Module 1-7 (MIDTERM)

Question 1

What are the purposes of organization in nursing?

Answer 1

• Safety
• Health Promotion
• Conserve time & energy
• Allows flexibility

Question 2

What are the key actions nurses must take to manage their responsibilities?

Answer 2

• Be organized (arrive on time)
• Set priorities
• Manage time
• Effectively use resources (pt independence + use staff)
• Continuously re-evaluate (be flexible)

Question 3

According to Maslow’s hierarchy, what is the 1st/2nd/3rd/4th priority in nursing?

Answer 3

1. Address Immediate threats to pt. survival
2. Address actual problems impeding comfort (pain)
3. Address potential problems
4. Plan for the future

Question 4

What factors should be considered when setting priorities in nursing?

Answer 4

• Patients status: Maslow’s Hierarchy
• Patient preferences: Involve your pt. in the plan of care
• Time available and workload: # of patients, # tasks
• Assistance available: Instructor, RN, HCA, Peer?
• Agency routine: Mealtimes? Med times? Bath day?
• Specific treatments/tests: When? How long? Prep?

These factors help tailor care to individual patient needs.

Question 5

What is the typical time frame for STAT orders?

Answer 5

(~10 min)

Question 6

What is the typical time frame for PRN medication?

Answer 6

(~15 min)

Question 7

What are the key elements needed to create a culture of collaboration in professional settings?

Answer 7

• Common Goal
• Mutual Respect
• Shared Decision Making
• Role Clarity
• Message Clarity

These elements foster teamwork and effective communication.

Question 8

What is Total Patient Care?

Answer 8

aka: Patient Allocation Method

It involves one nurse providing total care for one patient during the entire work period.

Question 9

Define Functional Nursing.

Answer 9

A task-focused model where each healthcare worker performs specific tasks (e.g., meds, vitals) for many patients, based on their scope of practice.

This model is determined by the complexity of care required.

Question 10

What is the premise of Team Nursing?

Answer 10

A model where a team leader (RN) coordinates care provided by regulated and unregulated staff to a group of patients. Team members report to the leader.

Question 11

What does Primary Nursing emphasize?

Answer 11

A patient-focued model where one RN is responsible for a patient’s care throughout their hospital stay, focusing on relationship-based, continuous care.

This model optimizes relationship-based care.

Question 12

What is the Primary Nursing Hybrid: Partnership Model?

Answer 12

An RN is paired with another nurse, allowing the RN to do semi-primary care.
This model enhances the LPN’s responsibilities due to their greater scope of practice.

Question 13

Define Patient-Centred Care.

Answer 13

A team-based approach focused on the needs of the patient rather than the department

It requires building a culture of patient-centered care.

Question 14

What is Nursing Case Management?

Answer 14

The process of coordinating health care by planning, facilitating, and evaluating interventions

The goal is to manage individuals at their maximum level of comfort and independence.

Question 15

Define a Group.

Answer 15

A group is a number of individuals assembled together or who have a unifying relationship.

Question 16

Define a Team.

Answer 16

A number of individuals who work closely together towards a common purpose and are accountable to one another

Teams have defined goals and objectives.

Question 17

What is a Manager-Led Team?

Answer 17

The manager controls the agenda, decisions, direction, and outputs of the team

This type of team is typically more directive.

Question 18

What is a Self-Managing Team?

Answer 18

The manager sets the overall direction, while team members determine strategies to achieve goals

This team has more autonomy in decision-making.

Question 19

Define a Self-Directed Team.

Answer 19

Team members determine direction and strategies to achieve identified outcomes

Often functions in quality improvement initiatives.

Question 20

What is an Interdisciplinary Team?

Answer 20

Composed of members from different clinical disciplines who may or may not collaborate closely

Common in hospital settings for complex patient care.

Question 21

What is an Interprofessional Team?

Answer 21

Different healthcare disciplines working together towards a common goal for patient care

Team members divide work based on their scope of practice.

Question 22

Define an Intraprofessional Team.

Answer 22

A team composed of different nurses collaborating with one another

This type of team focuses on nursing practices.

Question 23

Define a Self-Governing Team.

