PSW Ch. 26 Flashcards
True/False
When documenting, you should use pencil
False
always use pen
True/False
When documenting, you should use abbreviations to shorten the entry
False
True/False
When documenting, you should use an eraser or correction fluid if you make a mistake
False
True/False
When documenting, you should skip lines between recorded entries
False
True/False
When documenting you should sign all entries with your name and title
True
True/False
When documenting you should paraphrase a clients works to make the meaning more understandable
False
True/False
Repeated complaints of pain can be omitted when documenting
False
What are the 4 senses you use to obtain information about a client
- Smell
- Hearing
- Touch
- Sight
Multiple choice
What information is included on the graphic sheet
A. Bowel sounds
B. Complaints of pain
C. Amount of food consumed
D. Temperature, pulse, and respirations
D. Temperature, pulse, and respirations
Multiple choice
What statement about electronic documentation is correct
A. You can use all types of abbreviations
B. It requires individual entries using a personal identification number (PIN) or code
C. All spelling errors are automatically corrected
D. In general, staff can take electronic tablets home to document on their own time
B. It requires individual entries using a personal identification number (PIN) or code
What is a client care plan
A written guide that gives direction about the care and services a client should receive
What is a nursing diagnosis
Description of a health problem that can be treated by nursing measures
What is nursing intervention
Action taken by a nursing team member to help the client reach a goal
What is a care planning process
Method used by nurses to plan and deliver nursing care
What is a medical diagnosis
Identification of a disease or condition by a doctor
