-Problem
-intervention
-Evaluation Correct Answers PIE
"if it wasn't documented, it wasn't ____" Correct Answers done
A ____ line is used when making corrections Correct Answers
single
A chart serves as a ______ document admissible in court
Correct Answers legal
A client statement such as "the pain in my hip is so bad" is an
example of ________ data Correct Answers subjective
A client tells the nurse, "This pill is a different color than the
one that I usually take at home." Which is the best response by
the nurse?
1. "Go ahead and take your medicine."
2." I will recheck your medication orders."
3. "Maybe the doctor ordered a different medication."
4. "I'll leave the pill here while I check with the doctor." Correct
Answers 2. If there is any doubt, the medication administration
process should be interrupted until the question is clarified.
A disadvantage of computer documentation is.....? Correct
Answers its expensive
A legal document Correct Answers chart
,A type of clock used when documenting Correct Answers 24
hour
A type of record vital signs are recorded on Correct Answers
graphic
Abnorma Findings of the Skin Correct Answers -abrasions:
scrape, open area that is very superficial
-excessive dryness
-acne
-erythema: redness or rash
-hirtuism: excessive amount of hair on a body part or face that
would be abnormal
-scabies: abnormally found such as lice, tick, or a parasite that
could cause skin breakdown
Abnormal Findings of Ears Correct Answers -asymmetrical,
excessively red or tender auricles
-lesions, flaky, scaly skin over auricles
-normal voice tones not heard
Abnormal Findings of Feet Correct Answers -excessive dryness
-areas of inflammation or swelling
-fissures, cracking, or scaling of skin
-plantar warts
-swelling and pitting edema (blanching and shaped doesn't
return)
-weak or absent pulses
-cool skin temperature in one or both feet
, Abnormal Findings of Nails Correct Answers -spoon nails
-excessive thickness or clubbing
-Beau's lines
-discolored or detached
-bluish or purplish tint to pallor (cyanosis)
-hangnails or paronychia (infection of tissue folds around the
nails)
-delayed capillary refilling time-blanched test
Abnormal Findings of the Eyes Correct Answers -loss of hair,
scaling, flaking eyebrows
-redness, swelling, flaking, crusting, discharge, asymmetrical
closing, ptosis of eyelids (drooping)
-poor vision
-PEARLL: pupils, equal, accomodate, round, react to light
Abnormal Findings of the Mouth Correct Answers -halitosis:
bad breath
-glossitis: inflammation of tongue
-gingivitis: inflammation of gums
-periodontal disease: bleeding of gum
-reddened or excoriated mucosa
-excessive dryness of the buccal mucosa
-cheilosis: cracking of the lips
-dental carries
-stomatitis: painful swelling and sores inside mouth
-parotitis: inflammation of parotid gland
Active Immunity Correct Answers host produces antibodies in
response to natural antigens or artificial antigens