Nursing Process, Communication, Critical Thinking, HIPAA, Safe/Effective Care

subjective data

symptoms the patient tells you - nausea, dizziness

best response

the answer to the question

stem

the part of the question that asks the question

Example of a SMART goal

the patient will breathe unlabored at 14-18 bpm by the end of the shift.

Functional components - environment

the place (physical and emotional climate) the conversation is taking place

what is public communication

to/within/between large groups, teaching, community presentations, written word about healthcare topics

functional component - receiver

person listening to the message

AAPIE

Assessment, Analysis, Planning, Implementation, Evaluation

Assessment

laying eyes on patient and seeing what is wrong with them. can also get assessment from patient report from other department, patient chart, and prior history

is the primary method of sharing patient information between shifts and ensuring continuity of care

nursing handover

Assessment

what do I think the issue is? why am I concerned?

Everything we do in nursing is based upon what

Evidence based practice (EBP)

Which of the following pieces of legislation mandated the establishment of a joint Health Care Fraud and Abuse Control (HCFAC) program?

Health Insurance Portability and Accountability Act (HIPAA)

therapeutic communication

paraphrase what patient says, rephrase it and ask it back to them

charge nurse will prepare the staff allocation according to...

nurse/patient ratio, patient care needs

Therapeutic communication

purposeful use of communication to build and maintain helping relationships. needs to be client centered and not socially centered. You are not there to make friends

A nurse is providing safety instruction to the mother of a child with hemophilia and tells the mother to do which of the following to promote a safe environment for the child

remove toys with sharp edges from the toy box

bullying

repeated words or acts of intimidation

incivility

rude dialogue or actions

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?

"I will determine the most important client problems that we should address."

Situation

what is going on with the patient right now

Which of the following actions should the nurse take when demonstrating an empathic presence to a client?

Use an open posture, Establish and maintain eye contact, and sit facing the client

Part of the SBAR communication technique that entails what you can suggest or what you want to happen next

Recommendation

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

Reassess the client to determine the reasons for inadequate pain relief.

Aphasic-Receptive

means they can't interpret or receive the message

SOB

shortness of breath

Part of the SBAR communication technique that briefly describes the current situation of the patient

situation

You can do this

YES I CAN!!

Recommendation

what should we do to respond to the situation

a patient who is visibly upset says to the nurse, "I want to talk with the head nurse! No, get me the supervisor and the DON and the owner of the hospital. I am mad." What is the best response from the nurse?

"you seem very upset."

HOB

head of bed

event

client or clinical event/situation

ABC

Airway, breathing, circulation

What Personal Health Information is covered under the federal law HIPAA

Demographic information, any account numbers, diagnosis/treatments/tests, physical/mental health records

A nurse in a surgeon's office is providing a preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives?

"I plan to write that I don't want them to keep me on a breathing machine."

Response

collaboration resulting in a plan of action.

event query

asks something specific about the client or clinical event/situation

Outcomes/goals for the patient need to be

SMART

EMR

electronic medical record

functional component - channel

how the message is communicates. posture, gestures, speech, facial expressions, sign language

What is one of the keys to ensuring safety?

Effective Communication

HIPAA

Health insurance portability accountability act

Which of the following actions should a nurse take after witnessing a breach of a client's confidentiality in a provider's office?

Complete a health information privacy complaint form

What is an incidental disclosure

discussing patient information with no intention of someone overhearing it.

parts of a question

event, event query, options

the best way to communicate amongst the healthcare team

SBAR(R)

lateral violence

abusive words or actions of peers. this includes gossiping, exclusion of information, threats of harm, actual harm

your client has met the goals set for improvement of ambulatory status. What would you do now

discontinue the care plan and create another care plan for another goal

After thoracic surgery a client has two chest tubes inserted into the right pleural space that are attached to drainage systems. To promote optimal respiratory functioning, the nurse plans to implement which of the following?

encourage the client to cough and deep breathe every hour

when to use SBAR

end of shift, transferred out of unit, transferred to other hospital

Characteristics of sympathy

feelings of concern or compassion, shares emotions and becomes emotionally involved, may cause projection of personal concerns, could shut the patient down because they feel not as important

territoriality

getting floated to another floor and feeling different as a nurse. It affects communication with coworkers due to different dynamics

his/her responsibility is to ensure the compliance of the policy in his/her department

head nurse

covered entity

health plan/health care provider that transmits ANY health information in electronic form in connection with a HIPAA transaction

End of life care

hearing is the last to go

what is beneficial with intrapersonal communication

helps assess clients and situations and helps us to think critically before communicating verbally

Background

what is the background of the patient? what got us to this point?

objective data

what you observe, cannot be objected

all incoming and incoming staff nurses will make rounds to their allocated patients and ensure that the following are checked properly:

patients call bell is in reach, patient ID band, IV canula, correct IV fluid rate, operative site/dressing/drain

functional component - sender

person sending the message

Maslow's Hierarchy of Needs basic level

physiological needs - breathing, food, water, shelter, clothing, sleep, ABC's could also fit into this category

A nurse is caring for a client who states, " I have to check with my partner and see if they think I am ready to go home." The nurse replies, " How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client?

