Nursing 120 exam 2 QUESTIONS AND ANSWERS
WITH VERIFIED SOLUTIONS
The act of charting or making written notation of all the things that are pertinent
to patient care. - ANSWER Documentation
Can be used with source-oriented or problem-oriented records. Stands for
Subjective data, Objective data, Assessment data, Plan/Intervention, Evaluation,
and Revision. - ANSWER SOAP/SOAPIER charting
No set formula is followed; rather, the health-care professional writes a detailed
account of the care the patient receives and events that occur in chronological
order including client condition, complaints, problems, assessment findings,
activities, treatments, and nursing care. - ANSWER Narrative Charting
This is patient-centered communication with a goal to promote a greater
understanding of a patient's needs, concerns, and feelings. - ANSWER
Therapeutic Communication
To complete the communication process, the receiver will send ___________, or a
return message, that indicates the message has been received, processed, and
comprehended. - ANSWER Feedback (loop)
Four personal space-distance zones have been identified for use in the United
States. Which one is associated with a distance range of 4 to 12 feet? -
ANSWER Social consultative zone
, Refers to a client's ability to understand basic health information? - ANSWER
health literacy
This phase of illness refers to a person who "doesn't feel good" and has general
aches and fatigue? - ANSWER Prodromal Phase
Four purposes of documentation - ANSWER communicate patient data,
permanent record, record of accountability, legal record
This record supplies a permanent source of medical history that can be used for a
reference when the client requires additional health-care in the future. -
ANSWER Permanent record of care
This ensures clients have access to their health information contained within the
medial record. - ANSWER HIPPA
The documentation form the nurse uses to record data received about client care
from the off-going shift nurse. - ANSWER Report Form
Medication errors, client injuries, visitor injuries, and employee injuries are
recorded on ________ ________. - ANSWER Incident report
Making entries in a timely manner, using black or blue ink, signing each entry,
following chronological order, and inclusion of date/time with each entry are
guidelines for ______. - ANSWER Guidelines Documentation
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