Vital Signs and Documentation

Question 1

reflect the body’s physiologic status and provide information critical to evaluating homeostatic balance.

Answer 1

Vital Signs

Question 2

Vital Signs includes:

Answer 2

Temperature, Pulse Rate, Respiratory Rate, and Blood Pressure

Question 3

It is the hotness or coldness of the body. It is the balance
between heat production and heat loss of the body

Answer 3

Temperature

Question 4

2 Kinds of Body Temperature

Answer 4

Core Temperature
Surface temperature

Question 5

temperature of internal organs

Answer 5

Core Temperature

Question 6

temperature of the skin, subcutaneous tissue and fat cells

Answer 6

Surface temperature

Question 7

For healthy adult the normal resting pulse range from

Answer 7

60 – 100 beats per minute

Question 8

is characterized a fast heart rate which is more than 100 beats per minute

Answer 8

Tachycardia

Question 9

is characterized as an abnormally low heart rate which is fewer than 60 beats per minute

Answer 9

Bradycardia

Question 10

Each respiration is divided into two phases:

Answer 10

Inhalation
Exhalation

Question 11

which is breathing in

Answer 11

Inhalation

Question 12

which is breathing out

Answer 12

Exhalation

Question 13

normal respiration rate

Answer 13

(12 – 20 respirations/minute)

Question 14

normal respiration (12 – 20 respirations/minute)

Answer 14

Eupnea

Question 15

Respirations above 20 respirations/minute

Answer 15

Tachypnea

Question 16

Respirations less than 12 respirations/minute

Answer 16

Bradypnea

Question 17

Is a measurement of the pressure or force exerted by the
blood on the wall of the arteries in the heart

Answer 17

Blood Pressure

Question 18

Formal, legal document that provides evidence of a client’s
care

Answer 18

Chart/ Client Record

Question 19

Recording AKA

Answer 19

charting / documenting

Question 20

process of making an entry on a client record

Answer 20

Recording

Question 21

Purposes of Records

Answer 21

Communication
Planning client care
Auditing health agencies
Research
Legal Documentation
Reimbursement

Question 22

Types of Charting

Answer 22

Narrative Charting
Focus Charting (FDAR)
Progress Notes (SOAPIE)

Question 23

a traditional part of source-oriented record

Answer 23

Narrative Charting

Question 24

It consist of written notes that include routine care, normal findings, and client problems

Answer 24

Narrative Charting

Question 25

FDAR

Answer 25

Focus, Data, Action, Response

Question 26

Intended to make the client and client concerns the focus of care

Answer 26

Focus Charting (FDAR)

Question 27

Provides a holistic perspective of the client and the client’s needs

Answer 27

Focus Charting (FDAR)

Question 28

Progress Notes (SOAPIE)

Answer 28

Subjective Data, Objective Data, Assessment, Plan, Intervention, Evaluation