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NRSE 260 > Final Exam: > Flashcards

Final Exam: Flashcards

1
Q

Teamwork:

A

A STRONG Nursing Team works together to achieve the best outcomes for patients

Effective team development requires team building and training, trust, communication, and a workplace that facililtates collaboration

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2
Q

Leadership Qualities and skill:

A

charismatic

dynamic

enthusiastic

poised

confident

self-directed

flexible

knowledgeable

politically aware

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3
Q

leadership Skills:

A

commitment to excellence

problem solving skills

commitment to and passion for ones work

trustworthiness and integrity

respectfulness

accessibility

empathy and caring

responsbility to enhance personal growth of all staff

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4
Q

Five Model components of Magnet Status:

A

transformational leadership

structural empowerment

exemplary professional practice

new knowledge, innovation, and improvements

empirical quality results

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5
Q

Conflict Resolution strategies:

A

avoiding

collaborating

competing

compromising

cooperating/accommodating

smoothing

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6
Q

Lewins Theory of change:

A

Unfreezing: the need for change is recognized

Moving: change is initiated after a careful process of planning

Refreezing: change becomes operational

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7
Q

Reasons for resistance to change:

A

threat to self

lack of understanding

limited tolerance for change

disagreement about the benefits of change

fear of increased responsibility

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8
Q

Overcoming resistance to change:

A

explain proposed change to all affected

list the advantages of the change

relate the change to the person existing beliefs and values

provide opportunites for open communication and feedback

indicate how change will be evaluated

introduce change gradually

provide incentives for commitment to change

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9
Q

Achieving self-knowledge:

A

identify your strengths

evaluate how you accomplish work

clarify your values

determine where you belong and what you can contribute

assume responsibility for relationships

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10
Q

developing leadership responsibilities:

A

Mentorship

Preceptorship

Nursing Organizations

Continuing education

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11
Q

Steps for using time effectively:

A

establish goals and priorities for each day

evaluate goals in terms of your ability to meet needs of patients

establish a time line

evaluate your success or failure in managing time

use these results to direct your day priorities and time line

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12
Q

Priorities setting:

A

determine which patient needs should address first:
High priority: immediate threat to patient survival or safety

Intermediate priority: nonemergent, non-life threatening

Low priority: actual or potential problems may or may not be directly related to patient illness or disease

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13
Q

Considerations when delegating Nursing Care:

A

patient condition

complexity of the activity

potential for harm

degree of problem solving and innovation necessary

level of interaction required with the patient

capabilities of the UAP

avaliability of professional staff to accomplish workload

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14
Q

ANA Principles for delegating Care:

A

the nursing profession determines the scope of nursing practice

the nursing profession defines and supervises UAP involved in providing direct nurse care

the RN is responsible and accountable for nursing practice

the RN supervises any assistant providing direct patient care

the purpose of UAP is to work in supportive role to the RN

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15
Q

Factors to consider prior to delegating patient care:

A

qualifications and capabilites of the UAP

stability of the patient condition

complexity of the activity to be delegated

the potential for harm

the predictability of the outcome

the overall context of other patient needs

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16
Q

Time Management:

A

remain goal oriented

identity priorities

establish personal goals

make to do list

delegate

anticipate

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17
Q

Purpose of patient record:

A

communication

diagnostic and therapeutic orders

care planning

quality process and performance improvement

research; decision analysis

education

credentialing, regulation, legislation

reimburesement

legal and historical documentation

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18
Q

characteristics of effective documentation:

A

Factual:
subjective data: pt yelling “ I want to kill my boyfriend”

Objective data:
Descriptive: what the nurse sees, hears, feels, and smells
do not write pt is agitated, write pt is pacing back and forth in his room yelling loudly

Accurate and concise:
facts only, exact measurement, only approve abbreviations

Complete and accurate:
timely: never pre-chart

Organized: communicate in a logical sequence

consistent with health laws and facility standards

legally prudent

confidential

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19
Q

Confidentiality:

A

all information about patient written on paper, spoken aloud, saved on computer

name, address, phone, fax, social security number

Reason the person is sick

treatment patient receives

information about past health conditions

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20
Q

potential breaches in patient confidently:

