Nursing Concepts Exam 3

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Fundamentals of Nursing
Chapters 24-26
Communication, informatics and documentation
updated 6 years ago by Boosh_75
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1

What is the cause of 66% of all sentinel events reported in the healthcare field?

Ineffective communication

2

Communication in the nursing field is very important because it helps build what with patients, families, and team members?

Relationships

3

This type of relationship is needed for friendship and socialization, it is wanted needed when you want someone to like you.

Social

4

This type of relationship is centered on the patient's needs and concerns, it helps them to adapt to changing life circumstances in a healthy way.

Therapeutic

5

This type of communication occurs within a healing relationship between a nurse and a patient.

Therapeutic

6

This type of communication can result in both harm and good.

Nurse's communication

7

This type of communication empowers others and enables people to know themselves and to make their own choices.

Skilled communication

8

Thinking is influenced by your perception of your five senses, culture, education, past events, critical thinking, self-confidence, and humility and your perceptual _________ of these of these events.

Bias

9

These variables affect communication by effecting a person bio-physically, phychosocially, and socioculturally by ways of sensory loss, anxiety, pain, culture, values, ect.

Internal variables

10

These variables affect communication by noise, discomfort, distractions, or lack of privacy.

External variables

11

Word difference among cultures may cause confusion when doing what with a patient?

Communicating

12

Using hospital jargon and codes may cause this when trying to communicate with a patient?

Confusion

13

This form of communication is the literal meaning of what you are trying to communicate.

Denotative communication

14

This form of communication uses words that are associated with the literal meaning for example one might the word "snake" in reference to someone being "evil".

Connotative

15

This aspect of verbal communication goes hand-in-hand with clarity and brevity of communication.

Intonation

16

This aspect of verbal communication has to do with timing and relevance of the conversation.

Pacing

17

These clues to to communication include sight, nonverbal sounds, touch, space, time, and congruence.

Nonverbal symbols and actions

18

This visual nonverbal action may be a barrier of communication to a patient of Asian decent as this is discouraged as a sign of disrespect or challenging authority in their culture.

Eye contact

19

Wearing a surgical masks during a patient visit could be considered a _________ ___________ to communication.

Physical barrier

20

Both crying and silence are considered what type of communication?

Nonverbal communication

21

When determining personal space a distance of 18 inches and closer is considered what?

Intimate distance

22

When determining personal space a distance of 18 inches to 4 feet is considered what?

Personal distance

23

When determining personal space a distance of 4 feet to 12 feet is considered what?

Social distance

24

When determining personal space a distance of more than 12 feet, usually used for formal speaking is considered what?

Public distance

25

When caring for a patient one should respect the patient or patient's family in their use of this? Example: vigil practices or cultural variations (ie Muslim prayer moments)

Time

26

This term is used to describe when a person's verbal and nonverbal communication match one another (i.e. voice and body language mean the same thing)

Congruence

27

The SOLER skills of active listening include:

Squarely (Face the patient), Open posture, Lean in, Eye contact, Relax

28

This form of communication from a patient may have you noticing a rosary, prayer beads, or other type of emblem or token on display.

Symbolic communication

29

When discussing the nurse-patient relationship this phase occurs prior to meeting the patient.

Preinteraction phase

30

When discussing the nurse-patient relationship this phase occurs when the nurse and patient meet each other and get to know each other.

Orientation phase

31

When discussing the nurse-patient relationship this phase occurs when the nurse and the patient work together to solve problems and accomplish goals.

Working phase

32

This phase of the nurse-patient relationship occurs at the end of the relationship

Termination phase

33

What are the 5 C's of communication?

Be Clear, be concise, be confident, be complete, be considerate and give compliments.

34

Lack of attention span and listening skills, inability to articulate words or ideas, difficulty in forming words or comprehension are all what?

Ways that patients may have difficulty with communication

35

Patients who cannot speak clearly, have cognitive impairment, hearing or visual impairment, do not speak English or are unresponsive are all people a nurse would have to do what with?

Adapt their communication techniques to

36

Appearance, demeanor, behavior, courtesy, trustworthiness, autonomy, responsibility and assertiveness are all elements of what?

Professional communication

37

A communication technique used in the healthcare field is known as SBAR. What does it stand for?

Situation, Background, Assessment, and Recommendation

38

Nurses are legally and ethically obligated to keep all patient information _____________.

Confidential

39

Nurses are responsible for protecting records from who?

All unauthorized readers

40

__________requires that disclosure or requests regarding health information are limited to the minimum necessary.

HIPPA

41

Current documentation standard require that each patient have what kind of assessment?

Physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs.

42

Nursing documentation standards are set by whom?

Federal and state regulations, state statues, standards of care, and accreditation agencies.

