regular neuromuscular assessments Show
pain management strategies, which may include epidural or intrathecal analgesia etc exercise of the affected joint use of an abductor pillow prophylactic anticoagulant drug for at least 10-14 days Chart (health care record) a legal record that is used to meet the many demands of the health, accreditation, medical insurance, and legal systems What are the 5 elements of documentation? assessment What are the 5 basic purposes for accurate and complete patient records? documented communications what 5 elements does proper charting cover about the patient? physical peer review systems an appraisal by professional coworkers of equal status quality assurance, assessment, and improvement an audit in health care the evaluates services provided and the results achieved compared with accepted standards diagnosis-related goups (DRG's) a system that classifies patients by age, diagnosis, surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount nursing notes the form on the patients chart on which nurses record their observations, the care given, and the patients responses What are 5 benefits of EHR's increased efficiency What is the difference between EHR and EMR? the EHR has the ability to exchange patient data The EMR is typically used to exchanged patient data within a facility
point of care system (POC) computer systems located at the patients bedside computers on wheels (Cows) a computer on a cart that can be wheeled around to each room nomenclature a classified system of technical or scientific names and terminology
informatics the study of information processing personal health record (PHR) an extension of the EHR that allows patients to input their own information into an electronic database SBAR situation, background, assessment, and recommendation - a method of communication among health care workers and a part of documentation if there is an additional "R" it stand for read back narrative charting recording of patient care in descriptive form SOAPIER S-ubjective information is what the patient states or feels; only the patient can provide this information
SOAPE More compact form than SOAPIER Subjective DARE D- ata is both subjective and objective and is equivalent to the assessment step of the nursing process CBE charting by exception the nurse charts complete physical assessments, observations, vital signs, IV site and rate, and other pertinent data at the begging of each shift. During the shift, the only notes the nurse makes are for additional treatments done or planned treatment withheld, changes in patient condition, and new concerns PIE problem Kardex (Rand) a system used by some facilities to consolidate patient orders and care needs in a centralized concise way Nursing care plan plan that outlines the proposed nursing care based on the nursing assessment and nursing diagnosis to provide continuity of care incident report form used to document any event not consistent with the routine operation of a health care unit or the routine care of a patient acuity charting uses a score that rates each patient by severity of illness clinical (critical) pathways
allow staff from all disciplines to develop standardized, integrated care plans for a projected length of stay for patients of a specific case type Omnibus budget reconciliation act (OBRA) of 1987 instituted extremely significant Medicare and Medicaid requirements for long term care privison and documentation SBARR situation name some guidelines for documentation - patient identification Who owns the EHR?
the facility in which you are charting for does the patient have a right to their own information yes can a family member have access to a patients chart? no, unless the patient has it written down that they are allowed A nursing assistant prepares a patient report. On
reviewing the report, the nurse manager states that the nursing notes are lengthy and irrelevant. How can the nursing assistant make the notes brief? a, d, e Which statement is correct
regarding the Health Insurance Portability and Accountability Act (HIPAA)? d A relief nurse arrives for duty and wants to locate the health status and interventions provided to
patients during the previous shift. Which document would help the nurse gather this information? d While assessing a patient's report, the nurse manager notices a great deal of abnormal patient data. Which patient charting method does the nurse manager suggest? Computer-assisted charting Charting by exception Case management system patient charting Focus patient charting charting by exception The new nurse manager assesses the facility's patient progress notes and includes implementation, evaluation, and revision to the current format. Which acronym best suits this new approach to documenting patient progress notes? SOAP SOAPIE SOAPIER SOAPI SOAPIE Because the patient's medical record is a legal document, what is the most important practice the nurse should perform when documenting? Clearly indicate goal-directed nursing care Minimize nursing notes to address priority nursing problems Provide information about adverse events that occur throughout the day Document subjective information provided by the patient, but not objective information Clearly indicate goal-directed nursing care While the nursing assistant is accessing a patient's data using an electronic health record, the nurse manager calls for an urgent meeting. What should the nursing assistant do? Ask the manager to wait. Lock the terminal. Ask a colleague to help. Shut down the computer. lock the