Mosby's Textbook for Nursing
Assistants- Chapter 8 Questions with
Complete Solutions.
Assessment - Answer Collecting information about the person; a step in the nursing process
Chart - Answer is the medical record is the legal account of a person's condition and
response to treatment and care (medical record, clinical record)
Clinical Record - Answer is the medical record is the legal account of a person's condition and
response to treatment and care (medical record, chart)
Electronic Health Record (EHR) - Answer An electronic version of a person's medical record;
electronic medical record
Electronic Medical Record (EMR) - Answer An electronic version of a person's medical record
(see "electronic health record")
end-of-shift report - Answer A report that the nurse gives at the end of the shift to the on-
coming shift; change-of-shift report
Examples: The care given, the care to give during other shifts, the person's current condition,
new or changed orders
Evaluation - Answer To measure if goals in the planning step were met
Implementation - Answer To perform or carry out nursing interventions (nursing measures,
nursing actions, nursing tasks) in the care plan; nursing process
Medical Record - Answer The legal account of a person's condition and response to
treatment and care; chart or clinical record
Nursing Care Plan - Answer A written guide about a person's nursing care; care plan
Nursing Diagnosis - Answer A health problem that can be treated by nursing measures; see
"nursing process"
, Nursing Intervention - Answer an action or measure taken by the nursing team to help the
person reach a goal; nursing action, nursing measure, nursing task
Nursing Process - Answer The method nurses use to plan and deliver nursing care; its 5 steps
are assessment, nursing diagnosis, planning, implementation, and evaluation
Objective Data - Answer information that is seen, heard, felt, or smelled by an observer;
signs
Observation - Answer Using the senses of sight, hearing, touch, and smell to collect
information
Planning - Answer setting priorities and goals; see "nursing process"
Note: Priorities- what is the most important for the person.
Goals- what is desired for or by a person as a result of nursing care.
Progress Note - Answer Describes the care given and the person's response and progress
Recording - Answer The written account of care and observations; charting, documentation
Reporting - Answer The oral account of care and observations
Note: Report ONLY what you observed and did yourself
Signs - Answer Information that is seen, heard, felt, or smelled by an observer; objective
data
Subjective Data - Answer Things a person tells you about that you cannot observe through
your senses ( a person's pain, fear, nausea)
Symptoms - Answer Things a person tells you about that you cannot observe through your
senses (see Subjective Data)
ADL - Answer activities of daily living
BMs - Answer bowel movements
Assistants- Chapter 8 Questions with
Complete Solutions.
Assessment - Answer Collecting information about the person; a step in the nursing process
Chart - Answer is the medical record is the legal account of a person's condition and
response to treatment and care (medical record, clinical record)
Clinical Record - Answer is the medical record is the legal account of a person's condition and
response to treatment and care (medical record, chart)
Electronic Health Record (EHR) - Answer An electronic version of a person's medical record;
electronic medical record
Electronic Medical Record (EMR) - Answer An electronic version of a person's medical record
(see "electronic health record")
end-of-shift report - Answer A report that the nurse gives at the end of the shift to the on-
coming shift; change-of-shift report
Examples: The care given, the care to give during other shifts, the person's current condition,
new or changed orders
Evaluation - Answer To measure if goals in the planning step were met
Implementation - Answer To perform or carry out nursing interventions (nursing measures,
nursing actions, nursing tasks) in the care plan; nursing process
Medical Record - Answer The legal account of a person's condition and response to
treatment and care; chart or clinical record
Nursing Care Plan - Answer A written guide about a person's nursing care; care plan
Nursing Diagnosis - Answer A health problem that can be treated by nursing measures; see
"nursing process"
, Nursing Intervention - Answer an action or measure taken by the nursing team to help the
person reach a goal; nursing action, nursing measure, nursing task
Nursing Process - Answer The method nurses use to plan and deliver nursing care; its 5 steps
are assessment, nursing diagnosis, planning, implementation, and evaluation
Objective Data - Answer information that is seen, heard, felt, or smelled by an observer;
signs
Observation - Answer Using the senses of sight, hearing, touch, and smell to collect
information
Planning - Answer setting priorities and goals; see "nursing process"
Note: Priorities- what is the most important for the person.
Goals- what is desired for or by a person as a result of nursing care.
Progress Note - Answer Describes the care given and the person's response and progress
Recording - Answer The written account of care and observations; charting, documentation
Reporting - Answer The oral account of care and observations
Note: Report ONLY what you observed and did yourself
Signs - Answer Information that is seen, heard, felt, or smelled by an observer; objective
data
Subjective Data - Answer Things a person tells you about that you cannot observe through
your senses ( a person's pain, fear, nausea)
Symptoms - Answer Things a person tells you about that you cannot observe through your
senses (see Subjective Data)
ADL - Answer activities of daily living
BMs - Answer bowel movements