43

This type of communication is vital within the care team itself and may consist of records or charting, reports, consultations and conferences.

Interdisciplinary communication

44

What is the purpose of keeping a health record?

Communications, legal documentation, reimbursement, education, research and auditing/monitoring

45

When recording in a patient chart quality documentation would assure that is a nurse is charting complete information that is also factual, accurate, current and organized. What should one not seen in quality documentation?

Personal opinion

46

When a nurse has a question regarding an order what should she do after she inquiring about it to the physician?

Record in the patient chart that clarification was sought.

47

This method of recording in the patient chart uses the SOAP method. What does this stand for?

Subjective, objective, assessment, plan

48

Focus charting uses the DAR method. What does this acronym stand for?

Data, action, response

49

Source records have what are organized how?

With a separate section for each discipline

50

When one uses charting by exception what is the focus?

Documenting deviations.

51

How does case management and critical pathways work?

They work by incorporating a multidisciplinary approach to care and variance when a patient does not fit into a standard plan of care.

52

This is a portable "flip-over" file or notebook with patient information.

Care summary or Kardex

53

These are preprinted,established guidelines used to care for patients who have similar health problems.

Standardized care plan

54

This is the application of computer and information science for the management of patient health-related data.

Health inoformatics

55

What is the focus of health informatics?

The patient and the process of care

56

What is the goal of health informatics?

To enhance the quality and efficiency of care provided to patients.

57

Health informatics was driven by whom?

Health Information Technology for Economic and Clinical Health Act (HITECH)

58

This is a group of systems used in a health care organization to support and enhance health care.

Healthcare Information system (HIS)

59

What are the two designs of the Nursing Information System?

Nursing process design and the protocol or critical pathway design

60

When a nurse adds clinical problems into a clinical decision support system what is the outcome?

It gives examples of possible solutions to the clinical issues

61

This is used to increase time spent with patients, gain access to information, reduce errors of omission, reduce hospital costs, increase compliance with accrediting agencies and develop a common clinical database.

Advantages of the Nursing Information System

62

What is a CPOE?

Computerized Provider Order Entry

63

What does a computer provider order entry do?

Improves accuracy, speeds implementation, improves productivity, and saves money

64

These may influence common sources of error like misinterpretation of physician orders, incorrect calculations, inaccurate charting, illegible handwriting, or inappropriate anticoagulation parameter porcesses

Point-of-Care technology

65

Bar-coded patient identification bracelets are a an example of what?

Point-of-Care technology

66

Individuals who violate this act may be subject to criminal penalties and civil monetary penalties.

HIPPA

67

When evaluating information on the internet make sure your source:

Is an authority on the subject, shows objectivity and accuracy, has current information, and the information is usable

68

Who set the standards for patient ad family education in healthcare?

The Joint Commission

69

What is the purpose of patient education?

To help individuals, families, or communities achieve optimal levels of health.

70

Patient education includes:

Maintenance and promotion of health and illness prevention, restoration of health, and coping with impaired functioning

71

When doing patient teaching what should always be documented about the teaching?

Patient understanding

72

This kind of teaching is usually done as a discussion with an individual or group and has a question-and-answer portion of the teaching

Cognitive

73

This kind of teaching may use role-reversal by having the patient teach the nurse how to care for them self (i.e. dressing changes or colostomy care)

Affective

74

This type of teaching uses demonstrations, practice, and sometimes learning games.

Psychomotor

75

This refers to a persons's perceived ability to successfully complete a task.

Self-efficacy

76

When does most of the learning occur for a patient?

When they are actively involved in the educational session.

77

This depends on the physical and cognitive ability, developmental level, and physical wellness of a patient?

Ability to learn

78

A nurse should respect a patient's life experience and use their __________ and ___________in the patient teachings.

experience; knowledge

79

The nursing process and the teaching process are the same or are they different?

Same

80

When does the teaching process begin?

When education becomes part of the care plan.

81

This is the ability to obtain, understand, and act on healthcare information and instructions.

Health literacy

82

This includes patients' reading and mathematics skills, comprehension, decision-making, and functioning skills with the regard to healthcare.

Health literacy

83

Taking medications on time, giving informed consent, self-care management of health condition, reading food labels in order to follow diet, and navigating the health system are all examples of what?

Health literacy

84

What is the average reading level in the United States?

4th-6th grade

85

When a nurse notices patient registration forms not being filled out, lack of patient follow-through, an inability to explain what was read, having limited amount of questions or using excuses like, "I forgot my glasses and will read these at home" she know these are examples of what?

Health literacy red-flags

86

This method has a nurse asking the patient to repeat in their own words what was discussed in a respectful manner.

Teach back method