terminal The nurse manager has to audit whether the nursing care provided to patients adhere to the accepted standards. Which part of the documentation should the nurse manager look into? Primary health care provider's orders Progress sheet Consultation sheet Nurse's notes nurse's notes A nurse is preparing to document patient care. What data are most important for the nurse to include? Time of care Patient's pain level Family members present Type of procedure performed Temperature of the environment -time of care The nurse works in a facility using a charting method that states the problem, intervention, and evaluation of the treatment given to a patient. Which charting method does this facility follow? Computer-assisted charting Charting by exception PIE charting Focus charting pie charting A patient files a claim with his medical insurance company. The insurance company rejects the claim, citing that the actual length of the hospital stay was shorter than the patient claimed. How did the insurance company learn this information? By reviewing the medical records of the health care unit By checking with the nursing practitioner By checking with the primary health care provider By checking with the patient's family by reviewing the medical records of the health care unit A student nurse asks her preceptor why it is so important to document. What is the best advice the preceptor can offer? "Good documentation proves that a nurse is competent." "Nursing documentation will assist the primary health care provider in the selection of a plan of care." "Failure to document patient care may result in the loss of reimbursement of funds from government and other agencies." "Lack of documentation on the patient's chart (health care record) will result in a penalty against the health care provider license." failure to document patient care may result in the loss of reimbursement of funds from government and other agencies A patient with an abnormal laboratory value has discharge orders. The nurse assessed the patient and called the primary health care provider for a prescription. The nurse read the phone prescription back to the primary health care provider and verified the dosage. Which tool did the nurse use to prevent a medication error caused by communication?" Focused charting Charting by exception (CBE) Problem-oriented charting Situation, Background, Assessment, Recommendation, Read Back (SBARR) situation, background, assessment, recommendation, read back (SBARR) communication a reciprocal process in which messages are sent and received between people
what kind of messages can be conveyed when communicating information sender of communication the one who conveys the message receiver of communication the person or people to whom the message is conveyed one way communication highly structures; the sender is in control and expects and gets very little response from the receiver has very little place in the nurse patient relationship two way communication requires that both the sender and the receiver participate in the interaction this is more promising in the medical world, also for the nurse and patient to communicate back and forth and establish trust verbal communication the use of spoken or written words or symbols connotative meaning a word is subjective and reflects the individual's perception or interpretation denotative meaning the commonly accepted definition of a particular word jargon commonplace language or terminology unique to people in a particular work setting, such as nursing nonverbal communication messages transmitted without the use of words, either oral or written gestures movements people use to emphasize the idea they are attempting to communicate posture the way that an individual sits, stands, and moves open posture a relaxed stance with uncrossed arms and legs while facing the other individual closed posture more formal, distant stance, generally with the arms, and possible the legs, tightly crossed assertiveness one's ability to confidently and comfortably express thoughts and feelings while still respecting the legitimate rights of the patient assertive communication is interaction that takes into account the feelings and needs of the patient, yet honors the nurse's rights as an individual aggressive communication when an individual interacts with another in an overpowering and forceful manner to meet one's own personal needs at the expense of the other unassertive communication this style sacrifices ones legitimate personal rights to the needs of the patient, and there is a price to pay; resentment therapeutic communication consists of an exchange of information that facilitates and actively involves the patient in all areas of care nontherapeutic communication blocks the development of a trusting and therapeutic relationship active listening requires full attention to what the patient is saying the nurse hears the message, interprets its meaning, and gives the patient feedback indicating understanding of the message passive listening is acting like they are listening but does not completely understand the message trying to be conveyed. list to the speaker is indicated either nonverbally through eye contact and nodding, or verbally through encouraging phrases. minimal encouragement a subtle therapeutic technique that communicates to the patient that the nurse is interested and wants to hear more closed question focused and seeks a particular answer
