Patient Observation & Documentation Flashcards
7 cards from real PCA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Observation & Documentation flashcards as text
A PCA notices a new pressure ulcer forming on a patient's heel. What stage is suspected when the skin is intact but red and does not blanch when pressed?
Answer: Stage 1
Stage 1 pressure injuries involve intact skin with non-blanchable redness, indicating early damage without open wounds.
Which of the following best describes 'objective' information in patient documentation?
Answer: Observable, measurable facts such as vital signs and wound appearance
Objective data includes measurable, observable findings such as vital signs, wound measurements, and lab values.
A patient's respiratory rate is 26 breaths per minute. How would this be documented?
Answer: Tachypnea — respirations 26/min, reported to nurse
26 breaths per minute is above the normal range of 12–20 and constitutes tachypnea, which should be documented and reported.
Which action violates patient confidentiality in documentation?
Answer: Discussing a patient's condition with a coworker in the break room
Discussing a patient's personal health information in non-private areas with unauthorized staff violates HIPAA and patient confidentiality.
A patient who normally walks independently has been refusing to get out of bed for two days. The PCA should:
Answer: Report the behavioral change and document it in the care record
A change in a patient's normal activity pattern may signal pain, depression, or illness and must be documented and reported.
What should a PCA do if they are unsure whether a symptom they observed should be reported?
Answer: Report it to the nurse — it is always better to report than to withhold
PCAs should always err on the side of reporting any unusual observation to the nurse, as they are not qualified to determine medical significance.
A PCA is asked to monitor a patient for signs of edema. Which finding indicates edema is present?
Answer: Pressing on the patient's ankle leaves a lasting indentation
Pitting edema is identified when pressing on swollen tissue leaves a temporary indentation (pit), indicating fluid accumulation in tissues.