Observing and Reporting Changes Flashcards

A GNA is caring for a resident who is normally alert and oriented. During morning care, the GNA notes the resident is suddenly quiet, confused about where they are, and unable to state the correct month. What is the GNA's MOST important immediate action?

Answer: Report the sudden change in mental status to the nurse immediately.

A sudden change in mental status, such as acute confusion, is a significant finding that could indicate a serious underlying medical issue like a urinary tract infection (UTI), stroke, or adverse medication reaction. This requires immediate reporting to the nurse for prompt assessment and intervention to ensure the resident's safety and well-being.

Which of the following is an example of an objective observation that a GNA should report?

Answer: The resident's urine is noted to be cloudy and has a strong odor.

Objective data consists of facts that are observed through the senses (sight, smell, touch, hearing) and can be measured. Cloudy, strong-smelling urine is a direct observation made by the GNA. The other options are subjective reports of feelings or symptoms from the resident or their family.

Mr. Smith, a resident with a history of congestive heart failure (CHF), had a recorded weight of 182 lbs yesterday. Today, his weight is 185 lbs and he has increased swelling in his ankles. What is the GNA's priority action?

Answer: Report the 3-pound weight gain and increased ankle swelling to the nurse.

Sudden weight gain of 2-3 pounds in a day and increased edema (swelling) are key signs of fluid retention, which can indicate a worsening of congestive heart failure. This condition requires prompt reporting to the nurse for immediate assessment and potential intervention to prevent serious complications.

While providing perineal care, the GNA notices a new, persistent, reddened area on a resident's coccyx. When the GNA presses on the area, it does not turn white (blanch). Which action should the GNA take first?

Answer: Reposition the resident to relieve pressure and report the finding to the nurse.

A non-blanchable reddened area on intact skin is the defining characteristic of a Stage 1 pressure injury. The priority actions are to immediately remove pressure from the affected area by repositioning the resident and to report the observation to the nurse for assessment and implementation of a care plan to prevent further skin breakdown.

Which of the following statements is the BEST example of proper, factual documentation by a GNA in a resident's chart?

Answer: "Resident consumed 50% of breakfast and drank 240 mL of orange juice."

Good documentation is objective, specific, and uses measurable data whenever possible. Stating the exact percentage of food eaten and the specific volume of fluid consumed provides clear, factual information that is useful for the care team. Terms like "uncooperative," "bad mood," and "small amount" are subjective opinions or vague estimates.

A resident complains of dizziness. The GNA takes their radial pulse and counts 48 beats in one minute. When reporting to the nurse, which information is most essential for the GNA to communicate?

Answer: The resident's subjective complaint of dizziness and the objective pulse rate of 48.

The GNA's role is to report factual observations accurately. This includes both the subjective information (what the resident says, i.e., "I feel dizzy") and the objective data (what the GNA measures, i.e., a pulse of 48). This combination gives the nurse critical information for their assessment. Offering opinions, irrelevant information about other residents, or other less critical data is inappropriate.