Test 2 Flashcards

Question

At what NREM stage of sleep does sleepwalking and bedwetting sometimes occur?

Answer 1

Duration increases with each sleep cycle and averages 20 minutes. Vivid, full-color dreaming occurs. Stage typically is characterized by rapidly moving eyes, fluctuation heart and respiratory rates, increased or fluctuating blood pressure, loss of skeletal muscle tone, and increase of gastric secretions. (arousal is very difficult)

Answer 2

a condition where a person experiences significant episodes of sleepiness, even after having 7 hours or more of quality sleep. Other terms used to describe hypersomnolence include excessive daytime sleepiness, excessive daytime somnolence, and hypersomnia.

Answer 3

the stages of sleep and wakefulness during nighttime sleep.

Answer 4

- Insomnia - abnormal movement or sensation during sleep or when waking up at night - Excessive daytime sleepiness

Answer 5

sudden muscle weakness during intense emotions such as anger, sadness, or laughter.

Answer 6

a sense that allows a person to recognize the size, shape, and texture of an object

Answer 7

``` o Sight/visual o Hearing/auditory o Touch/tactile o Smell/olfactory o Taste/gustatory o Position and motion/kinesthetic ```

Answer 8

the stimulation of sensory nerve fibers and the transmission of impulses to higher centers within the brain.

Answer 9

o Reception: stimulation of a receptor such as light, touch, or sound o Perception: integration and interpretation of stimuli o Reaction: only the most important stimuli will elicit a reaction

Answer 10

* Sensory deficits – deficit in the normal function of sensory reception and perception * Sensory deprivation – inadequate quality or quantity of stimulation * Sensory overload – reception of multiple sensory stimuli

Answer 11

* Drugs and Substances * Lifestyle * Usual sleep patterns * Emotional stress * Environment * Exercise and fatigue * Food and caloric intake

Answer 12

o Age - Various changes occur across the life span o Meaningful stimuli - Reduce the incidence of sensory deprivation o Amount of stimuli – can cause sensory overload o Social interaction – increases with lack of socialization with family o Environmental factors – Occupation, recreation, and sports activities o Cultural factors – sensory alterations occur in select groups

Answer 13

``` o Through the patient’s eyes o Sensory alteration history o Physical assessment o Health promotion habits o Communication methods o Use of assistive devices o Persons at risk – elderly o Mental status o Ability to perform self-care o Environmental hazards o Social support o Other factors affecting perception o Communication ```

