NSG 130 Test 1 Prep Flashcards

Reference material: 1. Giddens37 2. Potter 1 4. Giddens46 4. Potter26

1
Q

What are the 5 professional responsibilities and roles for nurses?

A

Caregiver, educator, advocate, communicator, manager

(Professionalism PPT)

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2
Q

What professional responsibility and role fits this description: “help patients maintain and regain health, manage disease and symptoms, and attain a maximal level of function and independence through the healing process. provide evidence-based nursing care to promote healing through both physical and interpersonal skills. support patients by providing measures that restore their emotional, spiritual, and social well-being. help the patient and family set outcomes and assist them with meeting those outcomes with minimal financial cost, time, and energy.”

A

Caregiver

(Potter1 Professionalism)

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3
Q

What professional responsibility and role fits this description: “protect your patient’s human and legal rights and provide assistance in asserting those rights if the need arises. As an advocate you act on behalf of your patient, such as safeguarding their care against errors, suggesting alternatives to care, securing your patient’s health care rights, and facilitating personal and cultural preferences”

A

Advocate

(Potter1 Professionalism)

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4
Q

What professional responsibility and role fits this description: “improves patients’ knowledge, skills, self-care activities, and ability to make informed decisions. identify patients’ willingness and ability to learn, explain concepts and facts about their health, describe the reason for care activities, demonstrate procedures such as self-care activities, reinforce learning or patient behavior, and evaluate the patient’s progress in learning. Assess your patient’s and family caregiver’s learning styles and needs and develop a teaching plan that meets your patients’ self-management objectives and includes teaching methods that match your patient’s and family’s needs”

A

Educator

(Potter1 Professionalism)

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5
Q

What professional responsibility and role fits this description: “Know your patients, including their preferences, strengths, weaknesses, and needs. routinely communicate with patients and families, other nurses and health care professionals, resource people, and the community. Fundamental to providing high-quality care, coordinating and managing patient care, assisting patients in rehabilitation, advocating for patients, assisting patients and families in decision making, and providing patient education.”

A

Communicator

(Potter1 Professionalism)

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6
Q

What professional responsibility and role fits this description: “Direct groups of nurses by establishing an environment for collaborative patient-centered care and safe, evidence-based quality care with positive patient outcomes. Coordinates the activities of members of a nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or agency. Uses appropriate leadership styles to create a nursing environment for patients and staff that reflects the mission and values of the health care organization”

A

Manager

(Potter1 Professionalism)

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7
Q

Caregiver/Provider, Educator, Patient Advocate, Leader, Manager, Change Agent, Researcher, Delegator, and Collaborator are all what kind of roles?

A

Inherent

(Sherpath Lesson: Nursing and Nursing Practice)

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8
Q

Faith Community Nurse, Flight Nurse, Forensic Nurse, Hospice Nurse, Informatics Nurse Specialist, Occupational Health Nurse, Quality Manager, School Nurse, Telephone Triage ans (Telehealth) Nurse are all what kind of roles?

A

Career Roles:

(Sherpath Lesson: Nursing and Nursing Practice)

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9
Q

Nurse educator, nurse administrator, nurse researcher, and case manager are what kind of nursing roles?

A

Expanded

(Sherpath Lesson: Nursing and Nursing Practice)

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10
Q

Preparation for this role occurs at the graduate and doctoral levels. They are competent in clinical practice and assume leadership in curriculum development, instruction, and evaluation. Knowledge of the learning process and classroom and clinical teaching methods that include engagement and online teaching is essential.

A

Nurse educator

(Sherpath Lesson: Nursing and Nursing Practice)

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11
Q

Which expanded role manages patient care and the delivery of specific nursing services within a health care agency. Experience and additional education sometimes lead to a middle-management position such as nurse manager of a specific patient care area or house supervisor or to an upper-management position such as associate director or director of nursing services.

