Medical Care Mastery
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Questions and Answers

Which one of the following is NOT a method of charting mentioned in the text?

  • Source-oriented records
  • Focus charting
  • Narrative charting (correct)
  • Problem-oriented records

    • Which one of the following is a purpose of the written record mentioned in the text?

  • To provide data regarding patient's overall condition
  • To measure baseline measurements against changes
  • To ensure client safety and continuity of care (correct)
  • To improve nurse-physician communication

    • What does the abbreviation 'AM' stand for in military time?

  • Noon
  • Morning (correct)
  • Midnight
  • Afternoon

    • Which one of the following is a suffix that refers to pressure/stretching?

    <p>-tension</p> Signup and view all the answers

    What is the purpose of the SBAR technique mentioned in the text?

    <p>To improve nurse-physician communication</p> Signup and view all the answers

    What does the prefix 'Brady-' refer to?

    <p>Slow heart</p> Signup and view all the answers

    What does the term 'MEDICAL RECORD' refer to?

    <p>All of the above</p> Signup and view all the answers

    Which of the following is NOT considered a primary source of client data in the nursing process?

    <p>Physician's History &amp; Physical</p> Signup and view all the answers

    What is the purpose of a nursing diagnosis?

    <p>To identify health problems that can be resolved through nursing interventions</p> Signup and view all the answers

    What does NANDA-I stand for?

    <p>North American Nursing Diagnosis Association International</p> Signup and view all the answers

    Who is responsible for analyzing data and identifying health problems in the nursing process?

    <p>RN</p> Signup and view all the answers

    Which of the following is an example of a nursing diagnosis?

    <p>Impaired Physical Mobility related to decreased muscle control</p> Signup and view all the answers

    What does the nurse do during the planning phase of the nursing process?

    <p>Write desired client goals</p> Signup and view all the answers

    What is a goal in the context of nursing interventions?

    <p>A statement that describes measurable, observable behavior that the client should demonstrate</p> Signup and view all the answers

    Which of the following is NOT a characteristic of a long-term goal?

    <p>It can be achieved within hours, days, or weeks</p> Signup and view all the answers

    What does SMART stand for when setting goals?

    <p>Specific, Measurable, Achievable, Realistic, Timely</p> Signup and view all the answers

    When should a physical assessment be performed?

    <p>When client condition changes</p> Signup and view all the answers

    What is the role of an LPN in a physical assessment?

    <p>Perform a focused assessment</p> Signup and view all the answers

    What is the difference between signs and symptoms in a physical assessment?

    <p>Signs are directly observable or measurable, while symptoms are verbalized by the patient</p> Signup and view all the answers

    What is the technique used in a physical assessment to listen to body organs for abnormal sounds?

    <p>Auscultation</p> Signup and view all the answers

    What should be monitored and noted during a respiratory assessment?

    <p>Crackles and rhonchi</p> Signup and view all the answers

    Which form of documentation is a quick reference for current information centrally at the nursing station?

    <p>Cardex</p> Signup and view all the answers

    What is the purpose of Nursing Care Plans?

    <p>To list the client's problems, goals, and nursing orders</p> Signup and view all the answers

    Which form of documentation is used to record frequently repeated assessment data?

    <p>Flow Sheets</p> Signup and view all the answers

    What is the purpose of Change-of-shift report?

    <p>To provide a discussion between nursing spokespersons</p> Signup and view all the answers

    Which form of documentation provides a discussion between nursing spokespersons?

    <p>Change-of-shift report</p> Signup and view all the answers

    What is the purpose of Cardex?

    <p>To serve as a quick reference for current information</p> Signup and view all the answers

    What is the purpose of Flow Sheets?

    <p>To evaluate trends</p> Signup and view all the answers

    Which form of documentation is a written or printed list of the client's problems, goals, and nursing orders?

    <p>Nursing Care Plans</p> Signup and view all the answers

    Which form of documentation is a form of documentation with sections for recording frequently repeated assessment data?

    <p>Flow Sheets</p> Signup and view all the answers

    What is the time frame for short-term goals in nursing interventions?

    <p>Within hours, days, or weeks</p> Signup and view all the answers

    What is the time frame for long-term goals in nursing interventions?

    <p>Within 6 months or more</p> Signup and view all the answers

    What is the purpose of setting SMART goals in nursing interventions?

    <p>To make goals achievable</p> Signup and view all the answers

    When does the nurse perform the implementation phase of the nursing process?

    <p>When putting the established plan into action</p> Signup and view all the answers

    What does the nurse do during the evaluation phase of the nursing process?

