Concepts Exam 2

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

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

Answer 3

charting by exception

Question 4

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

Answer 4

computerized provider order entry (CPOE)

Question 5

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

Answer 5

electronic health record (EHR)

Question 6

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

Answer 6

focus charting

Question 7

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.

Answer 7

medical record (chart)

Question 8

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

Answer 8

PIE charting

Question 9

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.

Answer 9

problem oriented medical record (POMR) charting

Question 10

Standard procedures.

Answer 10

protocols

Question 11

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

Answer 11

source oriented (narrative) charting

Question 12

Listening with great concentration and focused energy

Answer 12

active listening

Question 13

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

Answer 13

advocate

Question 14

Difficulty expressing or understanding language

Answer 14

aphasia

Question 15

Nonverbal communication

Answer 15

body language

Question 16

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

Answer 16

communication

Question 17

kept private

Answer 17

confidentiality

Question 18

in agreement

Answer 18

congruent

Question 19

authorize another person to do something; entrust to another

Answer 19

delegate

Question 20

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

Answer 20

empathy

Question 21

return of information and how it was interpreted

Answer 21

feedback

Question 22

berbal and nonverbal messages that do not agree

Answer 22

incongruent

Question 23

information put in

Answer 23

input

Question 24

promotes understanding between the sender and the receiver.

Answer 24

therapeutic communication

Question 25

encourages pt to continue or elaborate

Answer 25

general leads

Question 26

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

Answer 26

open ended questions or statements

Question 27

shows caring, concern and readiness to hlep

Answer 27

offering self

Question 28

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

Answer 28

restatement

Question 29

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

Answer 29

reflection

Question 30

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

Answer 30

seeking clarification

Question 31

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

Answer 31

focusing

Question 32

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

Answer 32

encouraging elaboration

Question 33

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

Answer 33

giving information

Question 34

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

Answer 34

looking at alternatives

Question 35

allows pt time to gather thoughts and sort them out

Answer 35

silence

Question 36

sums up the important points of an interaction

Answer 36

summarizing

Question 37

deprives the pt of the chance to verbalize concerns

Answer 37

changing the subject

Question 38

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

Answer 38

giving false reassurance

Question 39

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

Answer 39

judgmental response

Question 40

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

Answer 40

defensive response

Question 41

pries into the pts motives and therefore invades privacy

Answer 41

asking probing questions

Question 42

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

Answer 42

using cliches

Question 43

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

Answer 43

giving advice

Question 44

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

Answer 44

inattentive listening

Question 45

a social relationship differs from a therapeutic one in that...

Answer 45

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.

Question 46

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

Answer 46

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

Question 47

what are the two keys to effective nurse pt communication

Answer 47

trust and understanding

Question 48

ISBAR-R

Answer 48

``` introduction situation background assessment recommendation readback ```

Question 49

can students legally take telephone orders?

Answer 49

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.

Question 50

who is ultimately responsible for the outcomes of delegated tasks?

Answer 50

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

Question 51

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

Answer 51

the separation of notes on medical care and nursing care

Question 52

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

Answer 52

the health care agency

Question 53

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

Answer 53

it keeps all relevant data in one place

Question 54

the assumption in charting by exception is that

Answer 54

unless otherwise documented, all standards have been met

Question 55

an advantage of computer charting is that

Answer 55

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

Question 56

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

Answer 56

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

Question 57

what are the 3 ways people learn?

Answer 57

visual learning, auditory learning, and kinesthetic learning

Question 58

what are the 3 domains of learning?

Answer 58

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.

Question 59

what are some situational factors that interfere with learning

Answer 59

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

Question 60

what is the most commonly used nursing diagnoses?

Answer 60

deficient knowledge

Question 61

behavioral objectives

Answer 61

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

Question 62

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

Answer 62

a return demonstration of the skill

Question 63

the first step in teaching is?

Answer 63

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

Question 64

what are some factors that affect learning?

Answer 64

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

Question 65

what is essential in effective learning?

Answer 65

establishing rapport and mutual trust

Question 66

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

Answer 66

including the pt in the development of the plan

Question 67

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

Answer 67

provide correct and safe self care after discharge

Question 68

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

Answer 68

the disease process of diabetes

Question 69

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

Answer 69

briefly review what was taught in the 1st session

Question 70

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

Answer 70

use a doll to demonstrate an insulin injection

Question 71

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

Answer 71

write down the diet instructions

Question 72

an appropriate pt teaching plan

Answer 72

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

Question 73

to overcome barriers to learning for a hearing impaired person...

Answer 73

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.

Question 74

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

Answer 74

use aseptic technique for the dressing change

Question 75

who sets the standards for documentation

Answer 75

the joint commission