A

Nurse administrator

(Sherpath Lesson: Nursing and Nursing Practice)

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12
Q

What expanded role conducts evidence-based practice and research to improve nursing care and further define and expand the scope of nursing practice. He or she often works in an academic setting, hospital, or independent professional or community service agency. The preferred educational requirement is a doctoral degree, with at least a master’s degree in nursing.

A

Nurse researcher

(Sherpath Lesson: Nursing and Nursing Practice)

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13
Q

What expanded role encompasses the complex job of identifying the best resources at the lowest cost to achieve the optimal health outcome for the patient. This role can be provided in either the inpatient or outpatient setting.

A

Case manager

(Sherpath Lesson: Nursing and Nursing Practice)

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14
Q

__________ are the minimum acceptable guidelines for providing and evaluating nursing care.

A

Standards of practice

(Sherpath Lesson: Nursing and Nursing Practice)

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15
Q

The standards set forth by the APN consist of how many parts and what are they?

A

Two. The “Nursing Process” and the “Professional Nursing Practice”

(Sherpath Lesson: Nursing and Nursing Practice)

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16
Q

_____ is the multistep scientific approach nurses use to care for their patients.

(Sherpath Lesson: Nursing and Nursing Practice)

A

Nursing process

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17
Q

______ emphasizes standards of professional performance.

A

Professional nursing practice

(Sherpath Lesson: Nursing and Nursing Practice)

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18
Q

All of the following are considered to be under what. part of the standards of practice?

A

ethics, culturally congruent practice, communication, collaboration, leadership, education, evidence-based practice, research, quality of practice, professional practice evaluation, resource utilization, and environmental health

(Sherpath Lesson: Nursing and Nursing Practice)

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19
Q

What are the ANA’s Standards Of Practice?

A

Assessment, Diagnosis, Outcome identification, Planning, Implementation, and Evaluation

(Sherpath Lesson: Nursing as a Profession)

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20
Q

Which standard of practice is described as: “The registered nurse collects comprehensive data pertinent to theatient’s health or the situation.

(Sherpath Lesson: Nursing as a Profession)

A

Assessment

(Sherpath Lesson: Nursing as a Profession)

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21
Q

Which standard of practice is described as: “The registered nurse analyzes the assessment data to determine the diagnoses or issues.

A

Diagnosis

(Sherpath Lesson: Nursing as a Profession)

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22
Q

Which standard of practice is described as: “The registered nurse identifies expected outcomes for a plan that is individualized to the patient or situation.”

A

Outcomes identification

(Sherpath Lesson: Nursing as a Profession)

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23
Q

Which standard of practice is described as: “The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes.

A

Planning

(Sherpath Lesson: Nursing as a Profession)

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24
Q

Which standard of practice is described as: “ The registered nurse implements the identified plan with coordination of care and health teaching and health promotion?”

A

Implementation

(Sherpath Lesson: Nursing as a Profession)

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25
Q

Which standard of practice is described as: “The registered nurse evaluates progress toward attainment of outcomes.”

A

Evaluation

(Sherpath Lesson: Nursing as a Profession)

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26
Q

The first official nursing code of ethics was adopted in ____ by ____. Described in nine provisions:

A

1950 by the American Nurses Association (ANA)

(Sherpath Lesson: Nursing as a Profession)

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27
Q

How many provisions does the ANA describe the nursing code of ethics?

A

9

(Sherpath Lesson: Nursing as a Profession)

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28
Q

Which provision is “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. Expanded guides elaborate each provision such as”

A

Provision 1

(Sherpath Lesson: Nursing as a Profession)

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29
Q

Which provision is “The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population.”

A

Provision 2

(Sherpath Lesson: Nursing as a Profession)

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30
Q

Which provision is “The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.”

A

Provision 3

(Sherpath Lesson: Nursing as a Profession)

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31
Q

Which provision is The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care.”

A

Provision 4

(Sherpath Lesson: Nursing as a Profession)

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32
Q

Which provision is “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth.”

A

Provision 5

(Sherpath Lesson: Nursing as a Profession)

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33
Q

Which provision is “The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care.”

