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Inspector Cluseau
It's all a process.....
Didn't document it? It didn't happen!!
Charting, charting. charting...........
Who am I anyway?
100
Which of the following would a nurse expect to include in the assessment phase of the nursing process? a. selecting appropriate nursing interventions to assist the client to recover b. identifying difficulties within the client's family c. discussing any health care concerns or goals the client may have d. determining the client's intellectual level
What is c. discussing any health care concerns or goals the client may have
100
_________ ___________ is the second step of the nursing process, involves the analysis and synthesis of data gathered during the assessment phase to present a clinical judgment about a client's responses to actual or potential health problems or life processes
What is nursing diagnosis
100
A review of the client's care, intervention and education outcomes, client problems that either were resolved or continue, and instructions about medications, diet, activity, treatments, and follow-up to ensure that the most appropriate care was provided and to ensure all physician orders were carried out is called:
What is nursing audit
100
_____________ data is usually obtained from the client, including feelings, perceptions, and concerns.
What is subjective data
200
This assessment is usually completed when a client is admitted for health care services, includes a complete client health history and current needs assessment and provides baseline data against which changes in health status can be compared.
What is Comprehensive assessment
200
Using Maslow's hierarchy of needs to prioritize nursing diagnoses, which of these nursing diagnoses should the nurse focus on LAST? a. Airway clearance, ineffective, related to excessive secretions b. Anxiety related to unknown outcome of illness c. Coping, individual, ineffective, related to loss of independence d. Self-care deficit, feeding, related to decreased strength and endurance
What is c. Coping, individual, ineffective, related to loss of independence
200
Client documentation is important to medical researchers because it: a. confirms the care provided to the client b. determines whether clients meet criteria for a study c. satisfies legal and practice standards d. verifies the administration of tests, procedures, and treatments and confirms results
What is b. determines whether clients meet criteria for a a study.
200
If a nurse makes a mistake while charting, what action should she make:
What is Cross out the entry with a single line; then write "mistaken entry" with date, time, and initials.
200
Which of the following statements could be included in a definition of 'nursing diagnosis'? a. directly derived from pathological changes b. directly derived from client responses c. highly dependent on diagnostic test results d. purpose is to remove or modify the cause of the disease
What is b. directly derived from client responses
300
Who is the primary source of client data?
What is the client
300
Interventions initiated by the nurse and not requiring an order from another health professional are called?
What is Independent nursing interventions
300
A traditional method of nursing documentation, including descriptions of a clients status, interventions, and treatments is usually documented in the:
What is nursing progress notes
300
Which of these nursing documentation methods take an unstructured approach to documenting on the client record and often present disorganized client information? a. charting by exception and critical pathways b. computerized documentation and point-of-care charting c. narrative and source-oriented charting d. SOAP (-IE,-IER) and PIE charting
What is c. narrative and source-oriented charting
300
The person who the client would like to be, such as a good, moral, and well-respected person would be an example of:
What is ideal self
400
True or False. Client records are one of the BEST secondary sources of client information if the nurse is unable to obtain information from the client?
What is True (Secondary sources are considered to be family members, other health care providers, and medical records)
400
Which step of the nursing process involves the execution of the nursing implementations derived from the nursing care plan?
What is implementation (duh!)
400
True or False. The medical record may also contain advanced directives and signed forms that indicate a client's informed consent to procedures. There is NO legal requirement for informed consent to be written
What is True
400
When the client can consciously verbalize how he or she thinks, feels, believes, and knows how to behave in specific situations, the client is demonstrating: a. real self b. public self c. self-identity d. self-awareness
What is d. self-awareness
500
The nurse performs an initial assessment of a client's physiologic needs followed by assessment of higher-level needs. this is an example of: a. the body systems model b. functional health patterns c. the hierarchy of needs d. human response patterns
What is c. the hierarchy of needs
500
Comprehensive preprinted multidisciplinary standard plans of care for specific case situations reflecting the ideal course a treatment for the average client with the given diagnosis are called?
What is critical pathways
500
___________ ____________ are guidelines to be used only if a client cannot make medical decisions for him-or-herself.
What is Advance directives
500
What term is used when goals are not met or interventions are not performed within the established time frame while using a critical pathway?
What is Variances
500
________________ has elements in common with self-esteem and self-efficacy.
What is empowerment