Fundamentals 7, 8, 10

Question 1

Documentation that tracks variances from the clinical pathway

Answer 1

Case management system charting

Question 2

Documentation of the nursing process, treatment, and associated care

Answer 2

charting

Question 3

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

Answer 3

charting by exception

Question 4

Documentation in which data are input via the computer

Answer 4

computer-assisted charting

Question 5

The entering of provider orders into the medical record via computer

Answer 5

Computerized provider order entry (CPOE)

Question 6

Health record entered into a computer’s software program that is updated via the computer

Answer 6

electronic health record (EHR)

Question 7

Documentation that centers on the patient from a positive perspective; this form of documentation has three components: data, action, and response

Answer 7

focus charting

Question 8

Paper or electronic 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

Answer 8

medical record

Question 9

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

Answer 9

PIE charting

Question 10

Documentation that focuses on patient status, emphasizes the problem-solving approach to patient care, and provides a method for communication what, when, and how things are to be done to meet the patient’s needs

Answer 10

Problem-oriented medical record (POMR) charting

Question 11

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

Answer 11

Source–oriented (narrative) charting

Question 12

Difficulty expressing or understanding language

Answer 12

aphasia

Question 13

Technique for communication between members of the health care team; the acronym stands for Introduction, Situation, Background, Assessment, Recommendation, and Readback

Answer 13

ISBAR-R

Question 14

Recognizing the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s values, needs, and preferences

Answer 14

patient-centered care

Question 15

Communication that promotes understanding between the sender and the receiver

Answer 15

Therapeutic communication

Question 16

Leadership style of tight control and unlimited power

Answer 16

autocratic

Question 17

Leadership style practicing social equality or majority rule

Answer 17

democratic

Question 18

Leadership style that is based on noninterference with what others desire

Answer 18

Laissez-faire

Question 19

Encourages patient to continue or elaborate

Answer 19

General leads

Question 20

Encourages patient to elaborate rather than answer in one or two words

Answer 20

Open ended questions or statements

Question 21

Shows caring, concern, and readiness to help

Answer 21

offering self

Question 22

Restates received message back to patient. Also encourages further verbalization of feelings. Reflects feelings. Can also be used if the patient is unable to verbalize or if nonverbal information is incongruent with verbal

Answer 22

Reflection

Question 23

Seeks clarification about the source of the upset feeling. Helps the patient clarify thoughts or ideas

Answer 23

Seeking clarification

Question 24

Asking a goal-directed question helps the patient focus on key concerns

Answer 24

Focusing

Question 25

Helps the patient education relevant to specific health care needs or situation

Answer 25

giving information

Question 26

Helps patients see options and consider alternatives to make their own decisions about health care

Answer 26

looking at alternatives

Question 27

allows patient time to gather thoughts and sort them out

Answer 27

silence

Question 28

sums up the important points of an interaction

Answer 28

summarizing

Question 29

What is the difference between empathy and sympathy?

Answer 29

Empathy is the ability to place oneself in another’s position. With sympathy, concern and perhaps sorrow are felt, indicating that the person is experiencing something difficult

Question 30

What are the therapeutic techniques with communication? (11)

Answer 30

General Leads. Open ended questions or statements. Offering self. Restatement. Reflection. Seeking clarification. Encouraging elaboration. Giving information. Looking at alternatives. Silence. Summarizing.

Question 31

Who is responsible for the nursing care of patients during shift

Answer 31

charge nurse

Question 32

When you are documenting it should show progress towards what

Answer 32

expected outcomes and goals

Question 33

Charting by exception

Answer 33

Charting by exception is based on the assumption that all standards of practice are carried out and met with a normal or expected response unless otherwise documented. The nurse needs only to document abnormal findings or responses correlated with the nursing diagnoses listed on the nursing care plan. Charting by exception assumes that, unless documented to the contrary, all standards and protocols were followed and assessment values were within accepted limits.

Question 34

Leadership styles and their descriptions

Answer 34

Laissez-faire leader does not attempt to control the team and offers little if any direction. The authoritarian or autocratic leader tightly controls team members. This leader closely supervises the work of each staff member. The democratic leader consults with staff members and seeks staff participation in decision making. This leader is part of the team, not above it, and accepts responsibility for the team’s actions.