A

Provision 6

(Sherpath Lesson: Nursing as a Profession)

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34
Q

Which provision is “The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy.”

A

Provision 7

(Sherpath Lesson: Nursing as a Profession)

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35
Q

Which provision is “The nurse collaborates with other health professionals and the public to promote human rights, promote health diplomacy, and reduce health disparities.”

A

Provision 8

(Sherpath Lesson: Nursing as a Profession)

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36
Q

Which provision is “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy.”

A

Provision 9

(Sherpath Lesson: Nursing as a Profession)

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37
Q

What is described as the “essential element of professional nursing, involves the initiation of independent nursing interventions without medical orders, you are responsible professionally and legally for the type and quality of nursing, includes dependent, independent, and interdependent nursing”

A

Autonomy

(Potter1)

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38
Q

Nursing ______ is essential for developing trusting relationships with patients and coworkers. It involves accepting responsibility for actions and omissions, as well as legal, ethical, and professional implications.

A

Accountability

(Sherpath Lesson: Nursing and Nursing Practice)

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39
Q

Professionals have_______ in their decision making and practice. Professions are self-regulating, and they develop their own policies and procedures. It involves independent nursing actions in the care of patients. As a member of the nursing profession, each nurse has the ability to decide on how his or her individual nursing practice will be implemented.

A

autonomy

(Nursing as a Profession Sherpath Lesson)

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40
Q

In situations in which nurse professionals employ________, nurses and patients alike view this action as the “last line of defense” on behalf of the patient. This normative conception of the nurse as patient advocate is an example of a “signature image” of professional identity among nursing and other professions.

A

advocacy

(Giddens37)

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41
Q

Benner’s Level of Proficiency has how many levels and what are they?

A

Novice, Advanced Beginner, Competent, Proficient, Expert

(Nursing as a Profession Sherpath)

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42
Q

Student nurses progress from _____ to ____ during nursing school

A

Novice to advanced beginner

(Nursing as a Profession Sherpath Lesson)

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43
Q

The student nurse attains the competent level within ____ to ___ years of work experience.

A

2 to 3

(Nursing as a Profession Sherpath Lesson)

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44
Q

_____ is a sense of oneself, and in relation to others, that is influenced by characteristics, norms, and values of the nursing discipline, resulting in an individual thinking, acting, and feeling like a nurse.

A

Professional identity

(Giddens37)

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45
Q

Begins in training. Developed through real/simulated experiences, reflection, and role modeling by prof. colleagues. “__________/______” terms replacing “professional role/professionalism.” There is a need to internalize a value system of the profession. Every new identity destroys the prior, this sucks.

A

Professional identify/formation

(Giddens37)

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46
Q

Professionalism meets cerrtain criteria such as:

A

Altruism, Body of Knowledge and Research, Accountability, Higher Education, Licensure, Autonomy, Code of Ethics, Diversity, and Professional Organization

(Nursing as a Profession Sherpath Lesson)

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47
Q

A profession provides services needed by society.______ is public service over personal gain. Nurses recognize nursing as their life work and focus on service to their patients, families, and the community.

A

Altruism

(Nursing as a Profession Sherpath Lesson)

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48
Q

What criteria for the profession is described as “A profession develops, evaluates, and uses theory as a basis for practice. To advance knowledge in their field, professionals publish and communicate their knowledge. Nursing has a well-defined, specific, and unique body of theoretical knowledge. Theory in nursing leads to defined skills, abilities, and norms that are enlarged by research.”

A

Body of Knowledge and Research

(Nursing as a Profession Sherpath Lesson)

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49
Q

Nursing_______ is essential for developing trusting relationships with patients and coworkers. It involves accepting responsibility for actions and omissions, as well as legal, ethical, and professional implications.

A

Accountability

(Nursing as a Profession Sherpath Lesson)

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50
Q

A profession has clearly defined educational requirements for entry into practice. Nurses must have a diploma, an associate’s degree, or a bachelor’s degree in nursing to be eligible to take the NCLEX-RN examination. _________ offers nurses greater professional opportunities.

