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.

Accepted Answer

A, C

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:

Accepted Answer

A

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?

Accepted Answer

A

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?

Accepted Answer

The USA-Nursing Minimum Data Set (NMDS) includes nursing-specific information such as nursing diagnoses, which are essential for planning and evaluating nursing care.

Question 5

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

Accepted Answer

The Clinical Care Classification (CCC) system was developed with a focus on home care, aiming to provide a standardized method for documenting nursing care across various settings, including home health care.

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?

Accepted Answer

The answer of A nurse is reviewing information about the...

Question 7

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

Accepted Answer

LOINC (Logical Observation Identifiers Names and Codes) was adopted last by the American Nurses Association (ANA) for inclusion in the recognized terminologies that support nursing practice. LOINC, primarily used for laboratory and clinical observations, was added to facilitate the exchange and pooling of results, such as laboratory tests and clinical measures, across different systems.

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?

Accepted Answer

USA-NMDS is not an interface terminology; it is a minimum data set. Interface terminologies like NIC, NOC, and NANDA-1 are used to describe nursing interventions, outcomes, and diagnoses, respectively.

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?

Accepted Answer

The answer of A nursing informatics specialist is preparing a...

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.

Accepted Answer

The answer of An informatics nurse specialist is presenting a...

Question 11

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

Accepted Answer

The answer of A nurse is reading an online journal...

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?

Accepted Answer

SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) is widely recognized as a comprehensive, multilingual clinical healthcare terminology, which includes standardized terms for nursing documentation, making it a key reference in the field of nursing informatics.

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?

Accepted Answer

The answer of An electronic health record uses the Logical...

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?

Accepted Answer

Granularity refers to the level of detail or precision used in the description of data. In the context of standardized terminologies in healthcare, granularity would relate to how detailed a term or phrase is described, which is what the nursing informatics specialist is focusing on in the scenario.

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?

Accepted Answer

Florence Nightingale is recognized as the first individual to emphasize the importance of research and data collection in nursing. She used statistical data to improve sanitation and patient care during the Crimean War, laying the foundation for evidence-based practice in nursing.

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.

Accepted Answer

Standardized terminologies in nursing are crucial for several reasons. They give nursing a voice in healthcare planning by ensuring that nursing data is accurately represented and understood across different systems and disciplines. This standardization helps in justifying reimbursement by providing clear, consistent documentation of nursing care, which can be used to demonstrate the necessity and quality of care for reimbursement purposes. Additionally, standardized terminologies aid in improving client care policies by enabling the aggregation and analysis of nursing data, which can inform policy changes and improvements in patient care practices. Contrary to relieving nurses of the need for developing care plans (B) or providing limited support for decision-making (C), standardized terminologies actually support comprehensive care planning and enhance decision-making by providing a common language for describing patient care.

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.

Accepted Answer

Resistance to change, adjustment to a new way of thinking, and increased time for learning are common issues when instituting new systems or processes in healthcare settings. These factors can affect the adoption and effective use of standardized terminologies in electronic documentation systems.

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?

Accepted Answer

Organization in standardized terminologies refers to how the terms are structured to ensure they can be effectively used within the system.

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?

Accepted Answer

Mapping is the process of matching or linking concepts in one terminology or classification system to concepts in another. This is essential in healthcare informatics for ensuring consistency and interoperability between different systems and datasets.

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:

Accepted Answer

Interface terminology allows for the translation of common clinical phrases into structured data that computers can understand and use, facilitating effective documentation and data retrieval in electronic health records.

Quiz 16: Nursing Documentation