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68WM6 Documentation Test

Enter the letter for the matching Answer
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1.
Subjective Information
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2.
Telephone and Verbal orders can only be taken by whom?
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3.
Routine care
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4.
Grammar and cleanliness are worthwhile: messy notes give an appearance of
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5.
Medication orders must include
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6.
concentration of attention on the part of the body where signs and symptoms are localized or most active in order to determine their significance.
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7.
Factual, Objective Notations are
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8.
Secondary Source of Information
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9.
Possible
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10.
If it is documented, it is assumed to be
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11.
Planning
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12.
Ongoing Assesment
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13.
Diagnosis
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14.
If a patient wants to leave against medical advice what should you do?
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15.
An LVN can only execute what kind of orders?
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16.
Actual Nursing Diagnosis
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17.
Why use leading zero for decimals?
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18.
A lawyer may ask you this in regards to editing a nursing document in court.....
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19.
Focused assesments are appropriate for...
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20.
Hierarchy of needs (Maslow's)
A.
family members, significant others, health care team, medical records, diagnostic procedures, and nursing literature.
B.
verbal statements from the patient.
C.
More likely it is, “Did you alter the record in any way?.” This is much broader.
D.
critically ill, disoriented, or unable to respond patients.
E.
Chief complaint; subjective and objective findings; diagnosis; treatment plan; response to treatment.
F.
Medication name.Dose.Route.Frequency.
G.
accurate
H.
What you hear, see, feel, and smell.
I.
Written orders
J.
Focused
K.
messy care.
L.
systematic follow-up is required when problems are identified during a comprehensive or focused assessment.
M.
a condition that is currently present.
N.
the establishment of pt goals to prevent, reduce, or resolve the problems identified in the nursing diagnoses. The nsg dx guides the development pertinent nsg interventions.
O.
an analysis of pt data to identify patient strengths and health problems identified which independent nursing interventions can prevent or resolve.
P.
RN's
Q.
when a problem is considered feasible.
R.
Document every detail and advise the patient of the consequences. If possible, try to get patient to sign refusal of care document.
S.
(ensures decimal is recognized).
T.
individual's basic needs must be meet before higher-level needs can be met.
Type the Answer that corresponds to the displayed Question.
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21.
Is it okay to document ahead of time?
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22.
The chart is used as a
Type the Question that corresponds to the displayed Answer.
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23.
Professionals have an obligation to recognize condition change and take action. Can only illustrate this through documentation.
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24.
observable and measurable which can be recorded.
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25.
a systematic and continuous collection, and communication of pt data
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26.
process of putting data together in order to identify areas of the patient's problems and strengths. Mixing all your data together like a tasty martini
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27.
You may be asked whether or not you tampered with the record when the record is requested.
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28.
measurement of the extent to which the patient has achieved the goals specified in the plan of care.
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29.
Units vs. a zero (always write out units).
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30.
putting into practice the plan of care

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