A

Higher education

(Nursing as a Profession Sherpath Lesson)

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51
Q

A profession is committed to competence. Members of a profession have legally recognized licenses that demonstrate basic competency to practice. Nursing ______is mandatory in all states, and all licensed nurses must keep their knowledge base current by participating in both formal and informal continuing education.

A

licensure
(Nursing as a Profession Sherpath Lesson)

52
Q

Professionals have______ in their decision making and practice. Professions are self-regulating, and they develop their own policies and procedures. It involves independent nursing actions in the care of patients. As a member of the nursing profession, each nurse has the ability to autonomously decide on how his or her individual nursing practice will be implemented.

A

Autonomy

(Nursing as a Profession Sherpath Lesson)

53
Q

Practice and conduct within a profession is guided by a ______. They refer to the standards of right and wrong behavior. The International Council of Nurses (ICN) and the American Nurses Association (ANA) each developed a them for nurses. Public opinion polls consistently show that the nursing profession is viewed as the most honest and ethical of all professions.

A

code of ethics

(Nursing as a Profession Sherpath Lesson)

54
Q

Nurses provide care to patients with many different cultures and backgrounds. According to the ICN, nursing care is respectful of and unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race, or social status. To respect the________ of their patients, nurses practice culturally competent care, which means that the care is sensitive to the needs of people with varying cultural differences.

A

diversity

(Nursing as a Profession Sherpath Lesson)

55
Q

An important aspect of a profession is belonging to ________________. These give nurses access to current information and resources as well as a voice in the profession through educational programs and publications. Many support and encourage high standards in nursing. They provide opportunities for nurses to expand their roles in specialty areas.

A

professional organizations

(Nursing as a Profession Sherpath Lesson)

56
Q

Clinical Nurse Specialist, Nurse Practicioner, Certified Nurse-midwife, and Certified Registered Nurse Anasthetists are all condidered _________?

A

Advanced Practice Registered Nurse

(Potter1)

57
Q

______ provide direct (hands-on) patient care. Some additional certs may be required (peds, critical care, emergency, etc)

A

Clinician

(Potter1)

58
Q

_______ have educational preparation in at least of: adult-gerontology, perdiatrics, neonatology, women’s health/gender related, family/individual across the life span, and psychiatric mental health.

A

Advanced Practice Registered Nurse
(APRN)

(Potter1)

59
Q

____ will have an MSN/DNP and may be identified by a population, setting, disease specialty, type of care, or type of problem. Provide diagnosis, treatment, and ongoing management in all settings.

A

Clinical Nurse Specialist

(Potter1)

60
Q

____ will have an MSN/DNP. Provide primary, acute, and specialty health care to patients of all ages and in all types of health care settings. This care includes assessment, diagnosis, planning, and treatment; monitoring ongoing health status; evaluation of therapies; and health education.

A

Nurse practitioner

(Potter1)

61
Q

______ is educated in midwifery, and is certified. Full range of primary health care services for women from adolescence beyond menopause. Services include primary care; gynecological and family planning services; preconception care; care during pregnancy, childbirth, and the postpartum period; care of the normal newborn during the first 28 days of life; and treatment of male partners for sexually transmitted infections. Conducts physical examinations; prescribes medications, including controlled substances and contraceptive methods; admits, manages, and discharges patients; orders and interprets laboratory and diagnostic tests; and orders the use of medical devices.

A

Certified nurse-midwife (CNM)

(Potter1)

62
Q

_______ practice both autonomously and in collaboration with a variety of health care providers on the interprofessional team to deliver high-quality, holistic, evidence-based anesthesia and pain care services. under the guidance and supervision of an anesthesiologist,

A

Certified registered nurse anesthetist (CRNA)

(Potter1)

63
Q

______ works primarily in schools of nursing, staff development departments of health care agencies, and patient education departments

A

Nurse educator

(Potter1)

64
Q

_____ is responsible for management of the nursing staff in a health care agency. Five competencies detailing the skills, knowledge, and abilities that guide the practice of nurse leaders in administrative or executive practice. These include communication and relationship management; knowledge of the health care environment; leadership; professionalism; and business skills and principles. Functions of administrators include budgeting, staffing, strategic planning of programs and services, employee evaluation, and employee development.

