RNSG 1125 EXAM QUESTIONS AND ANSWERS A+
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Intrapersonal communication
Self-talk. Analyze, be thinking what I can do better for this patient. What could I have
done?
Interpersonal communication
Communication between two people. A sender and a receiver and a message in
between.
Therapeutic communication
Verbal and nonverbal communication techniques that encourage patients to express
their feelings and to achieve a positive relationship.
Nonverbal communication
communication using body movements, gestures, and facial expressions rather than
speech
Advocacy
-Protection and support of another's rights. Promoting dignity and well-being.
-Make sure your loyalty to your employer does not compromise your primary
commitment to your patient.
Care coordination
Using the nursing process to develop a plan of care for the patient using
interdisciplinary care teams working together to achieve optimal health for the patient.
Care transition
The movement patients make between health care practitioners and settings as their
condition and care need to change during the course of an illness. The goal is to avoid
complications and readmissions.
Discharge planning
Starts at admission!
We as care coordinators start this process.
Begins with first assessment of patient. Finding out health history and home
environment. Their strengths and weaknesses. We education patients and families
using teach back method for home care for their diagnosis.
Admission
Nurse responsible for ensuring patient safety, comfort, and wellbeing upon arrival. We
set up the room for patient needs. We welcome that patient to the room as they arrive.
Introduce ourselves and explain what is about to happen:
-Medication reconciliation (last dose taken)
-Valuables & belongings
-Admission questionnaire (smoke, alcohol, flu shot)
-Ask about advanced directive
-Head to toe assessment
-Confirm ID bands
-Allergies
-Code status
,REMEMBER WE ARE ASSESSING FOR DISCHARGE NEEDS
Patient leaving AMA
Patient has the right to leave at any time. They must be education on the complications
and consequences of leraving AMA and if they still want to go they must first sign
papers and get IV removed before leaving. This released the hospital and MD of any
liability. If they have insurance, the insurance company WILL NOT pay for readmission.
Focused charting
Used for narratives. It can include patients' strength, problem, or need. Focus on the
patient's needs, what we did for that need, and the response:
-patient concerns, behaviors, therapies, changes in condition
-significant events such as teaching, consultations, monitoring, ADLs management,
assessment of functional health problems
Narrative Format Examples:
DAR= Data-Action-Response
PIE= Problem-Intervention-Evaluation
SOAP=Subjective data-Objective data-Assessment-Plan
Incident Reporting
-Tools used to document anything out of the ordinary that has the potential to cause
harm to a patient, employee, or visitor.
-Not used for disciplinary purposes but for quality control to see if the event could be
prevented from occurring again. To identify risk.
-Should NEVER be noted in the official patient chart
Incident Report Includes
-Names of all involved
-Names of witnesses
-Complete facts of the incident
-Date, time, and place of incident
-Characteristics of the person involved (alert, ambulatory, asleep, etc.)
-Any equipment involved
-Any resources used
Health Information and Privacy
All information regarding a patient is considered confidential, this includes:
-Patient Name
-Address
-Telephone number
-Email address
-Social Security Number
-Treatments patient receives
-Past health history
HIPPA rights of patients
-To see a copy of health record
-To update their health record
-To request correction of any mistakes
-To get list of disclosures a health care institution has made independent of disclosures
, made for treatment, payment, and health care operations
-To request a restriction on specific uses or disclosures
-To choose how to receive health information
HIPPA Authorization Rule
Items allowed to be disclosed without prior authorization from the patient. Otherwise, if
health facility wants to release PHI for treatment, payment, or routine health care
purposes, the patient must sign an authorization.
Patient Confidentiality
All patients have a right to privacy and all information should remain privileged. Discuss
patient information only with the patient's physician or office personnel that need certain
information to do their job. Obtain a signed consent form to release medical information
to the insurance company or other individual.
Nursing Roles and Responsibilities
-Caregiver
-Advocate
-Teacher/Educator
-Communicator
-Leader
-Counselor
-Researcher
-Collaborator
Nursing Competencies: Personal Attributes
-Open minded
-A profound sense of the value of the person
-Self-awareness and knowledge of own beliefs
-Sense of personal responsibility for your actions
-Motivation to do what you need to do to the best of your ability because you care about
the well-being of those entrusted to your care
-Leadership skills
-Bravery to "question the system"
Nursing Competencies: Evidence-based Practice
-Cognitive
-Technical
-Interpersonal
-Ethical/Legal
The ability to use these creatively and critically when working with the patient to restore
health. We must develop critical thinking skills meaning being able to make a judgement
about a particular patient or situation or how best to intervene.
Proper Documentation: Content
-Complete, accurate, concise, and factual
-No interpretations, actual findings only
-No generalizations like "good"
-Problems in order of sequence
-Any precautions or preventions
-MD response to questionable orders (time, date, facts)
GRADED. Buy Quality Materials!
