142 EXAM #1 Questions and Answers
Baseline Assessment - Answer comprehensive, ASAP, basis to compare to for future reference.
ex: acute care, new admissions
Problem Focused Assessment - Answer system specific, ongoing, determine status of issue. ex:
shift change
Emergency Assessment - Answer psychological/physiological crisis, identify life threatening
issues/new issues. ex: pain, shortness of breath
Ongoing Assessment - Answer minutes to months after baseline. ex: home care/outpatient,
wounds, BP
Nursing Goals - Answer promote overall health, prevent illness, treat human response to
health/illness, advocate
Nursing Process ADPIE - Answer Assessment, diagnosis, plan, implement, evaluation
Database contains what? - Answer nursing health history, physical, primary care provider's
health history/physical, lab/diagnostic results
Process of collecting data - Answer Observe, Interview, examine, organize, validate, interpret
Types of examinations - Answer Inspection, palpation, percussion (direct/indirect),
auscultation (direct/indirect)
Parts of an interview - Answer Pre-interview, opening, body, closing
When can students use client records? - Answer client conferences, clinics, rounds, client
studies, and written papers
Uses of client records - Answer communication, planning, auditing, research, education,
reimbursement, legal documentation, healthcare analysis
Source Oriented record - Answer separate sheets for each healthcare professional, narrative,
convenient, cause decrease in flow of communication
, Problem Oriented record - Answer sequence according to problems, plan of care, progress
notes, easier to collaborate/track status of issues (problem list), may be inefficient due to
caregiver's ability to use format
Progress Notes SOAPIER - Answer Subjective, objective, assessment, plan, intervention,
evaluation, revision
PIE model - Answer problem, intervention, evaluation using flow sheets. client's
concerns/strengths are main focus, must be reviewed before giving care
Focus charting - Answer DAR (data, action, response), uses holistic perspective
CBE - Answer only record/chart abnormalities using flow sheets, bedside access. unrepitive,
changes are easy to see, some may believe in inaccuracy
Documenting Admissions - Answer initial database, nursing history/assessment, organized by
patterns, body systems, functional abilities, health risks, nursing model or setting, records
ongoing (re)assessment on flow sheet/progress notes
Care Plan - Answer evidence of assessments, nursing diagnosis or needs, interventions,
outcomes. Traditional vs standardized
Kardexes - Answer accessible, temporary, concise method, organized into allergies, meds, IV,
treatment processes, quick visual guide
Flow Sheets - Answer record quickly/concisely, input/output, MAR, skin assessment, graphic
record (BP, temp)
Progress notes - Answer progress, intervention, assessment
How to correct an error - Answer draw strikethrough, write "error" above, initial, write new
data
What is not approved by j.co when documenting? - Answer abbreviations, decimals, symbols
SBAR - Answer situation, background, assessment, recommendation
Lifespan Considerations in nutrition - Answer infants-nutrition during pregnancy, ht/wt,
formulas, breastfeeding
Baseline Assessment - Answer comprehensive, ASAP, basis to compare to for future reference.
ex: acute care, new admissions
Problem Focused Assessment - Answer system specific, ongoing, determine status of issue. ex:
shift change
Emergency Assessment - Answer psychological/physiological crisis, identify life threatening
issues/new issues. ex: pain, shortness of breath
Ongoing Assessment - Answer minutes to months after baseline. ex: home care/outpatient,
wounds, BP
Nursing Goals - Answer promote overall health, prevent illness, treat human response to
health/illness, advocate
Nursing Process ADPIE - Answer Assessment, diagnosis, plan, implement, evaluation
Database contains what? - Answer nursing health history, physical, primary care provider's
health history/physical, lab/diagnostic results
Process of collecting data - Answer Observe, Interview, examine, organize, validate, interpret
Types of examinations - Answer Inspection, palpation, percussion (direct/indirect),
auscultation (direct/indirect)
Parts of an interview - Answer Pre-interview, opening, body, closing
When can students use client records? - Answer client conferences, clinics, rounds, client
studies, and written papers
Uses of client records - Answer communication, planning, auditing, research, education,
reimbursement, legal documentation, healthcare analysis
Source Oriented record - Answer separate sheets for each healthcare professional, narrative,
convenient, cause decrease in flow of communication
, Problem Oriented record - Answer sequence according to problems, plan of care, progress
notes, easier to collaborate/track status of issues (problem list), may be inefficient due to
caregiver's ability to use format
Progress Notes SOAPIER - Answer Subjective, objective, assessment, plan, intervention,
evaluation, revision
PIE model - Answer problem, intervention, evaluation using flow sheets. client's
concerns/strengths are main focus, must be reviewed before giving care
Focus charting - Answer DAR (data, action, response), uses holistic perspective
CBE - Answer only record/chart abnormalities using flow sheets, bedside access. unrepitive,
changes are easy to see, some may believe in inaccuracy
Documenting Admissions - Answer initial database, nursing history/assessment, organized by
patterns, body systems, functional abilities, health risks, nursing model or setting, records
ongoing (re)assessment on flow sheet/progress notes
Care Plan - Answer evidence of assessments, nursing diagnosis or needs, interventions,
outcomes. Traditional vs standardized
Kardexes - Answer accessible, temporary, concise method, organized into allergies, meds, IV,
treatment processes, quick visual guide
Flow Sheets - Answer record quickly/concisely, input/output, MAR, skin assessment, graphic
record (BP, temp)
Progress notes - Answer progress, intervention, assessment
How to correct an error - Answer draw strikethrough, write "error" above, initial, write new
data
What is not approved by j.co when documenting? - Answer abbreviations, decimals, symbols
SBAR - Answer situation, background, assessment, recommendation
Lifespan Considerations in nutrition - Answer infants-nutrition during pregnancy, ht/wt,
formulas, breastfeeding