    <p>Determines the effectiveness of nursing care</p> Signup and view all the answers

    What is the purpose of data collection in a physical assessment?

    <p>To establish a baseline of the patient's condition</p> Signup and view all the answers

    What is the purpose of a focused assessment in a physical assessment?

    <p>To collect and report patient data</p> Signup and view all the answers

    Which of the following is a method of charting mentioned in the text?

    <p>All of the above</p> Signup and view all the answers

    What does the abbreviation 'AM' stand for in military time?

    <p>Ante Meridiem</p> Signup and view all the answers

    What is the purpose of the SBAR technique mentioned in the text?

    <p>All of the above</p> Signup and view all the answers

    What is the difference between signs and symptoms in a physical assessment?

    <p>Signs are observed by the nurse, while symptoms are reported by the client</p> Signup and view all the answers

    What is the purpose of Change-of-shift report?

    <p>All of the above</p> Signup and view all the answers

    What does the prefix 'Brady-' refer to?

    <p>Slow heart</p> Signup and view all the answers

    What is the purpose of the Written Record mentioned in the text?

    <p>All of the above</p> Signup and view all the answers

    Which of the following is NOT a component of the nursing process?

    <p>Evaluation</p> Signup and view all the answers

    What is the purpose of the NANDA-I diagnosis list?

    <p>To update nursing diagnoses based on evidence-based practices</p> Signup and view all the answers

    Which of the following is an example of a secondary source of client data in the nursing process?

    <p>Physician's History &amp; Physical</p> Signup and view all the answers

    What is the role of an LPN in the nursing process?

    <p>Collecting data</p> Signup and view all the answers

    What is the purpose of a nursing diagnosis?

    <p>To identify actual or potential health problems</p> Signup and view all the answers

    What is a goal in the context of nursing interventions?

    <p>A statement that describes measurable, observable behavior that the client should demonstrate after nursing interventions</p> Signup and view all the answers

    What is the purpose of the care plan in the nursing process?

    <p>To guide the implementation of nursing interventions</p> Signup and view all the answers

    Which form of documentation is used to record frequently repeated assessment data?

    <p>Flow Sheets</p> Signup and view all the answers

    What is the purpose of the SBAR technique mentioned in the text?

    <p>To facilitate effective communication during handoff</p> Signup and view all the answers

    What does the term 'Kardex' refer to?

    <p>A quick reference for current information centrally at the nursing station</p> Signup and view all the answers

    What is the purpose of Nursing Care Plans?

    <p>To promote the prevention, reduction, or resolution of the client's problems</p> Signup and view all the answers

    Which one of the following is NOT a method of charting mentioned in the text?

    <p>Cardex</p> Signup and view all the answers

    What is the purpose of Change-of-shift report?

    <p>To facilitate effective communication during handoff</p> Signup and view all the answers

    What is the purpose of Cardex?

    <p>To provide a quick reference for current information</p> Signup and view all the answers

    What is the purpose of Flow Sheets?

    <p>To record frequently repeated assessment data</p> Signup and view all the answers

    Which one of the following is a purpose of the written record mentioned in the text?

    <p>To promote the prevention, reduction, or resolution of the client's problems</p> Signup and view all the answers

    Study Notes

    Overview of Nursing Process Components and Documentation in Healthcare

    • Nursing process consists of five components: assessment, nursing diagnosis, planning, implementation, and evaluation.
    • Assessment includes gathering client data from primary and secondary sources, such as physical assessments, physician's history, lab results, and information from other health personnel.
    • Nursing diagnosis involves analyzing data to identify actual or potential health problems that can be addressed through nursing interventions.
    • NANDA-I provides a list of nursing diagnoses that are updated based on evidence-based practices.
    • Planning involves setting goals for client care and developing nursing interventions to achieve those goals.
    • Goals can be short-term or long-term and should be specific, measurable, achievable, realistic, and timely (SMART).
    • Implementation is the phase where the established care plan is put into action, including both independent and dependent nursing interventions.
    • Evaluation is the process of determining the client's progress toward goal achievement and the effectiveness of the nursing care plan.
    • Physical assessment is a crucial part of data collection, including comprehensive assessments, focused assessments, and initial head-to-toe shift assessments.
    • LPNs assist with physical assessments by collecting and reporting patient data and performing indirect patient care.
    • Physical assessment techniques include inspection, auscultation, palpation, percussion, and olfaction.
    • Vital signs are important indicators of a patient's overall condition and provide baseline measurements for monitoring changes.

    Note: The text provided is incomplete and cuts off abruptly.

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