Reflecting

Disclosure

Release or Divulgence of information by an entity to people or organizations outside of that entity

A newly hired nurse is reviewing information about the HIPAA privacy Rule during facility orientation. Which of the following statements by the nurse indicates an understanding of the privacy rule?

"I can give information about a client over the phone if the client gives permission."

A nurse is teaching a newly licensed nurse about using a computer to document in a client's health record. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I should remain aware of my surroundings when documenting in the computer."

A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make?

"Your daily routines will be different when you get home.", "Tell me about the support system you'll have after you leave the hospital.", and "It sounds like you are not sure how having a colostomy will affect swimming."

A nurse in a pediatrician's office is speaking on the telephone with the guardian of a school-age child who will become a new client at the office. The nurse should instruct the guardian to call the child's previous provider's office to request which of the following?

A form authorizing release of copies of the child's medical records to be signed by the guardian

Informed Consent

a person's agreement to allow an action based on full disclosure of risks, benefits, alternatives, and consequences of refusal. Patient must be informed of all of these.

Health Information

ANY information (written or spoken) in ANY medium that is created or received by a health care provider and relates to the past, present, or future physical or mental health or condition of an individual

A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing?

Assault

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?

Assessment

A nurse from the emergency room receives a telephone call from EMS and is told that several victims who survived a plane crash that are suffering from cold exposure will be transported to the hospital. The initial nursing action of the emergency nurse is what?

Call the nursing supervisor to activate the agency disaster plan

EHR

Electron health record

The Health Insurance Portability and Accountability Act (HIPAA) mandates that health care entities implement which of the following strategies to help reduce the Medicare fee-for-service error rate and prevent payment for potentially fraudulent activity?

Electronic Health records

A client with a diagnosis of heart failure report the occurrence of sudden SOB and dyspnea. The nurse takes which immediate action?

Elevates the HOB - least invasive first

Which of the following strategies should a nurse use to establish a helping relationship with a client?

Encourage the client to communicate their thoughts and feelings.

The client with a diagnosis of cancer is receiving a morphine sulphate 10 mg subcutaneously every 3-4 hours for pain. When preparing the plan of care for the client, the nurse includes which priority action?

Encourage the client to cough and deep breathe

Which of the following is an example of a best practice strategy to prevent fraud, waste and abuse

Establish procedures for maintaining and distributing medication samples.

A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit?

False Imprisonment

When teaching UAP about the importance of handwashing in preventing disease, the nurse makes which of the following statements?

Handwashing is best for preventing cross-contamination

What three types of entities are covered by the federal law HIPAA

Health plans, healthcare clearinghouses and healthcare providers

A nurse in the emergency department is caring for a client following a motor-vehicle crash. The client is unresponsive and the client's spouse is not present at the facility. Which of the following actions should the nurse take to assist with obtaining consent for the client's surgery?

Inform the provider of the spouse's contact information so consent can be obtained over the telephone.

Protected Health Information (PHI)

Information transmitted or maintained in any form or medium, which is held by a covered entity or its business associate, an that identifies an individual or offers a reasonable basis for identification; is created or received by a covered entity or an employer, relates to a past, present, or future physical or mental condition, provision of health care, or payment for health care

A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent?

Make sure the surgeon obtained the client's consent and witness the client's signature on the consent form.

Facility directories are allowed to list what patient information based on informal permission

Name, general condition, religious affiliation, location

A client tells a nurse that they feel their privacy has been violated and wants to file a formal complaint with someone other than the medical facility. Through which of the following agencies should the nurse instruct the client to file the complaint?

Office for Civil Rights (OCR)

Which of the following agencies of the U.S. government has the authority to exclude individuals and entities from participating in federal health care programs?

Office of Inspector General. The OIG has the authority to exclude individuals and entities from federal health care programs for fraud and abuse that affects these programs or their beneficiaries.

A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take?

Report the observations to the nurse manager on the unit.

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data?

Respiratory rate is 22/min with even and unlabored respirations, the client's skin is pink/warm/dry, the assistive personnel reports that the client walked with a limp.

Is a communication technique that provides an organized logical sequence and improved communication process to ensure patient safety

SBAR

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include?

Showing a client how to use progressive muscle relaxation, performing a daily bath after the evening meal and repositioning a client every 2 hr to reduce pressure injury risk

A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take?

Sit at eye level with the child

SBAR(R)

Situation, Background, Assessment, Recommendation (Response)

A nurse overhears a provider refer a client who has Medicare to a durable medical equipment company owned by the provider's father-in-law. The nurse should identify that which of the following statutes has been violated?

Stark Law

An employee in a provider's office suspects fraudulent activity. Which of the following actions should the employee take after contacting the Office of Inspector General (OIG) Hotline to report the fraudulent activity

Stop filing the suspicious bills and claims, pursue knowledgeable legal counsel, disengage professionally with the suspected perpetrator, and report and return overpayments

A group of nurses on a clinical unit are planning to research the incidence of falls among clients following joint replacement surgery. Which of the following actions should the nurses take to ensure the study complies wit the HIPAA Privacy Rule?