open question do not require a specific response and allow the patient to elaborate freely on a subject when replying restating the nurse repeats to the patient what is believed to be the main point that the patient is trying to convey paraphrasing is the restatement of the patients message in the nurses own words in an attempt to verify that the nurse has correctly interpreted the patients message clarifying takes restating and paraphrasing a step further and is useful when the patients message is incomplete or confusing or does not go deeply enough into the area being explored focusing is used when more specific information is needed to accurately understand the patients message reflecting is like restating, but involves inner feelings and thoughts more than facts stating observations often useful in validating the accuracy of observation offering information preparing a patient for what to expect before, during, and after an invasive diagnostic procedure is one example of how the nurse uses this communication technique summarizing providing a review of the main points covered in an interaction intimate space from the face to 18 inches away personal space 18 inches to 4 feet away social space 4 feet to 12 feet away public space beyond 12 feet away altered cognition the patient lacks the cognitive ability to receive, process, and send information, communication is disrupted expressive aphasia patients are unable to send the desired verbal message receptive aphasia the inability to recognize or interpret the verbal message being received what are some ways of nonverbal communication? voice what are some ways to communicate therapeutic communication? active listening physiologic factors that affect communication pain
psychosocial factors that affect communication stress special situation that affect communication ventilator dependence A nurse is communicating with the patient. Which cues have positive effect on the patient's immune system while communicating? Smiling Laughing Sitting position Focused energy Appropriate use of humor smiling, laughing, appropriate use of humor During nursing procedures, which nonverbal therapeutic communication technique is most likely to be used? Touch Silence Listening Conveying acceptance touch A patient has aphasia. Which interventions can help the nurse while interacting with the patient? Ask only one question at a time. Give the person time to respond to questions. Avoid repetition of sentences using the same word. Give directions with short phrases and simple terms. Make the environment as relaxed and quiet as possible. ask only one question at a time, give the person time to respond to questions, give directions with short phrases and simple terms, make the environment as relaxed and quiet as possible. A nurse is collecting data from a patient who is diabetic. Which statement, if made by the nurse, would elicit the most information? Do you monitor your diet? Are you on a prescribed diabetic diet? What time do you and your family eat? Tell me about your eating habits and diet. tell me about your eating habits and diet The nurse informs a patient, "I need to attend to another patient urgently. If you don't mind waiting, I will change your clothes at a later time or I can ask someone else to assist you." What kind of communication does the statement made by the nurse indicate? Assertive communication Aggressive communication Unassertive communication Non-therapeutic communication assertive communication A nurse is attempting to interview a patient in severe pain. In an effort to promote communication, what is the best action the nurse can take? Postpone the interview until the pain is manageable. Address the pain and then proceed with the interview. Ask the patient to ignore the pain during the interview. Promise the patient pain medication after the interview. address the pain and then proceed with the interview A terminally ill patient has just died. The family members are upset and crying. What is the most appropriate action the nurse can take to convey support and compassion? Ask the family to leave, then provide postmortem care. Stay with the family and use silence and therapeutic touch. Immediately leave the room and allow the family to grieve. Begin to make funeral arrangements so the family can give approval. stay with the family and use silence and therapeutic touch A nurse has been interviewing a patient for over an hour. To ensure that important information was collected, the nurse should use which communication technique? Touch Humor Silence Summarizing summarizing Communication is an important source of obtaining information from the patient. Which types of communication are used by the nurse while interacting with the patient? Verbal Nonverbal Congruent Expression Intonation verbal, nonverbal The nurse is communicating with a hearing-impaired patient. Which techniques should the nurse use for effective communication? Use short and simple sentences. Avoid shouting at the patient. Speak directly into the patient's ear. Maintain the voice pitch at mid-range. Give the person time to respond to questions. use short and simple sentences, avoid shouting at the patient, maintain the voice pitch at mid-range, give the person time to respond to questions A nurse is interviewing a patient who is to be admitted. The patient is providing the nurse with information that is too vague. In an effort to focus on essential information needed, the nurse should use which therapeutic communication technique? Focusing Posturing Positioning Offering information focusing Which nonverbal communication technique is therapeutic and effective but requires practice and a conscious effort by the nurse to use successfully? Touch Silence Listening Acceptance silence A patient arrives at the emergency room with respiratory distress. The nurse needs to get essential information for the planning of the patient's care. Based on the patient's condition, what should the nurse do? Offer information Ask open-ended questions Begin a detailed interview Ask closed-ended questions ask closed ended questions Therapeutic communication is a key to providing the best care possible to patients. Identify the factors that negatively affect therapeutic communication. Lack of trust Language barrier Indifferent attitude Cultural differences Use of active listening lack of trust, language barrier, indifferent attitude, cultural differences