A

Nurse administrator

(Potter1)

65
Q

______ conducts evidence-based practice, performance improvement, and research to improve nursing care and further define and expand the scope of nursing practice

A

Nurse researcher

(Potter1)

66
Q

_____ goes to school for 12-18mo, takes the NCLEX-PN, and practices under an RN. Does not use nursing process.

A

LPN/LVN

(Nursing as a Profession Sherpath Lesson)

67
Q

–2, 3, or 4-year programs. NCLEX-RN. Scope per state’s nurse practice act and SBON. Uses nursing process, crit. thinking, and delegation

A

RN

(Nursing as a Profession Sherpath Lesson)

68
Q

2yr program. (you!)

A

ADN

(Nursing as a Profession Sherpath Lesson)

69
Q

+2-4 years of education with specific area of practice. Four specialties (CNM, NP, CNS, CRNA) and educator, researcher, administrator

A

MSN

(Nursing as a Profession Sherpath Lesson)

70
Q

DNS/DSN and PhD are considered ____ degrees

A

Terminal

(Nursing as a Profession Sherpath Lesson)

71
Q

______ education involves educational programs offered by universities, hospitals, state nurses’ associations, professional nursing organizations, and educational and health care institutions.

A

Continuing

(Potter1)

72
Q

_____ education programs are instruction or training programs provided by a health care agency or institution.

A

In-service

(Potter1)

73
Q

The ______ has the following steps: recognize cues, analyze cues. prioritize hypotheses. generate solutions, take action. evaluate outcomes

A

Clinical Judgement Measurement Model (CJMM)

(Nursing & Nursing Practice Sherpath Lesson)

74
Q

What are the components of the Clinical Judgement Measurement Model?

A

Recognize cues, analyze cues, prioritize hypothesis, generate solutions, take actions, evaluate outcomes.

(Nursing & Nursing Practice Sherpath Lesson)

75
Q

What are the five categories of the professional identity?

A

Doing, being, acting ethically, flourishing, and changing identities

(Giddens37)

76
Q

______ or the consensus or sociological perspective, incorporates the societal and professional codes and standards that are part of the nursing discipline. Strong focus on doing in new role.

A

Doing

(Giddens37)

77
Q

______ or the personal or psychological view of the nurse professional, explains what it means to do the right thing even when no one is looking.

A

Being

(Giddens37)

78
Q

_______ is a critical component of professional identity and professional identity formation. “Live according to principles” - Socrates

A

Acting ethically or doing the right thing,

(Giddens37)

79
Q

A transformational or human ______ perspective is necessary for professional identity to move past the initial phases of formation

A

flourishing

(Giddens37)

80
Q

________ is a reworking of the person’s identity occurs in order to resolve this new developmental issue final attribute of professional identity and the process of professional identity formation.

A

Changing identities

(Giddens37)

81
Q

Doing, being, acting ethically, flourishing, and changing identities are all subcategories of what?

A

Professional identity formation

(Giddens37)

82
Q

________ provide the guidelines for implementing and evaluating nursing care.

A

Nursing standards

(Potter1 Key Points)

83
Q

What changes in society affect the practice of nursing?

A

health care reform, changing demographic patterns, increases in the medically underserved population, and increased consumerism

(Potter1 Key Points)

84
Q

___________ have an impact on educational standards and certifications, specialty practice, consumerism, and patient advocacy.

A

Professional nursing organizations

(Potter1 Key Points)

85
Q

______consists of holistic activities that concentrate on the comprehensive needs of patients and the provision of quality care.