Answer 14

``` o Risk-prone health behavior o Impaired verbal communication (related to stroke) o Risk for injury o Impaired physical mobility o Bathing self-care deficit o Situational low self-esteem o Risk for falls o Social isolation ```

Answer 15

loss of ability to understand or express speech, caused by brain damage

Answer 16

- Partner with patient and use your knowledge to decide goals and outcomes. - Set priorities according to type and extend of sensory alterations, safety, and patient preferences. - Collaborate with colleagues that need to be involved

Answer 17

Of abrupt onset, in reference to a disease. Acute often also connotes an illness that is of short duration, rapidly progressive, and in need of urgent care. "Acute" is a measure of the time scale of a disease and is in contrast to "subacute" and "chronic."

Answer 18

- Screening - Preventive measures - Use of assistive devices - Promoting meaningful stimuli - Establishing safe environments - Communication

Answer 19

- orientation to the environment - Communication - controlling sensory stimuli - safety measures

Answer 20

- maintaining healthy lifestyles - understanding sensory loss - socialization - promoting self-care

Answer 21

ASK IF THEY WEAR/USE ASSISTIVE DEVICES SUCH AS HEARING AIDES, GLASSES, ETC. AND MAKE SURE THEY HAVE THEM.

Answer 22

AS ADULTS OUR SENSORY DECLINES - MOST OLDER ADULTS WILL HAVE SOME KIND OF SENSORY IMPAIRMENT.

Answer 23

THEY START TO DIMINISH (EX. DRIVING AT NIGHT BECOMES AN ISSUE BECAUSE THE STOPLIGHTS ARE HARD TO DETERMINE)

Answer 24

WHEN PEOPLE HAVE A HARD TIME INTERACTING WITH OTHER PEOPLE DUE TO A SENSORY IMPAIRMENT, THEY TEND TO START ISOLATING THEMSELVES SO AS NOT TO HAVE TO DEAL WITH IT.

Answer 25

THEY HELP TO STIMULATE AND EXERCISE THE SENSES.

Answer 26

ANY ILLNESS THAT CAUSES PAIN, PHYSICAL DISCOMFORT, OR MOOD PROBLEMS SUCH AS ANXIETY OR DEPRESSION OFTEN RESULT IN SLEEP PROBLEMS DUE TO DISRUPTED SLEEP PATTERNS.

Answer 27

- RESPIRATORY DISEASE OFTEN CAUSES SHORTNESS OF BREATH AND THE NEED TO SLEEP WITH HEAD RAISED (UNFAMILIAR/UNCOMFORTABLE POSITIONS) - ASTHAM, BRONCHITIS, ALLERGIES ALER THE RHYTHM OF BREATHING - COMMON COLD CAUSES NASAL CONGESTION - HYPERTENSION - PEPTIC ULCERS - NOCTURIA (URINATION DURING THE NIGHT) - RESTLESS LEG SYNDROME

Answer 28

OLDER ADULTS EXPERIENCE INCREASED SLEEPING DIFFICULTIES; EPISODES OF REM SLEEP TEND TO SHORTEN - ELDERLY SUFFER FROM SLEEP DEPRIVATION DUE TO AGE AND OTHER HEALTH RELATED ISSUES

Answer 29

NOT NECESSARILY - "RESTED" IS A SUBJECTIVE TERM. A PERSON MUST FEEL RESTED IN ORDER FOR IT TO APPLY.

Answer 30

- Environmental controls - Bedtime routines - Promoting Safety - Promoting Comfort - Establishing periods of rest and sleep - Stress reduction - Bedtime snacks - Pharmacological approaches

Answer 31

- DESCRIPTION OF SLEEPING PROBLEMS - USUAL SLEEP PATTERN - PHYSICAL AND PSYCHOLOGICAL ILLNESS - CURRENT LIFE EVENTS - EMOTIONAL AND MENTAL STATUS - BEDTIME ROUTINES - BEDTIME ENVIRONMENT - BEHAVIORS OF SLEEP DEPRIVATION

Answer 32

ASK QUESTIONS TO SEE IF THE PATIENT FEELS MORE RESTED AND GOALS HAVE BEEN MET.

Answer 33

- ineffective breathing pattern - acute confusion - ineffective coping - insomnia - fatigue - disturbed sleep pattern - sleep deprivation - readiness for enhanced sleep

Answer 34

helps with learning, memory, and adaptation to stress

Answer 35

1. body tissue restoration 2. restoration of biological processes 3. energy conservation 4. brain tissue restoration 5. dreams

Answer 36

the support of a particular cause (a nurse advocates for the health, safety, and rights of patients, including their right to privacy and their right to refuse treatment)

Answer 37

protection of patients' personal health information

Answer 38

set of guiding principles that all members of a profession accept

Answer 39

- advocacy - responsibility - accountability - confidentiality

Answer 40

a willingness to respect one's professional obligations and to follow through (a nurse is responsible for her/his actions and those they delegate tasks to)

Answer 41

the ability to answer for one's actions (a nurses actions are explainable to your patients and your employer)

Answer 42

the importance of understanding relationships, especially as they are revealed in personal narratives.

Answer 43

freedom from external control

Answer 44

taking positive actions to help others - the agreement to act with beneficence implies that the best interests of the patient remain more important than self-interest.

Answer 45

you loose your ability to think objectively

Answer 46

the avoidance of harm or hurt

Answer 47

the promotion of open discussion without fear of recrimination whenever mistakes, especially those involving adverse events, occur or nearly occur. (accountability and quality are achieved by improving processes and systems in the work environment)

Answer 48

the agreement to keep promises - nurses need to follow through on actions and interventions.

Answer 49

value, fact, and opinion

Answer 50

Clarifying the values of those involved (ie. your own, your patients', your co-workers)

Answer 51

a proposed system of ethics that defines actions as right or wrong on the basis of their "right-making characteristics" such as fidelity to promises, truthfulness, and justice. (most familiar in health care practitioners)

Answer 52

a system of ethics that proposes that the value of something is determined by its usefulness (aka consequentialism because its main emphasis is on the outcome or consequence of action

Answer 53

system of ethics that looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible. (closely relates to ethics of care)

Answer 54

care-based reasoning that turns away from conventional principles of ethics as a way to determine best actions and focuses instead on an intimate understanding of particular situations.

