Observation and Reporting
Indicate the answer choice that best completes the statement or answers the question. |
1. What are the five steps of the nursing process. 1.Assessment 2.Problem identification and making a nursing diagnosis for each problem. 3.Planning 4.Implementation 5.Evaluation 2. What is the role of the Nursing Assistant for each step of the nursing process. The nursing assistant is responsible for reporting to the nurse. |
3. What should you describe when reporting pain? Approach cannot be carried out for any reason. Patient is having problems with the approach. Patient refuses care listed in the approaches. Nursing assistant identifies a more effective approach (method of meeting a goal).
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4. What is a Subjective symptom? |
A subjective symptom is a statement or complaint made by the patient.
5. What is an Objective symptoms? An objective symptom is one that is factual or measurable. |
6. How should signs and symptoms be reported? |
When reporting signs, avoid using “labels” based on your judgment of the patient. Report only the facts of what you see and hear.
7. Why is it important for you as a nursing assistant to know what normal observations are? This information tells the nurse and physician whether the patient’s condition is improving. |
8. When making observations, what method helps so you don’t miss anything? Giving an oral report is one method used to relay information from one person to another. |
9. When making observations what should you note? When making observations, you should note details like the patient's appearance, behavior, and any changes in condition. |
11. The medical record is?
The medical record is a complete file of a patient's health history and care, kept by healthcare providers. |
13. Know how to use international (military) time.
To use international (military) time, remember that the hours go from 00 (midnight) to 23 (11 PM), with no AM or PM. Add 12 to any PM time to convert (e.g., 1 PM becomes 1300.
14. What are some non-verbal signs of pain?
Non-verbal signs of pain include facial expressions, body tension, moaning, or restlessness. |
15. If a patient states they have pain, should your visual observation of what they are doing at the moment contribute to your report of the patient's pain? |
No, the patient’s statement about their pain is the priority, even if they don’t appear to be in pain.
16. What is the pain assessment (rating) scale is used for?
The pain assessment (rating) scale is used to measure the level of pain a patient is experiencing, usually from 0 (no pain) to 10 (worst pain). |
17. What does HIPAA do and who is able to access patient information?
HIPAA protects patient privacy, ensuring only authorized healthcare professionals access their information. |
18. Why is it necessary to link the handheld computer to a full-size computer do?
Linking the handheld computer to a full-size computer allows for data transfer, storage, and analysis. |
19. What should you do with patient documents that are no longer needed? |
Patient documents that are no longer needed should be securely disposed of, typically by shredding. |
20. What does SBAR communication stands for? And what information is provided for each step? |
SBAR stands for Situation, Background, Assessment, and Recommendation. Each step provides structured communication: what’s happening, patient history, current assessment, and recommended action.
21. A Minimum Data Set (MDS) is collected by? |
A Minimum Data Set (MDS) is collected by nurses or healthcare professionals in long-term care facilities.
22. What rules of documentation should you follow?
Documentation rules include accuracy, clarity, timeliness, and using only approved abbreviations. |
23. What is an electronic version of a paper medical record called?
An electronic version of a paper medical record is called an Electronic Health Record (EHR). |
24. What is POCT at where is it performed?
POCT stands for Point-of-Care Testing and is performed at the patient’s bedside or nearby for quick results. |
25. What is the purpose of a nursing diagnosis? |
The purpose of a nursing diagnosis is to identify and describe a patient’s health issues to guide care and treatment. |