Answer 23

This team is a collection of individuals who come together to create something new or address an opportunity or challenge. The team determines appropriate membership, sets its own direction, defines the outcomes, and then manages the team performance and outcomes

Question 24

What is the Nursing Process?

Answer 24

• A problem solving approach that reflects a systematic and logical method of care planning and promotes individualized nursing care.
• It is a way to identify patient problems and assists the nurse to prioritize them.
• The Nursing Process utilizes components of critical thinking in each of its 5 steps.

It helps identify patient problems and assists the nurse in prioritizing them.

Question 25

List the **5 Steps of the Nursing Process**.

Answer 25

* Assessment * Diagnosis * Planning * Implementation * Evaluation ## Footnote ADPIE

Question 26

What is involved in the **Assessment** step of the Nursing Process?

Answer 26

* Collection and interpretation of clinical info * Patient’s health & response to illness * Identifying problems & strengths ## Footnote Data is collected from varied sources including interviews and assessments.

Question 27

What types of data are collected during the **Assessment** step?

Answer 27

* Subjective Data * Objective Data * Physiological Data * Psychosocial Data ## Footnote Each type of data provides different insights into the patient's health status.

Question 28

Define **Subjective Data**.

Answer 28

Patient’s **verbal descriptions** of their health problems

Question 29

Define **Objective Data**.

Answer 29

Observations & measurements of patient’s health status

Question 30

What is a **Nursing Diagnosis**?

Answer 30

A statement of a health problem that a nurse is licensed to treat ## Footnote It involves therapeutic decisions and accountability for outcomes.

Question 31

What is NOT a **Nursing Diagnosis**?

Answer 31

* A medical diagnosis * A diagnostic test * A piece of equipment * A problem with equipment * A nurse’s problem with a patient * A nursing goal ## Footnote Nursing diagnoses focus on patient responses, not medical conditions.

Question 32

Differentiate between **Actual Diagnosis** and **Potential Diagnosis**.

Answer 32

* Actual Diagnosis: Actual problem, what's causing the problem, the evidence * Potential Diagnosis: At risk for problem, contributing factors, does not include evidence

Question 33

What is a **Medical Diagnosis**?

Answer 33

Identification of a disease condition based on evaluation of signs, symptoms, medical history, and diagnostic tests ## Footnote This is distinct from nursing diagnoses which focus on patient responses.

Question 34

What does **Planning** involve in the Nursing Process?

Answer 34

Setting mutually defined, achievable, measurable goal(s) ## Footnote Goals are based on a Nursing Diagnosis.

Question 35

What are **S.M.A.R.T. Goals**?

Answer 35

* Specific * Measurable * Achievable * Relevant * Timely ## Footnote These criteria help in setting effective nursing goals.

Question 36

Critical Thinking that Lead to **Innovative Improvements**? Anita Dorr: Sisters Teri Barton-Salinas and Gail: Barton-Hay:

Answer 36

Anita Dorr: Invented the emergency crash cart for fast access Sisters Teri Barton-Salinas and Gail: Developed the FACES Pain Rating Scale Barton-Hay: Created a womb-mimicking mat to sooth preemies and colicky babies

Question 37

Define **Physiological Data**.

Answer 37

Patient’s needs of their physical body (ie. air, water, food, sleep, intact skin)

Question 38

Define **Psychosocial Data**.

Answer 38

Patient’s needs of their mental well being related to autonomy, competence and relatedness (ie. ability to complete self-care, healthy body image, or, anxiety, social isolation, hopelessness)

Question 39

What are the 3 types of interventions in **Implementation** in the Nursing Process?

Answer 39

**1.** Independent nursing interventions: done by the nurse without a doctor’s order **2.** Dependent nursing interventions: requires a physician’s order **3.** Collaborative interventions (interdependent): nvolve working with other healthcare professionals

Question 40

What does **Evaluation** involve in the Nursing Process?

Answer 40

Continuously assess patient response to nursing Assess goal achievement: Goal met/ Goal partially met / Goal not met If goal not met: Make revisions as needed

Question 41

Define **Assertiveness**.

Answer 41

* Honest * Direct * Empathetic

Question 42

Define **Aggressive** communication.

Answer 42

* Blaming * Controlling

Question 43

Define **Passive-Aggressive** behavior.