What interventions should the nurse take while caring for a comatose patient? Talk to the patient about daily activities. Encourage the family members to talk to the patient. Explain the activity or procedure that involves the patient. Ask the family to talk about instances of illness or accidents. Discuss the patient's health status in the patient's presence. talk to the patient about daily activities, encourage the family members to talk to the patient, explain the activity or procedure that involves the patient Which factor can interfere with the patient developing a trusting relationship with the nurse? A pleasant experience at a hospital. The perception of a competent nurse. A negative encounter with a health care worker. A valued relationship with the primary health care provider. a negative encounter with a health care worker A patient states, "My son hasn't been to see me in months." The nurse responds, "You miss your son." Which therapeutic communication technique is the nurse using here? Focusing Reflection General leads Restatement restatement Which statement is true regarding the medical record? When the patient is discharged, the patient will take it home. When the patient is discharged, the institution will maintain the health care record. When the patient is discharged, the institution will shred or delete the records unless there is a court case pending. When the patient is admitted, anyone the patients wants to review his or her record can do so without restrictions. when the patient is discharged, the institution will maintain the health care record A nursing assistant's neighbor's ex-husband is ill and the neighbor wants to know the health status. What should the nursing assistant do? The nursing assistant should give the details of illness to the patient's ex-wife. The nursing assistant should give details to a colleague to share the information. The nursing assistant should protect the patient's privacy and not leak information at all. The nursing assistant can ask the primary health care provider's permission to give the information. the nursing assistant should protect the patient's privacy and not leak information at all A health care worker accidently faxes a copy of laboratory data and test results to an incorrect fax number. The health care worker resends the fax to the correct number and makes no attempt to retrieve the data. What violation has occurred if the health care worker fails to get the fax returned? Charting by exception (CBE) Problem Intervention Evaluation (PIE) charting Subjective Objective Assessment Plan Evaluation (SOAPE) Health Insurance Portability and Accountability Act (HIPAA) HIPPA Which protocol allows a patient to acquire access to his or her medical record? Requesting copies from the nurse Submitting a request in written form Reading the chart with the nurse's permission Visiting the Department of Health and Human Services Submitting a request in written form Which component of the health care record must a patient receive before discharge from a medical facility? Nurses' notes Progress notes A discharge summary A history and physical examination a discharge summary A health care facility uses problem-oriented medical record (PMOR) charting for documenting patient records. The new nurse manager feels that the word "problem" can carry negative connotations. Which charting method can the nurse manager suggest as an alternative, keeping in mind that minimal structural change can be made? Narrative charting Charting by exception Case management system charting Focus charting focus charting What is the advantage of electronic health records (EHR) over electronic medical records (EMR)? EHR has less accuracy in recording patient data. EHR has less efficiency in recording patient data. EHR has greater consistency in recording patient data. EHR can exchange the patient data with other facilities. EHR can exchange the patient data with other facilities A nurse manager wants to know if a patient is allergic to a particular medication. The health care facility uses Kardex. Why is the nurse manager not able to procure the information? Kardex covers only personal information. Kardex covers only scheduled tests. Kardex covers the medication list without citing allergic details. Kardex covers only surgery-related information. Kardex covers the medication list without citing allergic details On what basis do insurance companies decide upon reimbursement rates for a patient? Traditional (block) chart Personal health record (PHR) Diagnosis-related groups (DRGs) Electronic medical record (EMR) DRGs Which action is essential for the nurse to take during the charting process? Chart at the nurse's leisure. Chart only if the patient's condition changes. Chart in the nurses' lounge during designated