Question 35

guidelines for documentation

Answer 35

Only record what you have done for the patient, not what you plan to do. Documentation should be accurate, brief, and complete. Verify you are on the correct patient’s computer screen before documenting. Use a 24-hr clock. Documentation is done only by the person who made the observation. Record objective data after completing each task. Follow hospital policy for amending the record. Clearly identify care given by another team member. Record when a patient refuses. Spell medical record entries correctly. If you suspect an order is incorrect seek clarification.

Question 36

Essential information that needs to be included in documentation

Answer 36

Admission note. Assessment data for all body systems. Body care. Death. Degree of activity. Diagnostic test. Diet and fluids. Discharge from the facility. Dressings and wound care. Intake and output. Intravenous infusions. Medications. Mental state and mood. Mood, concerns, or discomfort. Oxygen in use. Primary care provider’s visits and calls to providers. Postoperative care. Procedures performed. Sleep. Specimens obtained and their disposition. Patient education. Travel from the unit. Tubes and equipment in use. Visitors.

Question 37

Characteristics of effective communication (5) and (3)

Answer 37

Active listening, interpreting nonverbal messages, obtaining feedback, focusing, adjusting style. Communicating effectively includes taking the time to attend to the person by stopping what you are doing, establishing eye contact, and being polite

Question 38

Elements of good communication

Answer 38

Good communication requires active listening, timely feedback, and validation of assumptions about nonverbal cues

Question 39

How do you document behavior and where do you document it

Answer 39

Document behaviors in your nurse’s notes. You must choose which behaviors and observations are noteworthy, or your nurse’s notes will be lengthy and irrelevant. A rule of thumb is that if the behavior or finding is abnormal or is a change from previous behavior or data, document it.

Question 40

Advantages to source oriented or narrative charting (6)

Answer 40

1 It gives information on the patient’s condition and care in chronological order. #2 It indicates the patient’s baseline condition for each shift. #3 It includes aspects of all steps of the nursing process. #4 It encourages documentation of both normal and abnormal findings, making it difficult to separate pertinent from irrelevant information. #5 It requires extensive documentation time by the staff. #6 It discourages physicians and other health team members from reading all parts of the medical record because of the lengthy descriptive entries in it

Question 41

What are effective strategies in conflict resolution

Answer 41

Try to remain calm and open and actively listen to the problem. Accept responsibility for any part you played in development of the conflict. Focus on the issue rather than on the feelings of those involved. Mediate by communicating openly. Sort out issues involved by identifying key themes in the discussion. Consider the options and weigh the consequences of each option.

Question 42

Briefing

Answer 42

often used when there is new information to be shared. The team leader initiates the briefing. Included in a briefing: (a) who is in charge, (b) lines of communication, and © member responsibilities and expected behaviors.

Question 43

huddle

Answer 43

an impromptu meeting held when the need arises. A huddle is a chance for team members to touch base with each other, evaluate changes in the plan that might be needed, and reorganize the workflow.

Question 44

debrief

Answer 44

An informal meeting held after a situation or event to discuss the event; usually including what went well, what didn’t work, and how the situation might be handled differently next time.

Question 45

What does the joint commission expect of you when receiving a telephone order

Answer 45

The nurse is expected to enter the orders in the computer for the prescribing care provider to verify later. Verbal orders can only be taken by licensed nurses, and in some states only by an RN. The provider must authenticate the order by electronically signing the written form of the verbal order as soon as possible.

Question 46

Delegation to unlicensed assistive personnel and whats appropriate and whats not

Answer 46

basically nothing a tech does, only what the helpers and activities people at wyndridge do (check study guide for full chart)

Question 47

If you are unclear about an order what do you do

Answer 47

check the drug administration record

Question 48

How can you limit the liability of a lawsuit against a facility?

Answer 48

By documenting what you need to document. Documentation provides a written record of the history, treatment, care, and response of the patient while under medical and nursing care. Documentation can be used as evidence in the court of law because it shows the use of the nursing process, and provides data for quality-assurance studies.

Question 49

When you are giving directions what are some characteristics of giving them, how should you give them and in what kind of way

Answer 49

Give clear, concise messages and listen carefully to feedback.