A

Nursing

(Nursing & Nursing Practice Sherpath Lesson)

86
Q

Hailed as the founder of modern nursing, ________ emerged in the 1850s as the first among many nurse leaders. She worked to revolutionize care provided to the poor and needy.

A

Florence Nightingale

(Nursing & Nursing Practice Sherpath Lesson)

87
Q

________ and _______ affect nursing and have assisted in the transformation and evolution of nursing practice over previous generations.

A

Societal trends and technological advances

(Nursing & Nursing Practice Sherpath Lesson)

88
Q

Nursing practice is governed by _______ and necessitates combining knowledge and practice standards with a compassionate approach to patient care to meet the multidimensional needs of patients.

A

state nurse practice acts

(Nursing & Nursing Practice Sherpath Lesson)

89
Q

A______ is an occupation that has a clear standard of education related to a specific body of knowledge.

A

profession

(Nursing as a Profession Sherpath Lesson)

90
Q

Nurses meet the criteria for a______ with altruism, body of knowledge and research, accountability, higher education, autonomy, code of ethics, professional organization, licensure, and diversity.

A

profession

(Nursing as a Profession Sherpath Lesson)

91
Q

________ are laws that provide the scope of practice as defined by each state or jurisdiction.

A

Nurse practice acts

(Nursing as a Profession Sherpath Lesson)

92
Q

The _________, published by the ANA, serves as the set of legal criteria that sets the standard for patient care.

A

Standards of Nursing Practice

(Nursing as a Profession Sherpath Lesson)

93
Q

The ______________ advocates for accountability, responsibility, and integrity in nursing practice while maintaining quality health care.

A

ANA Code of Ethics for Nurses

(Nursing as a Profession Sherpath Lesson)

94
Q

________ is the process by which an individual integrates into a profession.

A

Professional socialization

(Nursing as a Profession Sherpath Lesson)

95
Q

Nurses learn the norms, attitudes, behaviors, skills, roles, and values through ____________

A

mentors, preceptorships, certifications, and membership in professional organizations.

(Nursing as a Profession Sherpath Lesson)

96
Q

Nurses learn the _____________ through mentors, preceptorships, certifications, and membership in professional organizations.

A

norms, attitudes, behaviors, skills, roles, and values

(Nursing as a Profession Sherpath Lesson)

97
Q

The student nurse progresses from novice to advanced beginner during nursing school and attains the competent level after ________ of work experience after graduation.

A

approximately 2 to 3 years

(Nursing as a Profession Sherpath Lesson)

98
Q

Proper documentation must be _____, _____, ____, _____, _____, and _____

A

Factual, accurate, abbreviated appropriately, current, organized, and complete.

(InformaticsPPT)

99
Q

_________ system that allows health care providers to directly enter standardized, legible, and complete orders for patient care into a medical record from any computer in the HIS. Advanced _____ systems have built-in clinical decision support tools and alerts to help a health care provider select the most appropriate medication or diagnostic test and automatically check for drug interactions, medication allergies, and other potential problems. The direct entry of orders by providers eliminates safety issues related to illegible handwriting and transcription errors. ____ systems have significant potential to reduce medication errors associated with inappropriate drug use and dosing

A

Computerized provider order entry (CPOE)

(Potter26)

100
Q

______ during medication administration has been associated with a reduction in medication administration errors.

A

Bar-code use
(Sherpath Informatics)

101
Q

_______ is a discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology. Involves the use of technology and information systems to support the healthcare industry.

A

Health informatics

(Giddens46)

102
Q

_______ is a branch of engineering that studies computation and computer technology, hardware, and software, as well as the theoretical foundations of information and computation techniques. It is the study of the theoretical foundations of information and computation as these techniques relate to implementation and application of computer systems.

A

Computer science

(Giddens46)

103
Q

______ is to processes as health information technology is to tools

A

Health informatics

104
Q

_________ is the application of information processing involving both computer hardware and computer software that deals with the storage, retrieval, sharing, and use of healthcare data, information, and knowledge for communication and decision making. Most promising tool for improving the overall quality, safety, and efficiency of the health delivery system.

