

Question 68

AM

Answer 68

IN THE MORNING OR BEFORE NOON

Question 69

A.D.

Answer 69

RIGHT EAR

Question 70

A.S.

Answer 70

LEFT EAR

Question 71

AQ.

Answer 71

WATER

Question 72

BID

Answer 72

TWICE A DAY

Question 73

GTT

Answer 73

DROP

Question 74

G

Answer 74

GRAM

Question 75

GR

Answer 75

GRAIN

Question 76

P.C.

Answer 76

AFTER MEAL

Question 77

OS

Answer 77

MOUTH

Question 78

PER OS/ PO

Answer 78

BY MOUTH

Question 79

PM

Answer 79

AFTERNOON, EVENING

Question 80

PRN

Answer 80

AS NEEDED

Question 81

Q

Answer 81

EVERY

Question 82

QH

Answer 82

EVERY HOUR

Question 83

QUID

Answer 83

FOUR TIMES A DAY

Question 84

RX

Answer 84

TAKE PRESCRIPTION

Question 85

SQ

Answer 85

SUBCUTANEOUS

Question 86

STAT.

Answer 86

IMMEDIATELY

Question 87

ANST.

Answer 87

AFTER NEGATIVE SKIN TESTING

Question 88

OD

Answer 88

ONCE A DAY

Question 89

SOL

Answer 89

SOLUTION

Question 90

ASAP

Answer 90

AS SOON AS POSSIBLE

Question 91

DAT

Answer 91

DIET AS TOLERTED