Answer 55

- the presumption of good will on the part of all participants - strict adherence to confidentiality - patient-centered decision making - welcome participation of families and primary caregivers

Answer 56

if the question is perplexing and the answer has relevance for several areas of human concern, an ethical dilemma exists.

Answer 57

1. Ask the question, Is this an ethical dilemma? 2. Gather info relevant to the case. (patient, family, institutional and social perspectives are important sources) 3. clarify values (fact, opinion, values) 4. verbalize the problem the facilitate discussion 5. identify possible courses of action 6. negotiate a plan (requires confidence in one's own point of view and a deep respect for the opinions of others) 7. evaluate the plan over time

Answer 58

- Quality of Life - Disabilities - Care at the End of Life - Health Care Reform

Answer 59

accountability refers to being responsible for your actions while responsibility refers to following through on your obligations of work

Answer 60

elected legislative bodies such as state legislatures and the U.S. Congress.

Answer 61

Statutory Law

Answer 62

the legal boundaries of nursing practice within each state; the scope of nursing practice and expanded nursing roles, sets education requirements for nurses, and distinguishes between nursing and medical practice. (contains the nursing standards of care as proposed by the ANA)

Answer 63

decisions made by administrative bodies such as State Boards of Nursing when rules and regulations are passed (ex. requirement to report incompetent or unethical nursing conduct to the state board of nursing)

Answer 64

judicial decisions made by courts when individual legal cases are decided (ex. a patient's right to refuse treatment)

Answer 65

1. Civil | 2. Criminal

Answer 66

civil law protects the rights of individuals and provide for fair and equitable treatment when civil wrongs or violations occur.

Answer 67

criminal laws protect society as a whole and provide punishment for crimes, which are defined by municipal, state, and federal legislation.

Answer 68

misdemeanors or felonies

Answer 69

a crime that causes injury but does not inflict serious harm

Answer 70

a serious offense that results in significant harm to another person or society in general.

Answer 71

the legal requirements for nursing practice that describe minimum acceptable nursing care.

Answer 72

a nurse's actual conduct is compared to nursing standards of care to determine whether the nurse acted as any reasonable prudent nurse would act under the same or similar circumstances.

Answer 73

the American Nurses Association (ANA)

Answer 74

They define the practice of nursing more specifically (ex. develop IV therapy or delegation procedures)

Answer 75

requires accredited hospitals to have written nursing policies and procedures specific to the agency that need to be accessible to all nursing units.

Answer 76

existing standards of practice established by Nurse Practice Acts, federal and state hospital licensing laws. TJC standards, professional organizations, institutional policies and procedures, job descriptions, and current nursing evidence-based literature

Answer 77

- Consumer rights and protections - Affordable health care coverage - Increased access to care - Stronger medicare to improve care for those most vulnerable in our society

Answer 78

- Created a new Patient’s Bill of Rights that prohibited patients from being denied health care coverage because of prior existing conditions, limits on the amount of care for those conditions and/or an accidental mistake in paperwork when a patient got sick. - Improves Medicare coverage for vulnerable populations by improving access to care and prescription, decreasing costs of medications, extending the life of the Medicare Trust Fund until 2024, and addressing fraud and abuse in billing practices.

Answer 79

o The nurse owed a duty of care to the patient o The nurse did not carry out the duty or breached it (failed to use that degree of skill and learning ordinarily used under the same or similar circumstances by members of the profession) o The patient was physically injured o The patient’s injury resulted in compensable damages that can be qualified as medical bills, lost wages, and pain and suffering. o The patient’s injury was caused by the nurse’s failure to carry out that duty.

Answer 80

a civil rights statute that protects the rights of people with physical or mental disabilities.

Answer 81

when a patient comes to the emergency department or the hospital, an appropriate medical screening occurs within the capacity of the hospital. If an emergency condition exists, staff must evaluate the patient and may not discharge or transfer him or her until the patient’s conditions stabilizes.

Answer 82

required insurance companies to offer the same level of coverage for mental health care that they provide for medical and surgical care.

Answer 83

requires health care institutions to provide written info to patients concerning their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. (Under PSDA a patient's record needs to document whether or not the patient has signed an advance directive.)

Answer 84

living wills, health care proxies, and durable powers of attorney for health care.

Answer 85

a patient must be declared legally incompetent or lack the capacity to make decisions regarding his or her own health care treatment.

Answer 86

written documents that direct treatment in accordance with a patient’s wishes in the event of a terminal illness or condition; patient is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state.

Answer 87

a legal document that designates a person or people of one’s choosing to make health care decisions when a patient is no longer able to make decisions on his or her own behalf.

