CHAP 4 Flashcards

1
Q

the process of confirming or verifying that the subjective and objective data you have collected are reliable and accurate

A

Validation of data

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2
Q

Conditions that require data to be rechecked and validated
include the following:

A
  • Discrepancies or gaps between the subjective and objective data
  • Discrepancies or gaps between what the client says at one time versus another
    time
  • Findings that are highly abnormal and/or inconsistent with other findings
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3
Q

ways to validate data

A

Recheck your own data through a repeat assessment

Clarify data with the client by asking additional questions

Verify the data with another health care professional

Compare your objective findings with your subjective findings to uncover
discrepancies.

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4
Q

2 types of documentation

A

Vague
clear and concise

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5
Q

three types of assessment forms
are used to document data:

A

Initial
Frequent/ongoing
Focused

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6
Q

is called a “nursing admission or admission database.”

A

Initial

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7
Q

this documentation consist of openended, cued or checklist, integrated cued checklist, and nursing minimum data set
(NMDS) forms.

A

Initial

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8
Q

cardiovascular or neurologic assessment documentation forms is under what type f assesment form

A

focused

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9
Q

model of communication is used throughout this book to
demonstrate a consistent way to communicate assessment data

A

SBAR

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10
Q

Meaning of SBAR

A

Situation
Background
Assessment
Recommendation

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