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Nursing 1 > Concepts Exam 2 > Flashcards

Concepts Exam 2 Flashcards

1
Q

Documentation that tracks variances from the clinical pathway

A

case management system charting

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2
Q

Documentation of the nursing process, treatment, and associated care.

A

charting

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3
Q

Charting that focuses on deviations from predefined norms, using preset protocols and standards of care.

A

charting by exception

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4
Q

The entering of provider orders into the medical record via computer, eliminating translation error due to poor handwriting or due to human translation error.

A

computerized provider order entry (CPOE)

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5
Q

A health record entered into a computer’s software program that is updated via the computer.

A

electronic health record (EHR)

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6
Q

Charging that centers on the patient from a positive perspective and having three components data, action, and response.

A

focus charting

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7
Q

A record that contains all orders, tests, treatments, and care that occurred during the time a person was under the care of a health care provider.

A

medical record (chart)

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8
Q

A method of charting in which “P” means problem identification, “I” means interventions, and E” means evaluation

A

PIE charting

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9
Q

Charting that focuses on patient status, emphasizes the problem solving approach to patient care, and provides a method for communicating what, when, and how things are to be done in order to meet the patient’s needs.

A

problem oriented medical record (POMR) charting

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10
Q

Standard procedures.

A

protocols

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11
Q

Charting that is organized by the “source” or author of the documentation.

A

source oriented (narrative) charting

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12
Q

Listening with great concentration and focused energy

A

active listening

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13
Q

Standing up for your patient’s rights; acting in the patients behalf; being a representative of your patient.

A

advocate

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14
Q

Difficulty expressing or understanding language

A

aphasia

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15
Q

Nonverbal communication

A

body language

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16
Q

the exchange of information and ideas by speech, writing, gesture, expression, body posture, intonation, and general appearance

A

communication

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17
Q

kept private

A

confidentiality

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18
Q

in agreement

A

congruent

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19
Q

authorize another person to do something; entrust to another

A

delegate

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20
Q

the ability to understand by seeing the situation from another’s perspective

A

empathy

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21
Q

return of information and how it was interpreted

A

feedback

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22
Q

berbal and nonverbal messages that do not agree

A

incongruent

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23
Q

information put in

A

input

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24
Q

promotes understanding between the sender and the receiver.

A

therapeutic communication

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25
Q

encourages pt to continue or elaborate

A

general leads

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26
Q

encourages pt to elaborate rather than answer in one or two words

A

open ended questions or statements

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27
Q

shows caring, concern and readiness to hlep

A

offering self

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28
Q

restates in different words what the pt said; encourages further communication on that topic

A

restatement

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29
Q

reflects received message back to pt. also encourages further verbalization of feelings. reflects feelings. can also be used if pt is unable to verbalize or if nonverbal information is incongruent with verbal

A

reflection

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30
Q

seeks clarification about the source of the upset feeling. helps the pt clarify thoughts or ideas

A

seeking clarification

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31
Q

asking a goal directed question helps the pt focus on key concerns

A

focusing

32
Q

helps the pt describe more fully the concern or problem under discussion

A

encouraging elaboration

33
Q

provides the pt with information relevant to specific health care or situation

A

giving information

34
Q

helps pts see options and consider alternatives to make their own decisions about health care

A

looking at alternatives

35
Q

allows pt time to gather thoughts and sort them out

A

silence

36
Q

sums up the important points of an interaction

A

summarizing

37
Q

deprives the pt of the chance to verbalize concerns

A

changing the subject

38
Q

negates the pts feelings and may give false hope, which, when things turn out differently can destroy trust in the nurse

A

giving false reassurance

39
Q

nurse is judging the pts action. implies that the pt must take on the nurses values and is demeaning to the pt

A

judgmental response

40
Q

nurse responds by defending the doctor. prevents pts from feeling free to express their feelings

A

defensive response

41
Q

pries into the pts motives and therefore invades privacy

A

asking probing questions

42
Q

negates the pts individual situation; stereotypes the pt this type of response sounds flippant and prevents the building of trust between pt and nurse

A

using cliches

43
Q

tends to be controlling and diminishes pts responsibility for taking charge of their own health

A

giving advice

44
Q

indicates that the pt is not important, that the nurse is bored, or that what is being said does not matter

A

inattentive listening

45
Q

a social relationship differs from a therapeutic one in that…

A

the focus is on both participants and the usual goal is to meet ones own needs. Social relationship is established for mutual enjoyment with considerable sharing of experiences life events and thought.