Answer 88

An individual who is at least 18 years of age has the right to make an organ donation

Answer 89

nurses must ensure that patient personal health information (PHI) is not inadvertently conveyed on social media and in particular that protected data are not disclosed other than as permitted by the patient.

Answer 90

includes chemical restraint as a form of restraint

Answer 91

the State Board of Nursing or Nursing Commission in the state in which they practice

Answer 92

the state is required to notify nurses of the charges brought against them and nurses have the opportunity to defend themselves in a hearing in front of a panel of professionals (does not occur in court).

Answer 93

health care agencies and the general public

Answer 94

- Encourages health care professionals to assist in emergencies - limits liability and offers legal immunity if a nurse helps at the scene of an accident as long as they act within their scope of practice - requires you to stay with the patient after providing emergency care until you can safely transfer his or her care to someone who can provide needed care such as an EMT.

Answer 95

protect populations, advocate for the rights of people, regulate health care and health care financing, and ensure professional accountability for care provided.

Answer 96

a competent individual with a terminal disease could make an oral and written request for medication to end his or her life in a humane and dignified manner.

Answer 97

as an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment, produce death within 6 months.

Answer 98

ANA believes that nurses’ participation violates the code of ethics for nurses

Answer 99

supports the International Council of Nurses’ mandate to ensure an individual’s peaceful end of life.

Answer 100

- When there are reasonable grounds to believe that a patient died as a result of violence, homicide, suicide, accident, or death in an unusual or suspicious manner, you need to notify the medical examiner for an autopsy. - If a patient’s death is unforeseen and sudden and a health care provider has not seen the patient in over 36 hours

Answer 101

civil wrongful acts or omissions made against a person or property

Answer 102

deliberate acts that violate another's rights such as assault, battery, and false imprisonment.

Answer 103

acts in which intent is lacking but volitional actions and direct causation occur such as in invasion of privacy and defamation of character.

Answer 104

negligence or malpractice

Answer 105

an intentional threat toward another person that places the person in reasonable fear of harmful, imminent, or unwelcome contact (ex. A nurse threatening to give a patient an injection when the patient has refused consent)

Answer 106

any intentional offensive touching without consent or lawful justification (ex. If a nurse actually gives an injection without the patients consent)

Answer 107

unjustified restraint of a person without a legal reason (ex. A nurse restrains a patient in a confined area to keep the person from freedom)

Answer 108

the publication of false statements that result in damage to a person’s reputation

Answer 109

one speaks falsely about another

Answer 110

the written defamation of character

Answer 111

a patient’s agreement to have a medical procedure after receiving full disclosure of risks, benefits, alternatives, and consequences of refusal.

Answer 112

a contract between a nurse and an insurance company that provides both malpractice and professional defense coverage for individual nurses.

Answer 113

team building and training, trust, communication, and a workplace that facilitates collaboration

Answer 114

priority setting is an organization of a vision of desired outcomes for a patient, not the ordering of a list of care tasks.

Answer 115

1. High priority - immediate threat to a patient's survival or safety 2. Intermediate priority - nonemergency, needs that are non life-threatening but involve a current situation (teaching about a new medication or taking measures to ensure a patient does not develop complications) 3. Low priority - not related to patients illness or disease (teaching a patient self-care for home before being discharged)

Answer 116

Effective use of time means doing the right things; efficient use of time means doing things right

Answer 117

- Right task – repetitive, require little supervision, relatively noninvasive, predictable results, potential minimal risk - Right circumstances – consider the appropriate setting when a patient’s condition is relatively stable - Right person – a RN knows which tasks to delegate to NAP for each specific patient. - Right direction/communication – clear concise communication of tasks and expectations that is ongoing - Right supervision/evaluation – appropriate monitoring, evaluation, intervention, and feedback; NAP needs to feel comfortable asking questions

Answer 118

when it is fulfilling a need that the learner has.

Answer 119

We have an ethical responsibility to teach our patients accurate, complete information relevant to the patient’s needs.

Answer 120

The Joint Commission (TJC) created the initiative to help patients understand their rights when receiving medical care. It encourages patients to ask questions.

Answer 121

* Speak up if you have questions or concerns. * Pay attention to the are you get * Educate yourself about your illness * Ask a trusted friend or family member to be your advocate. * Know which medicines you take and why * Use a health care organization that has been carefully evaluated. * Participate in all decisions about your treatment.

Answer 122

when they express a desire to learn

Answer 123

when they understand the content.

Answer 124

attitudes anxiety values

Answer 125

