A ______________ is a word element placed before the root; it changes the meaning of the word.
Prefix
An _____________ is a shortened form of a word or phrase
abbreviation
______________ is the exchange of information�a message sent is received and interpreted by the intended person.
Communication
A ____________ is a clash between opposing interests and ideas
Conflict
A type of card file that summarizes information found in the medical record is a _________________.
Kardex
A ________________ is the term used when symptoms, signs, or reasons for a problem are identified
Diagnosis
The _______________ is another name for the medical record.
Chart
______________ is a verbal account of care and observation.
Reporting
A written description of the care given and the person's response and progress is the __________________.
Progress note
A word element places after a root that changes the meaning of the word is a _______________.
Suffix
A word element containing the basic meaning of the word is the _____________.
Root
A ___________________ is a writing or electronic document of a person's condition and response to the treatment and care.
Medical record
The written account of care and observation is _________________.
Recording
A part of the word is the ________________.
Word element
For communication to be effective
a. Use the words that have the same meaning for the sender and receiver
b. Use the terms that's are unfamiliar to residents and families
c. Add unrelated information to the message
d. Answers should not be specific
a. Use words that have the same me and for the sender and receiver
The medical record will include
a. Physical examination results
b. The kardex
c. Change-of-shift reports
d. Hospital records
a. Physical examination results
to prevent errors and improper placement of records, the medical record is
a. Kept in the resident's room
b. Placed in a locked cabinet
c. Stamped with the person's name, room number, and other identifying information on each page
d. Printed on colored pa
c. Stamped with the person's name, room number, and other identifying information on each page
Before a nursing assistant reads a person's chart, he should
a. Know the center's policy
b. Ask the nurse for permission
c. Ask the doctor's permission
d. Sign a sheet to get permission
a. Know the center's policy
If a resident asks to see the chart, you should
a. Give it to him or her because the person always has a right to see the chart
b. Read the chart and tell the person what it says
c. Report the request to the nurse
d. Tell the person that resident's are no
c. Report the request to the nurse
The admission sheet is used to
a. Find out the person's physical condition
b. Help the person become familiar with the center
c. Learn identifying information about a person
d. Carry out a physical examination
c. Learn identifying information about a person
Progress notes are usually written
a. Every shift
b. When there is a change in the person's condition
c. Each day
d. Once a year
b. When there is a change in the person's condition
OBRA requires that summaries of care be written
a. Once a day
b. Once every month
c. At least every 3 months
d. Once a year
c. At least every 3 months
Which of these is included on the activities of daily living flow sheets?
a. Doctors orders
b. Vital signs
c. Care plan
d. Old records
b. Vital signs
Information in an electronic flow sheet
a. Cannot be entered by the nursing assistant
b. Is not confidential
c. Is often faster and easier than paper charting
d. Is entered only at the end of the shift
c. Is often faster and easier than paper charting
If you make and error when recording in a paper chart, you should follow center policy. Many centers require you to
a. Erase it
b. Use correction fluid to cover it
c. Throw away the page and start over
d. Draw a line through the incorrect part and date an
d. Draw a like through the incorrect part and date and initial the time
The resident and family can
a. Attend any resident care conference held on the unit
b. Accompany the staff on walking rounds
c. Refuse actions suggested by the health team at a conference
d. Add written notes to the chart
c. Refuse actions suggested by the health team at a conference
Slow heart rate
Bradycardia
Difficulty urinating
Dysuria
Paralysis of one side of the body
Hemiplegia
Opening into the ileum
Ileostomoy
Blue color or condition
Cyanosis
Opening into the trachea
tracheostomy
Pain in a nerve
neuralgia
Examination of a joint with a scope
Arthroscopy
Rapid breathing
Tachypnea
Removal of the gallbladder
cholecystectomy
When you are giving a computer password, you
a. Must never change it
b. Can share it with a co-worker
c. Should never tell anyone your password
d. Can use another person's password when entering the computer
c. Should never tell anyone your password
Computers should not be used to
a. Send messages and reports to the nursing unit
b. Store resident records and care plans
c. Send e-mails that require immediate reporting
d. Monitor blood pleasures, temperatures, and heart rates
c. Send e-mails that require immediate reporting
When you answer the telephone, do not put callers on hold if
a. The person has an emergency
b. It is a doctor
c. The call needs to be transferred to another unit
d. You are too busy to find the nurse
a. The person has an emergency
If you have a conflict with a co-worker, you should
a. Ask the nurse in charge to schedule you at different times
b. Ignore the person
c. Identify the problem and try to resolve it
d. Talk to other co-workers to explain your side of the story
c. Identify the problem and try to resolve it
When a conflict occurs, what is the first step you should take?
a. Talk with other co-workers to see if they also have a conflict with the person
b. Confront the person and demand that he or she meet with you
c. Identify or define the real problem
d. Assu
d. Identify or define the real problem
Why is it so important to resolve a conflict at work?
a. Unkind words or actions may occur
b. The work environment becomes unpleasant
c. Care is affected
d. All of the above
d. All of the above
What does ADL stand for?
activities of daily living
What does EHR stand for?
electronic health record
What does EMR stand for?
electronic medical record
What does EPHI stand for?
electronic protected health information
What does HIPAA stand for?