46
Q

characteristics in the nurse that facilitate a therapeutic nurse patient relationship include? 8

A

effective communications skills, empathy, a desire to help, honesty, a nonjudgmental attitude, genuineness, acceptance and respect.

47
Q

what are the two keys to effective nurse pt communication

A

trust and understanding

48
Q

ISBAR-R

A 
introduction
situation
background 
assessment
recommendation
readback
49
Q

can students legally take telephone orders?

A

No. they can take the order but they must have another nurse or instructor standing by to speak with the physician and take the order again including read back.

50
Q

who is ultimately responsible for the outcomes of delegated tasks?

A

the person who delegates the certain task is ultimately responsible for the outcomes of that delegation

51
Q

one characteristic differentiating source oriented (narrative) charting from POMR charting is?

A

the separation of notes on medical care and nursing care

52
Q

when a pts medical record is needed as evidence for a legal action, you are aware that the record is the property of>

A

the health care agency

53
Q

the advantage of POMR charting when using an interdisciplinary care system is that

A

it keeps all relevant data in one place

54
Q

the assumption in charting by exception is that

A

unless otherwise documented, all standards have been met

55
Q

an advantage of computer charting is that

A

is it cost effective because it saves nursing time compared with writing out notes

56
Q

when charting the pts condition and nursing care, the nurse records?

A

the interventions performed and the pts responses
pt statements and behaviors that are observed
clinical data measurements

57
Q

what are the 3 ways people learn?

A

visual learning, auditory learning, and kinesthetic learning

58
Q

what are the 3 domains of learning?

A

1) cognitive domain - the learner takes in and processes information by listening to or reading the material.
2) affective domain - the material is presented in a way that appeals to the learner’s beliefs, feelings, and values. (pple must value cleanliness before they will wash hands)
3) psychomotor domain - the learner processes the information by performing an action or carrying out a task.

59
Q

what are some situational factors that interfere with learning

A

pain, nausea, fatigue, a sense of being overwhelmed by all that is happening and multiple interruptions

60
Q

what is the most commonly used nursing diagnoses?

A

deficient knowledge

61
Q

behavioral objectives

A

represent the desired changes or additions to current behaviors and attitudes. They state what you are trying to teach the pt to do.

62
Q

what is one way to evaluate that the pt is learning what is being taught

A

a return demonstration of the skill

63
Q

the first step in teaching is?

A

to assess what the patient needs to know )learning needs, knowledge deficits)

64
Q

what are some factors that affect learning?

A

physical limitations, situational factors (including pain) readiness to learn, personal values and expectations, age, attitude, and ability to comprehend.

65
Q

what is essential in effective learning?

A

establishing rapport and mutual trust

66
Q

how can you keep the pt involved in the educational plan?

A

including the pt in the development of the plan

67
Q

evidence that the primary purpose of pt teaching has been achieved is that pts …

A

provide correct and safe self care after discharge

68
Q

a pt newly diagnosed with diabetes has stated that he doesn’t understand why he needs insulin. his statement indicates a learning need regarding?

A

the disease process of diabetes

69
Q

when starting the 2nd teaching session for a pt, the nurse should first

A

briefly review what was taught in the 1st session

70
Q

when 1st teaching a young child about insulin injections, it is appropriate to

A

use a doll to demonstrate an insulin injection

71
Q

when teaching the leery about a needed diet change, to reinforce the information

A

write down the diet instructions

72
Q

an appropriate pt teaching plan

A

includes input from all disciplines involved in the care, as well as from the pt

73
Q

to overcome barriers to learning for a hearing impaired person…

A

be certain the hearing aid is turned on and adjusted, eliminate other noise in the room as much as possible, gain the pts attention and speak in a normal low tone while facing him.

74
Q

the most important objective for a pt who needs to learn about a dressing change is, the pt will…

A

use aseptic technique for the dressing change

75
Q

who sets the standards for documentation

A

the joint commission

Nursing 1 (9 decks)

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