``` > Developmental capability > Age of learner > Physical capability emotional and physical health education cultural perspective patient's values about their health previous knowledge ```

Answer 126

o Perception: being aware of objects or qualities through the use of sensory stimulation o Set: readiness to take a particular action; there are three sets: mental, physical, and emotional. o Guided response: early stages of learning a particular skill under the guidance of an instructor that involves imitation and practice of a demonstrated act o Mechanism: higher level of behavior in which a person gains confidence and proficiency in performing a skill that is more complex or involves several more steps than a guided response. o Complex overt response: smoothly and accurately performing a motor skill that requires complex movement patterns o Adaptation: motor skills are well developed, and movements can be modified when unexpected problems occur o Origination: using existing psychomotor skills to create new movement patterns and perform them as needed in response to a particular situation or problem.

Answer 127

- motivation to learn - ability to learn - learning environment

Answer 128

* Attentional set (do they need pain meds to be able to concentrate better?) * Motivation * Use of theory to enhance motivation and learning * Psychosocial adaptation to illness (brand new diagnosis or struggling to breath makes learning difficult) * Active participation (are they asking questions or just listening)

Answer 129

a person's perceived ability to successfully complete a task. (when a person believes he or she is able to to execute a task, they are more likely to perform it consistently and correctly..

Answer 130

calm, little noise as possible, adequate lighting, comfortable temp

Answer 131

- Privacy - Trusting relationship - Minimal distractions - Size of the learning group (potential for direct interaction) - Room size - The ability for learners to view each other and observe verbal and non-verbal cues.

