Deck 16: Nursing Documentation

Question 1

While researching information for a paper, a nurse comes across two versions of a nursing minimum data set: one that is international and one from the United States. Which data would the nurse identify as included in international set but not included in the U.S. set? Select all that apply.

A) Training/education
B) Intensity of nursing care
C) Reason for admission
D) Nursing diagnoses
E) Nursing outcomes

Answer 1

Training/education
Reason for admission

Question 2

A nurse writes a nursing diagnosis and includes information about the etiology along with manifestations associated with that etiology. The nurse is demonstrating an understanding of:

A) Granularity.
B) Taxonomy.
C) Interface terminology.
D) Mapping.

Answer 2

Granularity.

Question 3

A nurse is reading a journal article about the different standardized terminologies used in nursing. The nurse demonstrates understanding of the information when the nurse identifies which example of an interface terminology?

A) Nursing Interventions Classification
B) USA Nursing Minimum Data Set
C) SNOMED Clinical Terms
D) Logical Observations: Identifiers, Names, Codes (LOINC)

Answer 3

Nursing Interventions Classification

Question 4

When working with the USA-Nursing Minimum Data Set (NMDS), which information would the nurse expect to see as part of data collected for nursing care?

A) Registered nurse provider
B) Admission date
C) Client disposition
D) Nursing diagnosis

Question 5

Which catalogue involving standardized terminologies for nursing was developed from a home care focus?

A) North American Nursing Diagnosis Association (NANDA) taxonomy
B) Clinical Care Classification
C) Nursing Interventions Classification
D) Nursing Outcomes Classification

Question 6

A nurse is reviewing information about the International Classification for Nursing Practice. The nurse demonstrates a need for additional review when the nurse identifies terminology related to which category as being included?

A) Nursing diagnoses
B) Nursing interventions
C) Nursing patient-sensitive outcomes
D) Outcome problem rating scale

Question 7

Based on the evolution of the development of standardized terminology adopted by the American Nurses Association (ANA), which terminology was adopted last?

A) Logical Observation Identifiers Names and Codes (LOINC)
B) The Omaha System
C) Nursing Interventions Classification System
D) Nursing Outcomes Classification System

Question 8

A nurse is reviewing information about standardized terminology. The nurse demonstrates the need for additional reading when identifying which as an interface terminology?

A) NIC
B) NOC
C) NANDA-1
D) USA-NMDS

Question 9

A nursing informatics specialist is preparing a class on electronic documentation for a group of staff nurses. As part of the class, the nurse specialist is planning to describe nursing documentation of the past. Which characteristic would the nurse specialist most likely include?

A) It focused on the multiple clients.
B) It used simplistic language.
C) It was highly sophisticated.
D) It was often archived with client records.

Question 10

An informatics nurse specialist is presenting a program about the importance of standardized terminology to provide data. The nurse specialist is describing the concept of outcomes potentially sensitive to nursing (OPSN). Which example would the nurse specialist most likely include when describing this concept? Select all that apply.

A) Pneumonia
B) Pressure ulcer
C) Normal blood glucose level ranges
D) Shock
E) Intact surgical incision

Question 11

A nurse is reading an online journal article about the development of standardized healthcare terminologies. Which statement best reflects these terminologies?

A) Efforts for standardization began in the late 20th century.
B) Client mortality and morbidity were used as the basis for early terminologies.
C) Medical, surgical, and diagnostic services are excluded from the terminologies.
D) Acute inpatient care is the focus of standardized terminology.

Question 12

A nursing informatics specialist is preparing a presentation about standardized terminologies recognized by the ANA. Which system would the nurse specialist most likely describe as the standard reference terminology for nursing documentation?

A) Clinical Care Classification
B) SNOMED CT
C) North American Nursing Diagnosis Association International
D) Perioperative Nursing Data Set

Question 13

An electronic health record uses the Logical Observations: Identifiers, Names, Codes (LOINC). The nurse understands that this terminology integrates elements from which catalogues?

A) Systematized Nomenclature of Medicine Clinical Terminology
B) Omaha System
C) North American Nursing Diagnosis Association-International
D) Alternative Billing Codes

Question 14

A nursing informatics specialist is preparing an in-service program for a group of staff nurses about standardized terminologies. As part of this program, the nurse specialist describes the detail about a term or phrase. The nurse specialist is describing which concept?

A) Granularity
B) Nomenclature
C) Mapping
D) Organization

Question 15

A nurse is reading a journal article about nursing, documentation, and nursing data. The nurse demonstrates understanding of the information when the nurse identifies which person as being the first individual for emphasizing research and data collection?

A) Florence Nightingale
B) Bertha Harmer
C) Karen Martin
D) Gloria Bulechek

Question 16

A nursing informatics specialist is preparing a presentation for a group of nursing administrators who have just begun to use electronic documentation in their facilities. The nurse specialist identifies the need to address standardized terminologies in nursing. Which information would the nurse specialist most likely include about this topic? Select all that apply.

A) Will give nursing a voice in healthcare planning
B) Will relieve nurses of the need for developing care plans
C) Will provide limited support for decision-making
D) Will help justify reimbursement
E) Will aid in improving client care policies

Question 17

A nurse manager is working on a committee that will be instituting standardized terminologies into the current electronic documentation system. When preparing to adopt and implement the new system, the nurse manager would need to be alert for which issues? Select all that apply.

A) Resistance to change
B) Temporary increase in productivity
C) Adjustment to a new way of thinking
D) Increased time for learning
E) Decreased level of accountability

Question 18

An informatics nurse specialist is discussing the use of standardized terminologies used in healthcare. As part of the discussion, the nurse specialist is describing the concept of organization. Which information would the nurse include about this concept?

A) "It refers to how one concept in one terminology matches to another concept in another terminology."
B) "Organization refers to how the terms in the terminology are structured so that they can be used."
C) "It is a grouping of related ideas into a taxonomy that is based on an underlying perspective."
D) "Organization refers to the detail or specificity of a term or a phrase being used."

Question 19

Which term would an informatics nurse specialist use to describe the matching of a term or concept in one standardized terminology to another?

A) Granularity
B) Mapping
C) Harmonization
D) Integration

Question 20

A nurse is documenting in a patient's electronic health record and enters the common phrases such as blood pressure, intact skin incision, and active bowel sounds. The system translates these common phrases into data that the computer can use. This activity reflects use of a:

A) Minimum data set.
B) Reference terminology.
C) Interface terminology.
D) Classification.