A

displaying information on a public screen

sending confidential e-mail messages via public networks

sharing printers among units with differing functions

discard copies of patient information in trash cans

holding confidential information to unauthorized persons

sending confidental messages overheard on pagers

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21
Q

documentation tips

A

be accurate

avoid late entry: always date, time and signature/title

prioritize legibility

black, non-erasable ink

use the right tools

follow policy on abbreviations

document physician consultantion

chart the symptom and the treatment

avoid opinions and hearsay

chart only for yourself

do not leave black spaces, line or boxes on chart

write enough to convince a reader that the patient was adequately cared for

do not use correction fluid, erase, scratch out, or blacken out errors, make line through and sign

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22
Q

Common Nursing Documentation Errors:

A

medication, allergy or pertinent health omission

failing to record nursing action

failing to record that medications have been given

recording on the wrong chart

blank items on a chart

unclear orders, transcribe order improperly

failure to communicate and monitor

failure to record drug reactions or changes in the patient condition

failure to document a discontinued medication

writing illegible

failure to date, time, and sign medical entry

document subjective data

using the wrong abberviations

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23
Q

8 behaviors of purposeful rounding:

A

use opening key words (C-I-CARE) with PRESENCE

accomplish scheduled task

address four Ps

address additional personal needs, questions

conduct enviromental assessment

Ask is there anything else I can do for you? I have time.

Tell the patient when you will be back

document the round

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24
Q

Conferring about care:

A

consultations and referrals

nursing and interdiscipinary team care conferences

nursing care round

purposeful rounding

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25
Q

HIPPA:

A

Health insurance portability and accountability act

security and privacy of medical records and protected health information (PHI)

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26
Q

Protecting patient Privacy:

A

tips for safeguarding PHI:

Paper:
never leave a medical record or other printed or written PHI where other can access it
shred any printed or written patient information for reporting or patient care after use
properly dispose of document in a confidental waste container

Electronic:
log off from computer before leaving the workstation
make sure computer screens cannot be viewed by the public
never share a user ID or password with anyone

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27
Q

Social Media Precautions:

A

know the implications of HIPAA before using social networking sites for school or work related communication

many organizations, it will be against the code of conduct when taking pictures in an hospital

become familiar with your facility policy regarding the use of social networking

do not use or view social networking media in clinical setting

do not post information about your facility, clinical sites, clinical experience, patient or other health care staff

do not take pictures that show patient or family members

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28
Q

Patient Rights

A

patient have the right to:
see and copy their health record
update their health record
get a list of disclosures
request a restriction on certain uses or disclosures
choose how to recieve health information

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29
Q

Change of Shift/Hand- off reports:

A

basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicans

current appraisal of each patient health status

current orders (esp any new changed orders)

abnormal occurrences during shift

any unfilled orders that need to be continues onto next shift

patient/family questions, concern, needs

report on transfers/discharge

30
Q

Telephone/Telemedicine Reports:

A

identify yourself and the patient, state relationship to patient

report concisely and accurately the change in the patient condition that is of concern and what has already been done in reponse to this condition

report patient vital signs and clinical manifestations

have patient record at hand to make knowledgeable responses to any physcian inquiries

concisely record time and date of the call, what was communicated and physicians response

31
Q

Formats for Nursing Documentation:

A

initial nursing assessement

care plan; patient care summary

critical collaborative pathway

progress notes

flow sheets and graphic records

medication record

acuity record

discharge and transfer summary

long-term care and home health care documentation

32
Q

Method of documentation:

A

computerized documentation/ electronic health records (EHRs)

source- oriented records

problem-oriented medical records

PIE charting (problem, intervention, evaluation)

focus charting

charting by exception

case management model

33
Q

Duties of RN receiving Telephone Orders (TO)

A

record the orders in patient medical record

read orders back to practitioner to verify accuracy

date and note the time orders were issued

record telephone records, and full name and title of physician or nurse who issued orders

sign the orders with name and title

34
Q

Verbal Orders:

A

review orders for accuracy

sign orders with name, title, and pager number

date and note orders signed

35
Q

Protected Health Information (PHI)