lunch breaks. Chart at the bedside to save time and allow information to be updated immediately. chart at the bedside to save time and allow information to be updated immediately The Licensed Practice Nurse (LPN) uses the patient's case report for research purposes after receiving the Registered Nurse's permission. Following this, the LPN's license is revoked for not adhering to Health Insurance Portability and Accountability Act (HIPAA). Which action by the LPN would lead to the license being revoked? The LPN did not mention the patient's details in the research papers. The LPN did not place the case report near the patient's bed after using it. The LPN placed the patient's case report in a locker before leaving the hospital. The LPN did not shred the papers containing the patient's identity before leaving the hospital. the LPN did not shred the papers containing the patients identity before leaving the hospital Which record allows the patient to feed his or her own health information into an electronic database? Personal Health record (PHR) Electronic Health record (EHR) Electronic Medical record (EMR) Situation, Background, Assessment, and Recommendation record (SBAR) personal health record A patient with a chronic disease is admitted into an acute care facility. A team of primary health care provider, nurses, and therapists develop a care plan. All are required to document using the same progress notes, flow sheets, and narrative notes. What format of documentation does this reflect? Charting by exception (CBE) Problem-oriented medical record (POMR) Problem Intervention Evaluation (PIE) charting Subjective Objective Assessment Plan Evaluation (SOAPE) Problem oriented medical record The nurse works with a health care facility in a small town. The health care facility maintains patient records as manual files. The nurse finds it very difficult to create, maintain, and update the patient records. Which patient charting method does the nurse suggest to the administration? Computer-assisted charting Focus charting Problem-oriented medical record charting Source-oriented (narrative) charting computer assisted charting While charting a patient record, the nurse mentions, "The patient tolerated the walker well." The nurse manager asks the nurse to change the statement. How should the nurse rewrite the statement? "The patient walked the entire stretch of the hall using the walker without any problems." "The patient walked without the support of the walker or family." "The patient walked using support of his wife and the walker." "The patient walked the entire stretch of the hall without complaining." the patient walked the entire stretch of the hall using the walker without any problems A graduate nurse asks why her chart was audited. Which statement if made by the preceptor indicates a clear understanding of the purpose of a chart audit? "Audits are conducted only when a lawsuit occurs." "The audit determines whether the nurse will receive a raise." "Audits are required by the facility but do not serve any purpose" "Audits show whether prescribed care was charted as given and responses to treatments were noted." audits show whether prescribed care was charted as given and responses to treatments were noted Which statement if made by the nursing student indicates a need for additional teaching? "I should document my observations and not my opinions." "I will chart patient responses to medications and treatments." "It is best to use direct quotes and avoid judgmental statements." "Medications are to be charted immediately before I administer them." medications are to be charted immediately before i adminster them The primary health care provider instructs the LVN/LPN to medicate a patient if the patient's body temperature rises above 102 o F. In which section should the LVN/LPN record the information, using the SOAPIER documentation format? Objective Evaluation Assessment Intervention intervention The nurse is speaking to the parent of an adolescent who says, "I think my son has started taking drugs. If I tell my husband, he would be furious and may not allow my son out of the house. I do not want that to happen either." The nurse responds to the patient by asking, "What do you think you should do now?" Which type of therapeutic communication does this indicate? Focusing Restating Reflecting Summarizing reflecting While talking to the nurse about a deceased child, a patient suddenly starts crying. Which response of the nurse would indicate therapeutic communication? The nurse changes the topic of discussion. The nurse provides silent support by holding the hand. The nurse provides privacy by leaving the patient alone. The nurse encourages the patient to talk about the child. the nurse provides silent support by holding the hand Which action would enhance communication in a patient with aphasia? Avoid the use of communication aids. Encourage the patient to limit speech. Allow the patient extra time to respond. Use toddler speech and childlike phrases. allow the patient extra time to respond Which space should the nurse use to elicit information during the interview? Public space Social space Intimate space Personal space personal space A patient is from the United States. How can the nurse maintain the personal space while communicating with this patient? Ask open-ended questions to the patient. Sit with the legs crossed and a foot bouncing. Maintain direct eye contact with the patient. Keep 18 inches to 4 feet of distance between them. keep 18 inches to 4 feet of distance between