Submit their proposal to the institutional review board for review and describe how they will de-identify client information.

A nurse is assigned to care for a group of clients' medical records, the nurse determines that which client is at risk for excess fluid volume?

The client with renal failure

The clinic manager wants nurses working in the unit to administer moderate sedation. To legally include this procedure in their practice, the staff nurses determine first that it is acceptable according to which source?

The nurse Practice Act

A woman has been transferred to the PP unit from L&D. She gave birth vaginally, 2 hours ago. Which of the following nursing care goals is the highest priority for the PP nurse

The woman will have moderate lochia (bleeding)

According to recent estimates, which of the following sources of health care waste has had the largest financial impact?

Unwarranted use of medical resources or services

Which of the following methods of information exchange can occur without client authorization?

Walking rounds that involve two nurses discussing an assigned client at the client's bedside in a private room

A nurse recognizes that which of the following must be supplied to a client before an informed consent can be obtained

a description of the procedure to be done, why the procedure is needed, risks associated with the procedure, possible alternative treatments that might have similar results for the client

written authorization

a document that must be signed by a patient, explains the uses and disclosures a covered entity may make without the individual's authorization as permitted by the Privacy Rule, and states that any other uses or disclosures will be made only with the individuals' written authorization.

Privacy Officer

a person appointed to receive and be responsible for complaints about privacy policies and procedures, required by HIPAA's Privacy Rule

part of the SBAR communication technique that summarize the facts and give your best assessment, what's going on, using your best judgement

assessment

Characteristics of Empathy

awareness of how the client feels/experiences, being kind, good listener, good nursing care, positively influences client outcomes and helps the patient to feel better about themselves.

part of the SBAR technique that state the pertinent history and leads what got us to this point

background

Functional components - Interpersonal variables

boundaries, barricades, barriers...things that affect communication... language issues, educational levels

parts of a multiple-choice question

case, stem, distracters, best response

before the shift endorsement the allocated nurse will...

check the patient file, make sure all physician orders are carried out, planned care is ready for intervention

what is interpersonal communication

communication between two people exchanging information. It is the most common type of communication

what is small group communication

communication with a group of people who are working toward a mutual goal. These include committees, research teams and support groups

Nonverbal communication

consists of 65% of all communication

If there is a HIPAA breach against a patient you must

notify them in writing and if more than 500 patients are involved you must notify national media

A client with a compound fracture of the radius has a cast applied in the ER. The nurse provides home-care instructions and tells the client to seek medical attention if which of the following occurs?

numbness and tingling in the fingers

its purpose is to provide framework for an effective communication among members of the healthcare team in order to ensure consistency of communication

nursing handover report policy

A nurse is planning to teach a client in skeletal leg traction about measures to increase bed mobility. Which item would be most helpful for this client?

overhead trapeze

what are the benefits of SBAR

helps everyone to understand the overall picture of the patients needs, fosters the use of clear and unambiguous language to reduce confusion and misinterpretation, provides for an ongoing dialogue so that everyone is involved with the patients care in planning/thinking ahead, improved safety for the patient

distracters

incorrect but feasible choices

the allocated nurse will?

initiate the complete report for each patient and the verbal report will reflect and reinforce appropriate information recorded in patients records

functional component - message

intended purpose for conversation

what is a purposeful disclosure

knowingly breaking HIPAA to find out and pass along patient information

unambiguous messages and expectations

make sure what we say is what we are trying to say. Don't use a lot of fluff that confuses patients. Be direct and straight to the point

options

may be multiple choice, prioritizing, sequencing

Aphasic-Expressive

means they can't speak but can still understand

A nurse assigned to care for a client experiencing dystocia. When assisting with planning care, the nurse would consider the highest priority to be frequent:

monitory for changes in the physical condition of the mother and fetus (O2 level, HR)

Functional component - Referent

motivation for conversation between two people. This could include a grade on a test or a lab value on a patient

Maslow's Hierarcy of Needs - second level

safety and security - health, employment, property, family, social stability

case

scenario - description of the patient and what is happening

Examples of Intrapersonal communication

self talk, internal discussions, it's like our personal "filter"

part of SBAR communication technique that briefly describes the current situation of the patient

situation

SBAR stands for

situation, background, assessment, recommendation

SMART

specific, measurable, attainable, relevant, time-based

pain is ________ until you put a number to it even if patient exhibits outward signs

subjective

What certain uses and disclosures do not require a patient authorization under the federal law HIPAA

treatment/payment/operations that are related to suspected child abuse and communicable diseases that are required by law with a court order

For 30 hours after the birth, the baby's temperature has remained normal. The nurse does the assessment and the temperature is significantly lower than it was 4 hours ago. The baby is lethargic, pale and does not want to breastfeed. Which of the findings from the mother's chart should the nurse consider as a possible link to the baby's behavior

what drugs the mother took in labor, if the mother is GBS positive and if she was treated with antibiotics (abx), and if the mother's membranes were ruptured and if so for how long