Answer 132

1. denial or disbelief (avoid, withdraw, disregards, suppresses) 2. Anger (blame and complain) 3. Bargaining (offering to live better for promise of better health) 4. Resolution (expression of emotions, asks questions) 5. Acceptance (recognizes reality, pursues info)

Answer 133

1. Assessment: collect date about patient's health/gather data about patient's learning needs 2. Nursing diagnosis: Identify appropriate nursing diagnoses on basis of assessment findings/Identify patient's learning needs on basis of three domains of learning. 3. Planning: Develop a care plan and goals or expected outcomes/Establish learning objectives stated in behavioral terms. come up with teaching plan. 4. Implementation: Perform nursing care therapies/Implement teaching methods 5. Evaluation: Identify success in meeting desired outcomes and goals of nursing care. Alter interventions where goals are not met/Determine outcomes of teaching-learning process. measure patients achievement of learning objectives.

Answer 134

``` Learning needs Motivation to learn Ability to learn Teaching environment Resources for learning Health literacy and learning disabilities ```

Answer 135

- Info or skills needed by a patient to perform self-care and to understand the implications of a health problem. - Patient experiences that influence the need to learn (recurring problem or past hospitalizations) - Info that family caregivers require to support the patient's needs.

Answer 136

- Behavior (attention span, memory, ability to concentrate) - Health beliefs and sociocultural background - Perception of the severity and susceptibility of a health problem. - Perceived ability to perform needed health behaviors - Desire to learn - Attitude about health care providers. - Learning style preference

Answer 137

- Physical strength, endurance, movement, dexterity, and coordination. - Sensory deficits that affect a patient's ability to understand or follow instructions - Patient's reading level (ask a patient to read instructions from an educational handout and then explain their meaning) - Patient's developmental level - Patient's cognitive function, including memory, knowledge, association, and judgement. - Pain, fatigue, depression, anxiety, or other physical or psychological symptoms that interfere with the ability to learn.

Answer 138

- the readiness and ability of family caregivers to learn the information necessary for the care of the patient (if the patient allows their medical information to be shared with them). - financial or material resources such as insurance or equipment needed. - Printed teaching tools/literature

Answer 139

the inability to read above a fifth-grade level.

Answer 140

the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health.

Answer 141

- elderly (age 65+) - minority populations - immigrant populations - people of low income - people with chronic mental and/or physical health conditions

Answer 142

- older adults - men - people who did not speak english before entering high school - people living below poverty level - people without a high school education

Answer 143

6th grade level or lower

Answer 144

- Decisional Conflict - Deficient Knowledge (Affective, Cognitive, Psychomotor) - Ineffective Health Maintenance - Noncompliance - Readiness for Enhanced Health Management - Self-Neglect - Impaired Home Maintenance - Ineffective family therapeutic regiment management

Answer 145

When you can manage or eliminate health care problems through education (ex. Ineffective health maintenance related to deficient knowledge regarding scheduling of medications)

Answer 146

develop a teaching plan, determine goals and expected outcomes, and involve the patient in selecting learning experiences.

Answer 147

patient's immediate needs, nursing diagnoses, and the goals and outcomes established for him or her.

Answer 148

- material should progress from simple to complex - begin instruction with essential content - start with content considered to be high priority

Answer 149

evaluate the learning objectives and determine which teaching and learning principles most effective and efficiently help the patient meet expected goals and outcomes.

Answer 150

- Telling (limited info; outlines the task and gives instructions; no feedback) - Participating (nurse and patient involved in the learning process together) - Entrusting (provides a patient the opportunity to manage self-care) - Reinforcing (requires the use of a stimulus to increase the probability of a desired response; can be positive or negative)

Answer 151

- One-on-one discussion - Group instruction - Preparatory Instruction (reduces procedure anxiety and helps patients know what to expect) - Demonstrations - Analogies - Role play - Simulation

Answer 152

six or less to avoid distracting behaviors

Answer 153

create a safe, shame-free environment, using clear and purposeful communication techniques, using visual aids to reinforce spoken material, and taking special care to evaluate patient understanding

Answer 154