Intrapersonal communication
Self-talk. Analyze, be thinking what I can do better for this patient. What could I have
done?
Interpersonal communication
Communication between two people. A sender and a receiver and a message in
between.
Therapeutic communication
Verbal and nonverbal communication techniques that encourage patients to express
their feelings and to achieve a positive relationship.
Nonverbal communication
communication using body movements, gestures, and facial expressions rather than
speech
Advocacy
-Protection and support of another's rights. Promoting dignity and well-being.
-Make sure your loyalty to your employer does not compromise your primary
commitment to your patient.
Care coordination
Using the nursing process to develop a plan of care for the patient using
interdisciplinary care teams working together to achieve optimal health for the patient.
Care transition
The movement patients make between health care practitioners and settings as their
condition and care need to change during the course of an illness. The goal is to avoid
complications and readmissions.
Discharge planning
Starts at admission!
We as care coordinators start this process.
Begins with first assessment of patient. Finding out health history and home
environment. Their strengths and weaknesses. We education patients and families
using teach back method for home care for their diagnosis.
Admission
Nurse responsible for ensuring patient safety, comfort, and wellbeing upon arrival. We
set up the room for patient needs. We welcome that patient to the room as they arrive.
Introduce ourselves and explain what is about to happen:
-Medication reconciliation (last dose taken)
-Valuables & belongings
-Admission questionnaire (smoke, alcohol, flu shot)
-Ask about advanced directive
-Head to toe assessment
-Confirm ID bands
-Allergies
-Code status
,REMEMBER WE ARE ASSESSING FOR DISCHARGE NEEDS
Patient leaving AMA
Patient has the right to leave at any time. They must be education on the complications
and consequences of leraving AMA and if they still want to go they must first sign
papers and get IV removed before leaving. This released the hospital and MD of any
liability. If they have insurance, the insurance company WILL NOT pay for readmission.
Focused charting
Used for narratives. It can include patients' strength, problem, or need. Focus on the
patient's needs, what we did for that need, and the response:
-patient concerns, behaviors, therapies, changes in condition
-significant events such as teaching, consultations, monitoring, ADLs management,
assessment of functional health problems
Narrative Format Examples:
DAR= Data-Action-Response
PIE= Problem-Intervention-Evaluation
SOAP=Subjective data-Objective data-Assessment-Plan
Incident Reporting
-Tools used to document anything out of the ordinary that has the potential to cause
harm to a patient, employee, or visitor.
-Not used for disciplinary purposes but for quality control to see if the event could be
prevented from occurring again. To identify risk.
-Should NEVER be noted in the official patient chart
Incident Report Includes
-Names of all involved
-Names of witnesses
-Complete facts of the incident
-Date, time, and place of incident
-Characteristics of the person involved (alert, ambulatory, asleep, etc.)
-Any equipment involved
-Any resources used
Health Information and Privacy
All information regarding a patient is considered confidential, this includes:
-Patient Name
-Address
-Telephone number
-Email address
-Social Security Number
-Treatments patient receives
-Past health history
HIPPA rights of patients
-To see a copy of health record
-To update their health record
-To request correction of any mistakes
-To get list of disclosures a health care institution has made independent of disclosures
, made for treatment, payment, and health care operations
-To request a restriction on specific uses or disclosures
-To choose how to receive health information
HIPPA Authorization Rule
Items allowed to be disclosed without prior authorization from the patient. Otherwise, if
health facility wants to release PHI for treatment, payment, or routine health care
purposes, the patient must sign an authorization.
Patient Confidentiality
All patients have a right to privacy and all information should remain privileged. Discuss
patient information only with the patient's physician or office personnel that need certain
information to do their job. Obtain a signed consent form to release medical information
to the insurance company or other individual.
Nursing Roles and Responsibilities
-Caregiver
-Advocate
-Teacher/Educator
-Communicator
-Leader
-Counselor
-Researcher
-Collaborator
Nursing Competencies: Personal Attributes
-Open minded
-A profound sense of the value of the person
-Self-awareness and knowledge of own beliefs
-Sense of personal responsibility for your actions
-Motivation to do what you need to do to the best of your ability because you care about
the well-being of those entrusted to your care
-Leadership skills
-Bravery to "question the system"
Nursing Competencies: Evidence-based Practice
-Cognitive
-Technical
-Interpersonal
-Ethical/Legal
The ability to use these creatively and critically when working with the patient to restore
health. We must develop critical thinking skills meaning being able to make a judgement
about a particular patient or situation or how best to intervene.
Proper Documentation: Content
-Complete, accurate, concise, and factual
-No interpretations, actual findings only
-No generalizations like "good"
-Problems in order of sequence
-Any precautions or preventions
-MD response to questionable orders (time, date, facts)
