chapter 16/17/18/19/20

Question 1

medical diagnoses

Answer 1

statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession

Question 2

nursing diagnoses

Answer 2

actual or potential health problem that an independent nursing intervention can prevent or resolve

Question 3

risk nursing diagnosis

Answer 3

clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation

Question 4

health promotion nursing diagnosis

Answer 4

behavior of an individual motivated by a personal desire to increase well-being and health potential

Question 5

PPMP

Answer 5

predicts the most common complications, prevent them, manage them if cant prevent, and promote optimum function

Question 6

Nursing Interventions Classification (NIC)

Answer 6

first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions

Question 7

Nursing Outcomes Classification (NOC)

Answer 7

developed by the Iowa Outcomes Project and presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing intervention

Question 8

nurse-initiated intervention

Answer 8

independent nursing actions that involve carrying out nurse-prescribed interventions written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional and that result from their assessment of patient needs

Question 9

physician-initiated interventions

Answer 9

dependent nursing actions, involving carrying out physician-prescribed orders

Question 10

initial planning

Answer 10

developed by the nurse who performs the nursing history

Question 11

ongoing planning

Answer 11

carried by any nurse who works with the patient, keeps plan up to date and states problems more clearly

Question 12

discharge planning

Answer 12

carried out by the nurse who worked most closely with the patient and begins when the patient is admitted

Question 13

Which nursing action would most likely occur during the ongoing planning stage?

Answer 13

the nurse collects new data and uses them to update the plan

Question 14

cognitive outcomes

Answer 14

describes increase in patient knowledge or intellectual behaviors

Question 15

psychomotors

Answer 15

patient achievement of new skills

Question 16

affective outcomes

Answer 16

change in patient values, beliefs, and attitudes

Question 17

What is an effective affective outcome?

Answer 17

By 6/9/19, the patient will verbalize valuing his health enough to stop smoking.

Question 18

collaborative intervention

Answer 18

initiated by other providers and carried out by a nurse

Question 19

standing orders

Answer 19

detail nursing activities which can be initiated in specific situations without the order or supervision of a health care provider.

Question 20

adverse reaction

Answer 20

an adverse reaction is an unwanted or harmful reaction experienced following the administration of a drug, diagnostic test, or therapeutic intervention under normal conditions of use.

Question 21

direct care intervention

Answer 21

treatment performed through interaction with the patient

Question 22

indirect care intervention

Answer 22

treatment performed away from the patient but on behalf of a patient or group of patients

Question 23

scope of practice

Answer 23

The American Nurses Association states that the Nursing Scope and Standards of Practice describe the “who,” “what,” “where,” “when,” “why,” and “how” of nursing practice in keeping with the terms of their professional license.

Question 24

National Database of Nursing Quality Indicators

Answer 24

indicators aimed at promoting and facilitating the standardization of information submitted by hospitals across the United States on nursing quality and patient outcomes

Question 25

cognitive outcome

Answer 25

increase in patient knowledge

Question 26

psychomotor

Answer 26

patients achievement of new skills

Question 27

affective

Answer 27

changes in patient values, beliefs, and attitudes

Question 28

physiologic

Answer 28

physical changes in patient

Question 29

bedside report

Answer 29

standardized, streamlined shift report system at the bedside; helps ensure the safe handoff of care between nurses by involving the patient and family

Question 30

change-of-shift report

Answer 30

communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care;

Question 31

charting by exception (CBE)

Answer 31

shorthand method for documenting patient data that are based on well-defined standards of practice, only focuses on a specific problem and not the body as a whole

Question 32

electronic health records

Answer 32

digital version of a patient’s chart that may contain the patient’s medical history, diagnoses, medications, treatment plan

Question 33

graphic record

Answer 33

form used to record specific patient variables

Question 34

health information exchange

Answer 34

an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient’s vital medical information

Question 35

incident report

Answer 35

a report of any event that is not consistent with the routine operation of the health care facility that results in or has the potential to result in harm to a patient, employee, or visitor

Question 36

Outcome and Assessment Information Set (

Answer 36

assessment instrument representing core items of a comprehensive assessment for adult nonmaternity home health care patients that forms the basis for measuring patient outcomes for the purpose of improving the quality of care provided

Question 37

problem-oriented medical record (

Answer 37

documentation system organized according to the person’s specific health problems;

Question 38

read back

Answer 38

a process in which a nurse or other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted

Question 39

Verbal Order Guidelines

Answer 39

must be given by the physician or nurse practitioner
-record in patient record with initials “VO”
-read back to verify

Question 40

Which method of documentation is unique in that it does not develop a separate course plan but incorporates it into the progress notes?

Answer 40

PIE

Question 41

genomics

Answer 41

study of the structure and interactions of all genes in the human body, including their interactions with each other as well as the environment;

Question 42

nursing informatics

Answer 42

the specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

Question 43

pharmacogenomics

Answer 43

use of information about a person’s genetic makeup, or genome, to choose the drugs and drug doses that are likely to work best for that person

Question 44

telehealth

Answer 44

the use of electronic info and telecommunications to support and promote long distance

Question 45

telemedicine

Answer 45

the use of telecommunications technologies to support the delivery of all types of medical

Question 46

telecare

Answer 46

refers to technology that allows consumers to stay safe and independent in their own homes