NR 361 Week 4 Graded Discussion: Your
Patient has a PHR (Patient Health
Record) Now What?
Question 1
What is the primary purpose of using standardized nursing terminologies in the
EHR?
A. To increase the time nurses spend documenting
B. To provide a common language for nursing practice that enables data
collection, communication, and evidence-based decision-making
C. To replace the need for clinical judgment
D. To make documentation more complex
Answer: B. To provide a common language for nursing practice that enables data
collection, communication, and evidence-based decision-making
Rationale: Standardized terminologies (e.g., NANDA, NIC, NOC) provide a common,
structured language for nurses to document care. This allows for consistent data
collection, enhances communication among healthcare providers, supports evidence-
,based practice, and enables outcomes measurement. Standardized language is essential
for demonstrating the unique contribution of nursing to patient care outcomes.
Question 2
Which of the following is an example of a standardized nursing terminology?
A. NANDA-International (NANDA-I) nursing diagnoses
B. ICD-10 codes
C. CPT codes
D. DSM-5
Answer: A. NANDA-International (NANDA-I) nursing diagnoses
Rationale: NANDA-I is a standardized nursing terminology used to identify and label
nursing diagnoses. ICD-10 and CPT codes are used for medical diagnoses and billing.
DSM-5 is used for psychiatric diagnoses. SNOMED CT, LOINC, and RxNorm are other
standardized terminologies used in healthcare, but NANDA-I is specific to nursing.
Question 3
A nurse documents a patient's response to pain medication using a 0-10 pain
scale. This is an example of:
A. Narrative charting
B. Problem-oriented charting
C. Standardized terminology and assessment tool
D. Free-text documentation
Answer: C. Standardized terminology and assessment tool
Rationale: The 0-10 pain scale is a standardized assessment tool that ensures consistent
measurement and communication of pain intensity. It allows for objective tracking of
pain over time and evaluation of interventions. Standardized assessment tools are a key
component of structured EHR documentation.
, Question 4
What is the relationship between standardized nursing terminologies and
evidence-based practice (EBP)?
A. Standardized terminologies allow for aggregation of nursing data to identify
best practices and outcomes
B. Standardized terminologies replace the need for evidence-based practice
C. Standardized terminologies are unrelated to evidence-based practice
D. Standardized terminologies prevent the use of evidence-based practice
Answer: A. Standardized terminologies allow for aggregation of nursing data to
identify best practices and outcomes
Rationale: Standardized terminologies enable the collection of large datasets that can
be analyzed to identify best practices, evaluate interventions, and improve patient
outcomes. This data-driven approach supports evidence-based practice by providing
empirical evidence of what works in nursing care.
Question 5
A nurse uses the Nursing Outcomes Classification (NOC) to document patient
progress. What does NOC measure?
A. Nursing diagnoses
B. Patient outcomes sensitive to nursing interventions
C. Nursing interventions
D. Medical diagnoses
Answer: B. Patient outcomes sensitive to nursing interventions
Rationale: NOC is a standardized classification of patient outcomes that are sensitive to
nursing interventions. It provides a framework for measuring and evaluating the
effectiveness of nursing care. NOC outcomes are used in conjunction with NANDA-I
diagnoses and NIC interventions to create a complete nursing care plan.
Patient has a PHR (Patient Health
Record) Now What?
Question 1
What is the primary purpose of using standardized nursing terminologies in the
EHR?
A. To increase the time nurses spend documenting
B. To provide a common language for nursing practice that enables data
collection, communication, and evidence-based decision-making
C. To replace the need for clinical judgment
D. To make documentation more complex
Answer: B. To provide a common language for nursing practice that enables data
collection, communication, and evidence-based decision-making
Rationale: Standardized terminologies (e.g., NANDA, NIC, NOC) provide a common,
structured language for nurses to document care. This allows for consistent data
collection, enhances communication among healthcare providers, supports evidence-
,based practice, and enables outcomes measurement. Standardized language is essential
for demonstrating the unique contribution of nursing to patient care outcomes.
Question 2
Which of the following is an example of a standardized nursing terminology?
A. NANDA-International (NANDA-I) nursing diagnoses
B. ICD-10 codes
C. CPT codes
D. DSM-5
Answer: A. NANDA-International (NANDA-I) nursing diagnoses
Rationale: NANDA-I is a standardized nursing terminology used to identify and label
nursing diagnoses. ICD-10 and CPT codes are used for medical diagnoses and billing.
DSM-5 is used for psychiatric diagnoses. SNOMED CT, LOINC, and RxNorm are other
standardized terminologies used in healthcare, but NANDA-I is specific to nursing.
Question 3
A nurse documents a patient's response to pain medication using a 0-10 pain
scale. This is an example of:
A. Narrative charting
B. Problem-oriented charting
C. Standardized terminology and assessment tool
D. Free-text documentation
Answer: C. Standardized terminology and assessment tool
Rationale: The 0-10 pain scale is a standardized assessment tool that ensures consistent
measurement and communication of pain intensity. It allows for objective tracking of
pain over time and evaluation of interventions. Standardized assessment tools are a key
component of structured EHR documentation.
, Question 4
What is the relationship between standardized nursing terminologies and
evidence-based practice (EBP)?
A. Standardized terminologies allow for aggregation of nursing data to identify
best practices and outcomes
B. Standardized terminologies replace the need for evidence-based practice
C. Standardized terminologies are unrelated to evidence-based practice
D. Standardized terminologies prevent the use of evidence-based practice
Answer: A. Standardized terminologies allow for aggregation of nursing data to
identify best practices and outcomes
Rationale: Standardized terminologies enable the collection of large datasets that can
be analyzed to identify best practices, evaluate interventions, and improve patient
outcomes. This data-driven approach supports evidence-based practice by providing
empirical evidence of what works in nursing care.
Question 5
A nurse uses the Nursing Outcomes Classification (NOC) to document patient
progress. What does NOC measure?
A. Nursing diagnoses
B. Patient outcomes sensitive to nursing interventions
C. Nursing interventions
D. Medical diagnoses
Answer: B. Patient outcomes sensitive to nursing interventions
Rationale: NOC is a standardized classification of patient outcomes that are sensitive to
nursing interventions. It provides a framework for measuring and evaluating the
effectiveness of nursing care. NOC outcomes are used in conjunction with NANDA-I
diagnoses and NIC interventions to create a complete nursing care plan.