A

HIPAA has defined 18 identifiers that compose individually identifiable health information:

names, including initials

street address, city, county, zip code

all elements of date

telephone number

fax number

email address

social security number

medical record number

Health plan ID number

account numbers

certificate/lisense number

vehicle identifer and serial number

device identifiers/serial number

web addresses

Internet IP address

biometric identifers

full face photographic and comparable images

any other unique identifying characterisitc or code

36
Q

7 Basic Tenets of bill of rights for RNS registered:

A

practice in a manner that fulfills obligations to society and to those who receive nursing care

practice in environments that allow them to act in accordance with professional standards and legally authorized scope of practice

work in environment that supports and facilitates ethical practice, in accordance with the Code of Ethics for Nurse

freely and openly advocate for themselves and their patient, without fear of retribution

receive fair compensation for their work, consistent with their knowledge, experience, and professional resonsibilites

practice in a work environment that is safe for themselves and their patient

negotiate the conditions of their emplyment, either as individuals or collectively, in all practice setting

37
Q

Basic Terms in Health Ethics:

A

Autonomy: commitment to include patient in decisions

Beneficence: taking positive actions to help others

Nonmaleficence: avoidance of harm or hurt

Justice: being fair

Fidelity: agreement to keep promises

38
Q

Values:

A

Value: personal belief about the worth of a given idea, attitude, custom or object that sets standards that influence behavior

Value Clarification:
ethical dilemmas almost always occur in the presence of conflicting value
to resolve ethical dilemmas, one needs to distinguish among value, fact and opinion

39
Q

Professional Value:

A

Altruism: concern for welfare and well-being of others

Autonomy: right to self-determination

Human dignity: respect for inherent worth and uniqueness of individuals and populations

Integrity: acting according to code of ethics and standard of practice

Social Justice: upholding moral, legal, and humanistic rights

40
Q

Processing an ethical dilemma:

A

Assess the situation (gather data)

diagnose (identify) the ethical problem

Plan:
identify options
think ethical problem though
make a decision

Implement your decision

evaluate your decision

41
Q

Institutional Resources:

A

ethics committee are usually multidiscipinary and serve several purpose; education, policy, recommendation, case review, and consultation, occasionally research

any person involved in an ethical dilemma, including nurse, physicians, health care providers, patient, and family member, can request access to an ethic committee

42
Q

Professional and Legal regulation of nursing practice:

A

nurse practice acts

standards

credentialing

accreditation

lisensure

certification

42
Q

Ethical Issues:

A

paternalism

deception

privacy

confidentiality

allocation of scarce nursing resources

valid consent or refusal

conflict concerning new technologies

unprofessional, imcompetent, unethical, or illegal physicican practice

unprofessional, imcompetent, unethical, or illegal nurse practice

short staffing and whistle blowing

beginning of life issue

end of life issue

43
Q

Reasons for suspending or revoking a license:

A

drug or alcohol abuse

fraud

deceptive practice

criminal acts

previous displinary actions

gross or ordinary negligence

physical or mental impairment including age

44
Q

Standards of Care:

A

Internal Standards:
Job description
education
expertise
institutional polices and procedures

45
Q

4 Elements of Liability:

A

duty

breach of duty

causation

damages

46
Q

Nursing Students and Liability:

A

you are liable if your action cause harm to patients, as is your instructor, hospital, and college/university

never perform a task that you dont feel prepared to safely complete

you are expected to perform as a professional when rendering care

you must separate your student nurse role from your work as certified nursing assistant (CNA)

47
Q

Incident Reports:

A

complete name of person and name of witness

factual account of incident

date, time, and place of incident

pertinent characteristics of person involved

any equipment or resources being used

any other important variables

documentation by physician of medical exam of person involved

48
Q

Legal Safeguards for nurse:

A

adequate staffing

whistle-blowing

professional liability insurance

risk management programs

just culture

incident, variance, or occurance reports; sentinel events and never events

patient rights

good samaritian law

student liability

competent practice

informed consent/ refusal

contracts

collective bargaining

patient education

executing physican orders

delegating nursing care

documentation

appropriate use of social media

49
Q

Elements of Informed consent:

