WCU NSG 212 (Exam 1) Dr. BarkerUpdated 2024/2025 Actual Questions and answers with complete solutions

4 common issues in malpractice caused by inadequate documentation... - -Not charting the correct time when events occurred -Failing to record verbal orders or failing to have them signed -Charting actions in advance to save time -Documenting incorrect data A professional nurse must perform what portion of the nursing process? - Assessment Assessment - Gather data Assessment definition - The systematic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community Assessment involves collecting information from... - -the patient -secondary sources -interpreting information -validating the information Bloom's Domains of Learning - -Psychomotor: involves physical movement -Cognitive: involves knowledge and intellectual skills -Affective: involves emotions, feelings, values, and attitudes care plan conference - -A meeting of a group of nurses to discuss possible solutions to certain problems of a client -Allows each nurse the opportunity to offer an opinion about possible solutions -Other health care providers invited to offer expertiseChange-of-Shift reports - -"Handoff" communication -Information communicated in a consistant manner including an opportunity to ask and respond to questions -Provide basic identifying information (can be verbal, walking rounds, or audio-recorded report) -Features: two way, face to face communication, written support tools, and content in handover which captures attention -SBAR tool and verbal report Charting by Exception - -Documentation according to standards involves a check mark -Exceptions to standards described in narrative form on nurses' notes -Incorporation of flow sheets, standards of nursing care, and bedside chart forms -Chart ONLY significant findings or exceptions to norms -Use pre-printed forms and checklists Confidentiality - Disclosure of information with the patient's consent for health care purposes or when legally required Congress enacted HIPPA in what year? - 1996 Diagnosis - Identify client's health needs Does physiological or psychosocial come first in prioritizing care - Physiological Evaluation - Judge whether your actions have successfully treated or prevented the client's health problems Failure to adhere to HIPPA guidelines can result in... - Reprimand, sanction, fine, or loss of licensure by the government or state board of nursing and/or loss of employment by the employer depending on the circumstancesFocus charting (DAR) - -data (assessment phase), action (Planning and implementing phase), response (Evaluation phase) -focus on clients concerns and strengths -holistic perspective of client needs -nursing process framework for progress notes