Chapter 5 - Communicating With The Health Team

Question 1

Chart

Answer 1

Medical record. The legal account of a persons condition and response to treatment and care

Question 2

Communication

Answer 2

The exchange of information – a message sent is received and correctly interpreted by the intended person

Question 3

End of shift report

Answer 3

A report that the nurse gives at the end of the shift to the oncoming shift; change of shift report

Question 4

Medical record

Answer 4

The legal account of a persons condition and response to treatment and care; chart

Question 5

Nursing care plan

Answer 5

A written guide about a person’s nursing care; care plan

Question 6

Nursing diagnosis

Answer 6

A health problem that can be treated by nursing measures

Question 7

Nursing process

Answer 7

The method nurses used to plan and deliver nursing care; its five steps are assessment, nursing diagnosis, planning, implementation, and evaluation

Question 8

Objective data

Answer 8

Information that is seen, heard, felt, or smelled by and observe her; signs

Question 9

Observation

Answer 9

Using the senses of sight, hearing, touch, and smell to collect information

Question 10

Planning

Answer 10

Setting priorities and goals

Question 11

Recording

Answer 11

The written account of care and observations; charting

Question 12

Reporting

Answer 12

The oral account of Care and observations

Question 13

Signs

Answer 13

Objective data the information that is seen heard felt or smelled by an observer signs

Question 14

Subjective data

Answer 14

Things a person tells you about that you cannot observe through your senses; symptoms

Question 15

Symptoms

Answer 15

I thing a person tells you about that you cannot observe through your senses; symptoms

Question 16

Kardex

Answer 16

The Kardex or summary care provides a quick, easy reference to the persons drugs, treatments, diagnosis, care measures, equipment, and special needs. It is a type of card file.