(Giddens46)

A

Health Information Technology (health IT)

105
Q

_______ is the use of information systems and other information technology to record, monitor, and deliver patient care, and to perform managerial and organizational functions in health care

A

Health information technology (HIT)
(Potter26)

106
Q

________ is the specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing and informatics practice. Graduate level.

A

Nursing informatics
(potter26)

107
Q

Purposes of the Health Care Record include:

A

Health care record is the most current and accurate, continuous source of information about a patient’s health care status, allowing the plan of care to be clear to anyone who accesses the recordroviding a legal record of care provided and justification for financial billing and reimbursement of care, Used to audit, monitor, and evaluate care provided to support the process needed for quality and performance improvement, and Resource for education and research

(potter 26)

108
Q

________ is the most current and accurate, continuous source of information about a patient’s health care status, allowing the plan of care to be clear to anyone who accesses the record

A

Health care record

(potter 26)

109
Q

______ is one of the best defenses for legal claims associated with nursing care

A

Accurate documentation

(potter 26)

110
Q

Mistakes in documentation can result in______,

A

malpractice

(potter 26)

111
Q

_______ offer information on recurrent health care problems, specific patient incidents, and whether health care providers follow standards of care. They help to identify areas for improvement and staff development.

A

Audits of health records

(potter 26)

112
Q

A variety of methods, such as limiting who can access electronic health records, firewalls, spyware detection software, automatic sign-offs, and the use of strong passwords are used to

A

secure the confidentiality of PHI in the EHR.

(Potter 26 Key Points)

113
Q

Who can have legitimate access to a patient’s health record?

A

Only members of the health care team who are directly involved in a patient’s care

(Potter26 Key Points)

114
Q

When information relevant to care is communicated by telephone, documentation includes:

A

when the call was made, the number called, who made the call, who was called, to whom information was given, what information was given, what information was received, and verification of information through use of a read-back process.

(Potter 26 KeyPoints)

115
Q

The ______ facilitates patient care by providing the right information to the right person and the right time. It is also a legal source of patient-related information requiring completeness, accuracy, and availability.

A

electronic health record

(Sherpath Key Points)

116
Q

The electronic health record contains a complete patient history to assist in providing appropriate evidence-based care.

A

electronic health record

(Sherpath Key Points)

117
Q

Two types of data that nurses document are

A

objective (observed and measurable) and subjective (patient perception).

118
Q

______ regulations require confidentiality, security, and privacy of all patient-related data and information.

A

HIPAA Privacy and Security

119
Q
A
120
Q

_______ is the application of information and communication technologies to the delivery of healthcare services

A

Clinical informatics

(Giddens46)

121
Q

_________ (also known as a patient care information system) is a large, computerized database management system that is used to access patient data needed to plan, implement, and evaluate care.

A

Clinical information system (CIS)

(Potter26)

122
Q

Health informatics is to processes as _______ is to tools

A

Health Information Technology

123
Q

Advantages of CIS include:

A

Better access to information, enhanced quality of documentation through prompts, reduced erros of omission, reduced hospital costs, increased nurse job satisfaction, adherence to requirements of accrediting agencies (TJC), development of a common clinical database, and the ability to track track records.

(Potter26)

124
Q

_______ is a discipline that sorts, enhances, processes, operates on, organizes, makes usable, and retrieves information related to human health and illness through the application of technology for the purpose of sharing data, information, knowledge, and wisdom among health providers, among consumers, and across organizations.

A

Health informatics

(Giddens46)

125
Q

The Standards of Nursing Practice has two parts: Part 1 focuses on ________, and part 2 focuses on __________

A

1: the six responsibilities of the nursing process
2: professional performance

(Nursing as a Profession Sherpath Lesson)

126
Q

Usually a 4-yr program. Recommendations of 80% nursing force hae this in 2020.

A

BSN

(Nursing as a Profession Sherpath Lesson)