Chapter 3: Communication Skills

Question 1

Subjective observations

Answer 1

• patient reports

- headache, stomachache, dizzy, tired, hungry

Question 2

Objective observations

Answer 2

• tested, measured or seen

- blood pressure, weight, height, respirations, pulse

Question 3

Non-verbal communication

Answer 3

-rolling your eyes, crossing your arms

Question 4

Minimum data set (MDS)

Answer 4

-must be completed with 14 days of resident admission

Question 5

Adverse event

Answer 5

-an unexpected event that results in serious injury or death

Question 6

Roles in communication

Answer 6

• sender

- receiver

Question 7

Positive vs negative body language

Answer 7

Positive: smiling, leaning forward to listen, nodding when the person is talking
Negative: crossing arms, rolling eyes, tapping feet, pointing at someone while speaking

Question 8

Accepting Communication

Answer 8

• you cannot take physician orders as a cna
• only accept appropriate communication
• know your scope of practice

Question 9

24 hour clock

Answer 9

0400 = 4am

• many facilities use military time to communicate times more effectively
• subtract 12
• 1200 is 12 noon
• 2400 or 0000 is midnight
• 0600 1800 6am vs 6pm

Question 10

Charting

Answer 10

• nursing assistants write down observations
• legal record
• what’s written on the chart is what is considered to have legally happened
• if you forget to chart something it didn’t happen
• always use black or dark blue ink
• sign any notes you make
• only use facts
• chart alone, be mindful of your surroundings
• NEVER document care before it is given

Question 11

HIPAA

Answer 11

• needs to know vs nice to know
• all information is confidential
• no identifiable factors

Question 12

Information found on a resident’s chart

Answer 12

• admissions information
• admission vital sgins
• history
• care plan
• doctor’s orders and progress notes
• nursing assesments
• anything from specialists
• flow sheet: list of things that were done for a resident
• I&O: are they drinking, eating, bowel movements
• consent forms
• advanced directive

Question 13

Who can access a resident’s chart

Answer 13

• resident
• care team
• doctors, nurses, specialists, parents if resident is a minor

Question 14

Abbreviations and Acronyms

Answer 14

-approved abbreviations and acronyms vary between facilities

Question 15

Describing observations

Answer 15

-compare to a size (dime, pea, quarter)