True Or False The following statements apply

True Or False The following statements apply to rules for recording. Circle T for true, or circle F for false. 1. T F Document in pencil. 2. T F Include the date whenever a new entry is made. 3. T F In written notes, all writing must be legible and neat. 4. T F Use any abbreviations needed to shorten an entry. 5. T F Use correct spelling, grammar, and punctuation. 6. T F For written documentation, use an eraser or correction fluid if you make an error. 7. T F Sign all entries with your name and title as required by your agency. 8. T F Skip lines between recorded entries. 9. T F Document what you or others did or observed. 10. T F Document all care and treatments early in the shift before beginning work. 11. T F Document your observations, interpretations, and judgements. 12. T F Document in a logical and sequential manner. 13. T F Avoid terms with more than one meaning. 14. T F Paraphrase the client’s words to make the meaning more understandable. 15. T F Document any changes from normal or changes in the client’s condition. 16. T F Repeated complaints of pain can be omitted when documenting. 17. T F Document safety measures used in caring for the client. 18. T F Objective data are things a client reports that you cannot observe or gather by using your senses. 19. T F Subjective data are pieces of information you can obtain about a client by using your senses. 20. T F When you document in the chart, you sign your name and write your title as per agency policy after each entry. Multiple Response From the list below, choose all of the correct answers. 21. What are the four senses you use to obtain information about a client? A. Smell B. Hearing C. Touch D. Instinct E. Sight 22. Which of the following basic observations will give you information about a client? A. ADLs B. Appetite C. Pain D. Respirations E. Skin condition F. Ability to respond 23. What basic observations and assessments can you make to determine a client’s ability to respond? A. The client can state his or her name, the time, and the location. B. The client can speak clearly. C. The client can follow directions. D. The family can answer questions. E. The client is easy to rouse. F. The client responds correctly to questions. 24. What observations and assessments will help to determine whether a client is moving appropriately? A. The client can squeeze your fingers with each hand. B. The client can move his or her arms and legs. C. The client’s movements are shaky or jerky. D. The client can ambulate without assistance. 25. What observations and assessments should be made about a client’s respirations? A. Do both sides of the client’s chest rise and fall with respirations? B. Is the client’s breathing noisy? C. Does the client complain of difficulty breathing? D. Does the client complain of gas? E. What is the amount and colour of sputum? F. What is the frequency of the client’s cough? Is it dry or productive? 26. What observations and assessments should be made about the skin? A. Is the skin pale or flushed? B. Is the skin moist or dry? C. Is the skin intact? D. Are bruises present? Where? E. Is the abdomen firm or soft? F. Does the client complain of itching? 27. What observations and assessments are important for determining how the bowels and bladder are functioning? A. Amount, colour, and consistency of stool B. Colour of the lips and nail beds C. Frequency of bowel movements D. Pain or difficulty urinating E. Client’s control of the passage of urine F. Frequency of urination 28. When reporting to the nurse, you should do which of the following? A. Report what you observed and did yourself B. Report what other support workers did C. Report any changes in the client’s condition. D. Report promptly, thoroughly, and accurately E. Report only at the end of your shift Multiple Choice Circle the correct answer. 29. What information is included on the graphic sheet? A. Bowel sounds B. Temperature, pulse, and respirations C. Complaints of pain D. Amount of food consumed 30. What statement about electronic documentation is correct? A. You are able to use all types of abbreviations. B. All spelling errors are automatically corrected. C. In general, staff can take electronic tablets home to document on their own time. D. It requires individual entries using a personal identification number (PIN) or code. 31. Which of these is a question about an activity of daily living? A. Can the client perform personal care without help? B. How much food on the tray did the client eat? C. What is the frequency of the client’s bowel movements? D. Can the client move his or her arms and legs? 32. When should the support worker contact the supervisor? A. When the pharmacy delivers the client’s medications to the house B. When you believe the client’s safety is at risk C. The support worker should provide the supervisor with hourly updates D. After completion of a procedure Matching Match the following descriptions with one of the key terms related to communication. 33. ______ Identification of a disease or condition by a doctor 34. ______ Determining whether the goals in the care plan have been met 35. ______ Description of a health problem that can be treated by nursing measures 36. ______ Written guide that gives direction about the care and services a client should receive 37. ______ Method used by nurses to plan and deliver nursing care 38. ______ Action taken by a nursing team member to help the client reach a goal A. Client care plan B. Nursing diagnosis C. Nursing intervention D. Care planning process E. Medical diagnosis F. Evaluation Match the following time with the corresponding time using the 24-hour clock. 39. ______ 8:45 a.m. 40. ______ 4:00 p.m. 41. ______ 11:59 p.m. 42. ______ 12:30 a.m. 43. ______ 9:50 p.m. 44. ______ midnight 45. ______ 6:30 a.m. 46. ______ 10:00 p.m. 47. ______ 1:30 p.m. 48. ______ 7:30 p.m. 49. ______ 3:30 p.m. 50. ______ 2:45 p.m. A. 0030 h B. 2400 or 0000 hr C. 2200 hr D. 0630 hr E. 1930 hr F. 1530 hr G. 0845 hr H. 2359 hr I. 1445 hr J. 1330 hr K. 2150 hr L. 1600 hr Fill in the Blanks The following words or phrases are either subjective (S) or objective (O) data. Fill in the blank with either an S or an O. 51. ______ Sleepy 52. ______ Chest pain 53. ______ Cool skin 54. ______ Bruises 55. ______ Difficulty breathing 56. ______ Gas pain 57. ______ Pain when urinating 58. ______ Productive cough 59. ______ Breath has a fruity odour 60. ______ Rapid pulse and shallow breathing 61. ______ Mr. Khan states that he is cold 62. ______ Mary has red hair 63. ______ Mrs. Smith says she has pain in her right shoulder 64. ______ Temperature 37.6°C (99.6 °F), pulse 72, respirations 16 65. ______ Mr. Kallio ate all of his breakfast 66. ______ Mrs. Foster says she is anxious about having surgery 67. Identify the meaning of each word in the SMART acronym for use when setting goals: S = _____________________________________________ M = ____________________________________________ A = ____________________________________________ R = ____________________________________________ T = ____________________________________________

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