them The nurse who is interviewing a patient looks frequently at the watch but tries to maintain eye contact with the patient. What does the nurse's gesture convey to the patient? The nurse is disrespectful and incompetent at work. The nurse is disinterested in interviewing the patient. The nurse is in a hurry but is respectful to the patient. The nurse is uncomfortable about interviewing the patient. the nurse is in a hurry but is respectful to the patient During the interview the patient states, "I am so depressed and confused." What would be the most appropriate reply the nurse can give? "Depression can be confusing." "You are depressed and confused?" "Is your depression causing confusion?" "How is the confusion causing depression?" you are depressed and confused? The nurse is communicating with a patient. Which factors may affect communication between the nurse and the patient? Select all that apply. Mood Culture Attitude Emotions Closed Questions mood, culture, attitude, emotions Which statement by the LPN is an example of using assertiveness? "Going to physical therapy (PT) will help you get stronger, so let's go to PT now, please." "You need to go to physical therapy (PT) sometime today; please let me know when you want to go." "It would be best for you to go to physical therapy (PT) now, but later is okay also. Please let me know." "It is time for you to go to physical therapy (PT). Do you want to walk part way or do you think you're strong enough to walk all the way?" It is time for you to go to physical therapy, do you want to walk part way or do you think you're strong enough to walk all the way Which nonverbal clue would send a negative message to a patient? Relaxed stance Crossed arms, legs Facing an individual Direct eye contact crossed arms, legs A nurse is administering care to a patient with a hearing aid. Which factor will enhance communication with a hearing-impaired patient? Shout so that the patient will understand better. Make sure the hearing aid is in place and in working order. Approach the patient on the side opposite the hearing aid. Escalate the background noises and approach patient at an angle. make sure the hearing aid is in place and in working order Good communication skills helps obtain detailed information about the patient. Which characteristics of communication help in effective patient care? Feedback Validation Expression Intonation Active listening feedback, active listening A nurse is interacting with an elderly patient. Which appropriate intervention can help in effective communication? Speak slowly with the elderly patient. Keep minimum eye contact with the patient. Check that hearing aids are in place and turned on. Allow more time for the patient to process the message. Face the patient to facilitate lip reading. speak slowly with the elderly patient, check that the hearing aides are in place and turned on, allow more time for the patient to process the message, face the patient to facilitate lip reading The nurse is assisting a patient with a leg injury who has difficulty while walking. The nurse grows frustrated and tells the patient, "You aren't really trying." What does the response made by the nurse indicate? The nurse is showing approval. The nurse is giving personal advice. The nurse is giving false reassurance. The nurse is making a false assumption. the nurse is making a false assumption A patient is diagnosed with a malignancy. The patient is unsure whether to choose chemotherapy, radiation, or both. Which type of technique is most appropriate for sorting out the patient's gathered thoughts? Silence Reflection Offering self General leads silence A patient needs discharge instructions on how to administer heparin. After the nurse demonstrates injection techniques, the patient states, "I need a nurse, I can't do this." Which would be an inappropriate response? "I can see that you're not trying." "Let's talk about how you're feeling." "I'll demonstrate as many times as needed." "Learning to give an injection may be frightening." i can see that your not trying Which action would the nurse take when communicating with a patient with aphasia?Don't “talk down” to the person with aphasia. Give them time to speak. Resist the urge to finish sentences or offer words. Communicate with drawings, gestures, writing and facial expressions in addition to speech.
Which action would the nurse perform for easy communication with a patient who has aphasia quizlet?Which action would the nurse perform for easy communication with a patient who has aphasia? aphasia has difficulty speaking. The nurse would encourage the patient to converse and collaborate with a speech therapist as needed; the nurse would not tell the patient to remain silent.
What is the best method of communication for a patient with aphasia quizlet?Gestures and/or symbols are helpful for persons with aphasia because they cannot recognize the spoken or written word. What is the best method of communication for a patient with aphasia?
Which intervention would help the nurse while interacting with a patient who has aphasia?A patient has aphasia. Which interventions can help the nurse while interacting with the patient? reduce environmental noise and greets the patient to get the patient's attention. The nurse speaks in a normal volume and asks the patient to reduce carbohydrate intake.
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Which action would the nurse take when communicating with a patient with aphasia quizlet?
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