Exam 3 Topic 8 Flashcards
American Cancer Society guidelines state that for people of average risk, beginning at the age of 50, what tests are recommended?
an annual fecal accult blood test is recommended. Flexible sigmoidoscopy and colonoscopy are recommended every 5 years in this population. A computed tomography (CT) colonoscopy is used every 5 years if recommended by the health care provider.
A wheal is an?
irregularly shaped, elevated area or superficial localized edema. A wheal varies in size (e.g hive
A 1-cm firm, solid mass describes a?
Nodule
A flat, brown area measuring 0.5 cm is a?
Macule
A pus-filled circumscribed elevation of the skin is a?
Pustule
CPOE allows the provider to?
enter the order directly, thus eliminating the need to transcribe orders
While reviewing the pulmonary assessment entered by a nurse in a patient’s electronic medical record (EMR), a physician notices that the only information documented in that section is “WDL” (within defined limits). The physician also is not able to find a narrative description of the patient’s respiratory status in the nurse’s progress notes. What is the most likely reason for this?
The nurse caring for the patient forgot to document on the pulmonary system. Incorrect
The EMR uses a charting-by-exception format. Correct
The computer shut down unexpectedly when the nurse was documenting the assessment.
The EMR uses a charting-by-exception format.
Because of HIPAA regulations, physicians are not authorized to view the nursing assessment.
Given that the initial assessment indicated that the pulmonary system was within normal limits, the facility is most likely documenting by exception. There is no need for further documentation unless the pulmonary assessment changes and is no longer within normal limits.
A flow sheet is utilized when?
repeated observations are to be recorded in a quick and accurate manner. The information from a flow sheet is retrieved quickly, too. An admission sheet is used to record the detailed initial assessment at the time of admission. An operative report records the summary of the patient’s surgery, complications, and preoperative and postoperative diagnoses. The physician’s order sheet contains the information of the physician’s orders for treatment and medications with date, time, and signature.
A clinical decision support system is based on?
rules that are triggered by data entry. When certain rules are not met, alerts, warnings, or other information may be provided to the user.
The exchange of information amongst the healthcare team members is done through?
written reports and oral communication. Pictures of patients are not used in routine communication, but they may be used by specialists like dermatologists and plastic surgeons. The patient’s health information is not exchanged through a thesis or electronic cards.
The patient’s admission sheet contains?
The patient’s demographic data such as name, address, contact numbers, age, date of birth, insurance, employment, and information about the guardian. The nurse accesses this to obtain the contact number of the patient’s guardian. The discharge summary is the summary of the patient’s hospital stay, condition, and treatment plan at the time of discharge. The nurse’s admission assessment consists of the patient’s health-related information. It contains the patient’s history and notes from the physical examination conducted by the nurse when the patient was admitted. The nurse’s notes record the nursing process throughout the course of treatment.
Coarse crackles are?
loud, bubbly sounds heard during inspiration that are not cleared with coughing. This is because of random, sudden reinflation of groups of alveoli and the disruption of the passage of air through the small airways. Crackles are most common in the dependent lobes such as the right and left lung bases.
An irregularly shaped, elevated area or superficial localized edema. varies in size (e.g., hive, mosquito bite).
A wheal
A 1-cm firm, solid mass describes a?
nodule.
A flat, brown area measuring 0.5 cm is a?
A macule.
A pus-filled circumscribed elevation of the skin is a?
pustule.
The CAGE acronym is useful in guiding assessment related to addiction or substance abuse.
C stands for Cut down, A stands for Annoyed, G stands for Guilty, and E stands for Eye-opener. The questions that the nurse needs to ask the patient include whether the patient feels guilty about the habit, whether the patient is annoyed by people who criticize, and whether the patient has tried to cut down drinking. A positive response for two or more questions indicates substance abuse. Questions on crimes and delusion are not included in the CAGE questionnaire.