A

disclosure

comprehension

competence

voluntariness

50
Q

Safeguards to competent Practice:

A

developing interpersonal communication skill

respecting legal boundaries of practice

following institutional procedures and policy

owning personal strengths and weakness

evaluating proposed assignment

keeping current in nursing knowledge and skills

respecting patient rights and developing rapport with patient

keeping careful documentation

working within agency for management policy

51
Q

Categories of Negligence that result in malpractice:

A

failure to follow standards of care

failure to use equipment in a responsible manner

failure to communicate

failure to document

failure to assess and monitor

failure to act as a client advocate

52
Q

Aims of teaching and counseling:

A

maintaining and promoting health

preventing illness

restoring health

facilitating coping

53
Q

Teaching Outcome:

A

high level wellness and related self care practice

disease prevention or early detection

quick recovery from trauma or illness with minimal or no complication

enhanced ability to adjust to developmental life changes and acute, chronic, and terminal illness

patient and family acceptance of lifestyle necessitated by illness or disability

54
Q

Basic Learning Principles:

A

Motivation to learn: addresses the patient desire or willingness to learn

Ability to learn: depends on physical and cognitive abilities, developmental level, physical wellness, thought processes

Learning Environment: allows a person to attend to instruction

55
Q

Factors affecting Patient learning:

A

age and developmental level

family support networks

financial resources

cultural influences

language deficits

health literacy level

56
Q

Critical development areas:

A

physical maturation and abilities

psychosocial development

cognitive capacity

emotional maturity

moral and spiritual development

57
Q

Four assumptions about adult learners:

A

as a person matures, one self- concept is likely to move from dependence to independence

the previous experience of the adult is a rich resource for learning

an adult readiness to learn if often related to a developmental task or social role

most adult orientation to learning is that material should be useful immediately, rather than at some time in the future

58
Q

COPE MODEL

A

C: creativity
O: optimism
P:planning
E: expert information

59
Q

Providing culturally competent patient education:

A

develop an understanding of the patient culture

work with multicultural team

be aware of personal assumptions, biases, and prejudices

understand the core cultural value of the patient or group

develop written material in patient preferred language

60
Q

Teaching plan for older adults:

A

identify learning barrier

allow extra time

plan short teaching sessions

accommodate for sensory deficits

reduce environmental distractions

relate new information to familiar activities or information

61
Q

Health literacy: ask me 3 questions

A

what is my main problem

what do i need to do?

why is it important for me to do this?

62
Q

Three learning domains:

A

cognitive: storing and recalling of new knowledge in brain

psychomotor: learning a physical skill

affective: changing attitude, value, feeling

63
Q

Assessment Parameters:

A

knowledge, attitude, and skills needed to be independent

readiness to learn

ability to learn

learning strengths

64
Q

Consideration for successful patient teaching:

A

forming contractual agreement

considering time constraints

scheduling

group vs. individual teaching

formal vs informal teaching

manipulating the physical enviroment

65
Q

Key points to effective communication:

A

be sincere and honest

avoid to much detail and stick to basics

ask for questions

be a cheerleader for the patient

use simple vocab

vary tone of voice

keep content clear and concise

listen and do not interupt

ensure that the environment is conducive to learning and free of interuptions

be sensitive to the timing of teaching sessions

66
Q

Documentation of the teaching- learning process:

A

Learner: patient, family, caregiver

How: verbal, demonstration, written, video, TV translator, group, class

Barrier to learning: communication difficulties, physical impairment, cognitive impairment, sensory impairment, cultural barriers, denies/resists, emotional barrier, religious barrier, language, readiness/motivation, no barrier

Evaluation: verbalized understanding, demonstrates ability, needs reinforcement, not able (explain)

67
Q

Teach Back:s

A

start with most important message

focus on 2-4 key points

use plain language no medical jargon

68
Q

Nurse Coaching Process

A

establishing relationship and identifying readiness for change

identifying opportunities, issue, and concern

establishing patient- centered goals

creating structure of the coaching interaction

empowering and motiviating patient to reach goal

assisting the patient to determine progress toward goal

69
Q
A

NRSE 260 (5 decks)

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