- Means of communication regarding the patient - It's a legal document (best defense for legal claims) - Insurance reimbursement - Internal auditing and monitoring - Health research (gathering statistical data) - Education (health care providers and student can compare records of different patients with the same medical problem and look for patterns) - Continuity of care (way to ensure everyone is on the same page regarding patient care)

Answer 155

1. failing to record pertinent health or drug info 2. failing to record nursing actions 3. failing to record medication administration 4. failing to record drug reactions or changes in patient's condition 5. incomplete or illegible records 6. failing to document discontinued medication

Answer 156

electronic health record

Answer 157

electronic medical record

Answer 158

- No personal opinions (must be non-biased and factual) - Correct all errors promptly - Record all facts (write down everything) - Document discussions (that impact health or care) - Document only for yourself - Avoid using generalized statements (be specific) - Use correct entry format (begin each entry with date and time and end with your signature and credential - Protect your password

Answer 159

- Do not erase - Do not leave blank spaces - Record legibly

Answer 160

that all patients admitted to a health care facility have an assessment of physical, psychosocial, environmental, self-care, knowledge level, and discharge planning

Answer 161

because it is a confidential, permanent, legal documentation of info relevant to a patient's health care.

Answer 162

1. factual 2. accurate 3. complete 4. current 5. organized

Answer 163

- U for unit - IU for international unit - Forms of QD and QOD for every day and every other day Trailing zero or lack of leading zero - MS for morphine sulfate or magnesium sulfate - MSO4 and MgSo4 (confused for on another)

Answer 164

- vital signs - pain assessment - admin of meds and treatments - preparation for diagnostic tests or surgery - change in status and who was notified - admission, transfer, discharge or death of a patient - treatment for sudden change in status - patient's response to treatment or intervention

Answer 165

the use of a storyline format to document information

Answer 166

- Database (all available assessment info) - Problem List - Care Plan - Progress Notes

Answer 167

o PIE – problem, intervention, evaluation o APIE – assessment, problem, intervention, evaluation o SOAP – subjective, objective, assessment, plan o SOAPIE, SOAPIER – subjective, objective, assessment, plan, intervention, evaluation, (revision) o Focus Charting (DAR) - Data, action, response

Answer 168

Charting by exception

Answer 169

unexpected outcomes, unmet goals, and interventions not specified within the critical pathway.

Answer 170

bar-coded medication administration

Answer 171

electronic medication administration record

Answer 172

a medical information system used by nursing staff as a way to communicate important information on their patients

Answer 173

- Admission Nursing History Form - Flow Sheets and Graphic Records - Patient Care Summary - Standardized Care Plans or Clinical Care Guidelines (CPGs) - Discharge Summary Forms - History and physical

Answer 174

it determines the hours of care and number of staff required for a given group of patients every shift or every 24 hours.

Answer 175

- clearly determine the patient's name, room number, and diagnosis. - use clarification questions to avoid misunderstandings - Write TO (telephone order) or VO (verbal order), including date and time, name of patient, the complete order; sign the name of the physician or health care provider and nurse - read back any prescribed orders to the physician or health care provider - follow agency policies

Answer 176

"read back and verified"

Answer 177

an unexpected occurrence involving death or serious physical or psychological injury or the risk of injury

Answer 178

when an unusual and unexpected event involving a patient, visitor, or staff member occurs

Answer 179

- better access to info - enhanced quality of documentation through prompts - reduced errors of omissin - reduced hospital costs - increased nurse job satisfaction - compliance with requirements of accrediting agencies - development of a common clinical database - enhanced ability to track records

Answer 180

- patient assessment - referral and intake forms, - Interprofessional plans of care - list of medications - reports to third-party payers - complete list of specific nursing services (direct skilled care, patient teaching, skilled observation, evaluation, etc)

Answer 181

Outcome and Assessment Information Set (OASIS) Omaha System

Answer 182

1. problem classification scheme 2. Intervention scheme 3. problem rating scale for outcomes

Answer 183

The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA)

Answer 184

an inter professional approach to the assessment and planning process for all patients

Answer 185

ability to move around freely

Answer 186

inability to move around freely

Answer 187

intervention that restricts for therapeutic reasons