Answer 43

* Self-enhancing at the expense of others

Question 44

Define **Passive** communication.

Answer 44

* Self-denying * Blaming * Apologetic

Question 45

What is **Attribution of blame**?

Answer 45

Assigning fault for a problem ## Footnote This can hinder effective communication and conflict resolution.

Question 46

Define **Placation**.

Answer 46

Over apologetic, keeping the peace ## Footnote This approach may avoid conflict but does not address underlying issues.

Question 47

What is **Constrained cool-headedness**?

Answer 47

Reduced ability to express or respond emotionally

Question 48

What does **Irrelevant** communication involve?

Answer 48

Avoiding the issue, changing the subject ## Footnote This can lead to misunderstandings and unresolved conflicts.

Question 49

Define **Congruence** in communication.

Answer 49

What someone says, feels, and shows are consistent and aligned

Question 50

**Conflict Management Styles** Avoidance: Accommodation: Competition: Compromise: Collaboration:

Answer 50

Avoidance: Withdrawn, postpone conflict Accommodation: Smooth over conflict Competition: Domination, agression Compromise: Each party gives a little Collaboration: Working together

Question 51

What are the components of **assertive communication**?

Answer 51

* Say 'no' * Ask for what you want * Appropriately express thoughts and feelings * Initiate, continue, and terminate interaction ## Footnote These skills help in maintaining healthy relationships.

Question 52

Define **Conflict**.

Answer 52

Disagreement arising from differences in attitudes, values, or needs

Question 53

Define **Overt**

Answer 53

Observable behavior or verbal expression

Question 54

What are the **stages of anger**?

Answer 54

* Mild: Feels some tension, irritability. Acts argumentative, sarcastic, or is difficult to please. * Moderate: Observably angry behaviors such as motor agitation and loud voice. * Severe: Shows acting out behaviors, cursing, using violent gestures but not yet out of control. * Rage: Behaving is an out-of-control manner, physically aggressive towards others or self.

Question 55

What are the steps in **conflict management with patients**?

Answer 55

* Be prepared for conflict * Identify the nature and context * Acknowledge patient’s thoughts and feelings * Recognize own feelings * Employ tension-reducing activities * Use assertiveness skills * Acknowledge conflict and involve all parties ## Footnote These steps promote effective resolution and understanding.

Question 56

Define the **Avoidance** conflict management style.

Answer 56

* Distance from patients * Withdraw due to discomfort * Picking battles * Postponing conflict ## Footnote This style can lead to future problems and relationship damage.

Question 57

Define the **Accommodation** conflict management style.

Answer 57

* Suffer needs to smooth over conflict * Cooperative but non-assertive * Maintains peace but doesn't deal with the issue ## Footnote This style is appropriate when the issue is more important to the other person.

Question 58

Define the **Competition** conflict management style.

Answer 58

* Characterized by domination * Exercise power at the expense of others * Aggression and lack of compromise ## Footnote This style can increase stress and conflict.

Question 59

Define the **Compromise** conflict management style.

Answer 59

* Each party gives a little and gains a little * Effective when both sides hold equal power * Can lead to dissatisfaction ## Footnote This style may result in an 'I lose, you lose' situation.

Question 60

Define the **Collaboration** conflict management style.

Answer 60

* Solution-oriented response * Work together cooperatively * Directly confront issues * Open communication ## Footnote This style aims for mutually agreeable solutions and satisfies everyone.

Question 61

Define **Covert**

Answer 61

Behavior or issue is hidden/buried

Question 62

What is **Documentation**?

Answer 62

Documentation includes any written and/or electronically generated information about a client that describes the care or service provided to that client.

Question 63

List the **purposes of patient records**.

Answer 63

* Communication & Care Planning * Legal Documentation * Education * Funding & Resource Management * Research * Auditing & Monitoring (Quality Review) ## Footnote Each purpose serves a critical role in healthcare delivery and management.

Question 64

What does **Legal Documentation** in patient records demonstrate?

Answer 64

* Accountability for practice * It serves as the best defense against legal claims, emphasizing that care not documented is care not given. “Care not documented is care not given”

Question 65

What does **Funding & Resource Management** in patient records indicate?