Health Insurance Portability and Accountability Act
What does MDS stand for?
minimum data set
What does OBRA stand for?
Omnibus Budget Reconciliation Act
What does PHI stand for?
Protected Health Information
What does POC stand for?
point of care
Urinating
t. Voiding
Part of a call system that allows a person to signal the nurses' station for help
a. Activities of daily living
b. Assist device
c. Atrophy
d. Call light
e. Care plan
f. Cognitive function
g. Contracture
h. Dementia
I. Dysphagia
j. Dyspnea
k. Feces
l. Fev
d. Call light
A semi-setting position; the head of the bed is raised between 45 and 60 degrees
a. Activities of daily living
b. Assist device
c. Atrophy
d. Call light
e. Care plan
f. Cognitive function
g. Contracture
h. Dementia
I. Dysphagia
j. Dyspnea
k. Feces
l. Feve
m. Fowler's position
Difficult, labored, or painful breathing
a. Activities of daily living
b. Assist device
c. Atrophy
d. Call light
e. Care plan
f. Cognitive function
g. Contracture
h. Dementia
I. Dysphagia
j. Dyspnea
k. Feces
l. Fever
m. Fowler's position
n. Incontinence
o
j. Dyspnea
Lack of joint mobility caused by abnormal shortening of a muscle
a. Activities of daily living
b. Assist device
c. Atrophy
d. Call light
e. Care plan
f. Cognitive function
g. Contracture
h. Dementia
I. Dysphagia
j. Dyspnea
k. Feces
l. Fever
m. Fowler's po
g. Contracture
Not being able to control urination or defecation
n. Incontinence
Involves memory, thinking, reasoning, ability to understand, judgement, and behavior
f. Cognitive function
Decrease in size or wasting away of tissue
c. Atrophy
temperature, pulse, respiration, blood pressure
Vital signs
Activities usually done during a normal day in a persons life
activities of daily living
the head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degrees
Semi-Fowler's position
Written guide about the persons care; provides staff with approaches to reach the resident's goals
Care plan
the semi-solid mass of waste products in the colon that is expelled through the anus
feces
The loss of cognitive and social function caused by changes in the brain
dementia
Localize injury to skin and/or underlying tissue, usually over a bony prominence
Pressure ulcer
Difficulty swallowing
dysphagia
back-lying or dorsal recumbent position
supine position
Any item used by the person or staff to promote the persons function or safety
Assist device
Laying on the abdomen with the head turned to one side
Prone
Elevated body temperature
fever
11:00 AM
1100
8:00AM
0800
4:00 PM
1600
7:30AM
0730
6:45PM
1845
12 NOON
1200
3:00AM
0300
4:50AM
0450
5:30PM
1730
10:45PM
2245
11:55PM
2355
9:15PM
2115
2:00AM
1400
10:30AM
2230
5:00AM
1700
9:30AM
0930
5:45PM
0545
10:45PM
1045
0600
6:00AM
1145
11:45AM
1800
6:00PM
2200
10:00PM
Auto-
self
Brady-
slow
Dys-
bad, difficult, abnormal
ecto-
outer, outside
Leuk-
white
Macro-
large
Neo-
new
Supra-
above, over
Uni-
one
Adeno
gland
Angio
vessel
Broncho
bronchus, bronchi
Cranio
skull
duodeno
duodenum
Entero
intestine
Gyneco
woman
Masto
breast
Pyo
pus
-asis
condition
-genic
producing
-megaly
enlargement
-oma
tumor
-phasia
speaking
-plegia
paralysis
-ptosis
falling
-scopy
examination using a scope
-stasis
maintaining a constant level
Before meals
AC, a.c
After meals
PC, p.c
With
C
Cancer
CA
Nothing by mouth
NPO, npo
Lower left quadrant
LLQ
Every 2 hours, every 3 hours, every 4 hours
q2h, q3h, q4h
Range-of-motion
ROM