General CNA Practice CNA Practice Documentation and Reporting 2

Question 1

What does the term 'subjective data' mean in nursing documentation?

Accepted Answer

Information reported by the resident about how they feel

Answer

Subjective data is what the resident tells you about their own experience, such as reporting pain, nausea, or dizziness.

Question 2

What does 'NPO' mean in medical documentation?

Accepted Answer

Nothing by mouth

Answer

NPO (from Latin 'nil per os') means nothing by mouth, indicating the resident must not eat or drink anything.

Question 3

A resident's skin shows new redness over their coccyx. What should the CNA do FIRST?

Accepted Answer

Report the finding to the nurse immediately

Answer

New skin changes should be reported to the nurse immediately so assessment and interventions can begin before the condition worsens.

Question 4

Which of the following is true about confidentiality in documentation?

Accepted Answer

Medical records should only be shared with those directly involved in the resident's care

Answer

HIPAA requires that medical information be shared only with those who have a legitimate need to know for care purposes.

Question 5

What is a care plan in the nursing home setting?

Accepted Answer

A written document outlining individualized goals and interventions for a specific resident

Answer

A care plan is an individualized document that outlines specific goals, identified needs, and planned interventions tailored to each resident.

General Practice Test