Answer 65

* Shows how health care resources have been used * Level of acuity of patient indicates the type and amount of resources requires

Question 66

What does **Research** in patient records indicate?

Answer 66

* Provides data for statistical purposes and analysis Examples include rates of infection post-surgery and rates of recovery.

Question 67

What is the purpose of **Quality Review** in patient records?

Answer 67

* Evaluation of the quality & appropriateness of care * Audit charts (multidisciplinary) * Deficiencies are shared with care team so new policies or practices can be introduced

Question 68

List the **guidelines for quality documentation**.

Answer 68

* Factual Information * Accurate * Complete * Current * Organized * Complies with Standards ## Footnote These guidelines ensure effective and reliable documentation.

Question 69

What is meant by **Factual Information** in documentation?

Answer 69

Descriptive, objective data ## Footnote Inferences without supporting data are unacceptable.

Question 70

What does **Accurate** documentation require?

Answer 70

Accurate & specific times, amounts, sizes, descriptions & responses ## Footnote Use acceptable abbreviations and agency policy.

Question 71

What does **Complete** documentation entail?

Answer 71

Comprehensive and paints a clear picture of patient status ## Footnote It should include timely entries recorded at the time of occurrence.

Question 72

What does **Current** documentation mean?

Answer 72

Timely entries recorded as soon as possible ## Footnote Vital signs, medication administration, and changes in status must be documented immediately.

Question 73

What does **Organized** documentation involve?

Answer 73

Logical order of notes: Data, Action, Response, Plan ## Footnote Writing notes on scrap paper first can help structure documentation.

Question 74

What does it mean to **Comply with Standards** in documentation?

Answer 74

Each page has patient name & ID, date, time, signature, and no blank spaces ## Footnote Proper use of abbreviations and corrections of errors is essential.

Question 75

What is **Narrative Charting**?

Answer 75

* Traditional method using a story-like format to document patient conditions Would mostly be used in mental health ## Footnote It can be time-consuming and difficult to find specific data.

Question 76

What is the focus of **Focus Charting**?

Answer 76

Current patient concern, change in condition, significant event

Question 77

What does **DATA** in Focus Charting include?

Answer 77

Subjective and/or objective info supporting the stated focus ## Footnote Example: Quarter-sized reddened area noted to coccyx.

Question 78

What is documented under **ACTION** in Focus Charting?

Answer 78

What was done in response to the data ## Footnote Example: Area cleansed with bath wipe and barrier cream applied.

Question 79

What does **RESPONSE** in Focus Charting describe?

Answer 79

Impact of actions on patient outcome ## Footnote Example: Pain dissipated to 0/10 once repositioned.

Question 80

What is included in the **PLAN/EXPECTED** of Focus Charting?

Answer 80

Future actions/interventions related to the focus ## Footnote Example: Turn patient & monitor coccyx Q2H.

Question 81

What does **SBAR** stand for?

Answer 81

* Situation * Background * Assessment * Recommendation

Question 82

What does **SOAP** stand for?

Answer 82

* Subjective * Objective * Assessment * Plan

Question 83

What does **Communication & Care Planning** in patient records demonstrate?

Answer 83

* All HCT members communicate pt. needs, progress, care, treatments and education * Ensure consistency & continuity of care * Reflects the nursing process * Provides baseline data

Question 84

What does **Education** in patient records demonstrate?

Answer 84

* Nurses & students can learn about illness and patterns of behavior * Enables students to see patterns & types of care provided/needed

Question 85

Items that must be **documented immediately**?

Answer 85

* Vital Signs * Administration of meds * Treatments * Prep for tests/surgery * Change in status & associated treatments * Admission, discharge, birth, death

Question 86

**Notes are categorized by**?

Answer 86

DARP: Data, Action, Response, Plan.

Question 87

What are the **4Ps of Personalized Health Care**?

Answer 87

* Predictive * Preventive * Personalized * Participatory ## Footnote These elements focus on individual patient care.

Question 88

What is the difference between **EHR** and **EMR**and **EPR**?

Answer 88

* EHR: Portable across providers (EHRs are more comprehensive than EMRs) * EMR: Clinic or office-based record of patient visits * EPR: Facility-based electronic records used in hospitals and long-term care.