Exam (elaborations)
Chapter 13. NEW! Information Management
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- West Virginia School Of Osteopathic Medicine
Chapter 13. NEW! Information Management
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Chapter 13: Information ManagementMULTIPLE CHOICE
1. A new nurse is confused by the terminology used by the electronic health record (EHR).
When the nurse complains to the precepting nurse, the best explanation by the preceptor is
that this occurs because
a. many systems interact with each other and need a standardized language.
b. nursing is not the only discipline to use the EHR, so wording reflects this.
c. terminology used by the EHR is driven by financial reimbursement needs.
d. the system was designed by people in computer and information sciences.
ANS: A
The EHR uses different interconnecting modules, so it is imperative that terminology used in
each is standardized. This allows for seamless patient care delivery.
It is true that nursing is not the only discipline to use the EHR, but it is not the disciplines
themselves that use different vocabularies; it is the system each discipline uses that creates the
need for a standardized vocabulary.
Needs of the financial departments are considered when developing EHRs, but this is not the
only consideration.
The information technology side of EHR development allows for standardization of
terminology among disciplines. This is not the most inclusive answer.
DIF: Cognitive Level: Understand REF: 249
TOP: Integrated Process: Communication and Documentation
MSC: NCLEX Client Needs: Safe and Effective Care Environment: Management of Care
2. A hospital is planning to convert to an electronic health record (EHR) system. Which action
by administration would best address both legal and ethical issues related to EHRs?
a. Create consent forms that acknowledge the use of EHRs.
b. Develop policies and procedures related to patient privacy.
c. Hold public meetings to describe use of the EHR system.
d. Train the nursing staff on proper use of the EHR system.
ANS: B
Privacy is paramount to using an EHR. Federal privacy laws established under the Health
Insurance Portability and Accountability Act (HIPAA) require the development of privacy
rules for technologies that use electronic data exchange.
Merely acknowledging the use of the EHR system would not really address legal and ethical
concerns.
Public meetings might create goodwill but would not really address legal and ethical concerns
with the use of electronic records.
Training those who use the EHR is an important component of its proper use, but this does not
go far enough in addressing ethical and legal issues.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: NCLEX Client Needs: Safe and Effective Care Environment: Management of Care
3. The faculty member explains to students that the Omaha Problem Classification system
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, a. classifies problems based on their severity.
b. is designed for community health nursing.
c. helps nurses allocate resources in home health.
d. is the most complete nursing nomenclature system.
ANS: B
The Omaha Problem Classification system was designed to use with clients in community and
public health settings.
The Omaha Problem Classification system does not classify problems according to severity.
Allocation of resources is part of Saba’s Clinical Care Classification System.
Each system has uses for which it is appropriate; this system is used in community health
nursing and in that setting could be considered most complete, but it might not be complete or
even appropriate in other settings.
DIF: Cognitive Level: Understand REF: 241
TOP: Integrated Process: Communication and Documentation
MSC: NCLEX Client Needs: Safe and Effective Care Environment: Management of Care
4. A student is researching a topic for a class paper. The student would find the most information
by
a. looking for related research instruments.
b. querying a database such as the Cumulative Index to Nursing and Allied Health
Record (CINAHL).
c. reading textbook and journal indexes.
d. searching the newspaper’s online index.
ANS: B
Electronic databases such as CINAHL will provide the student access to a comprehensive set
of journals going back for many years. In these databases, the student can query key words
and phrases to find information on the topic quickly.
Although it might be important to find research articles related to the topic (depending on
what the topic is), research instruments themselves will not provide a lot of information.
Indexes are a good way to find out about the topics in a book or journal, but this is a time-
consuming process and limited to information only in that specific book or journal.
The newspaper might have information important to the student’s paper, but the information
will be limited to this one source.
DIF: Cognitive Level: Apply
TOP: Integrated Process: Communication and Documentation
MSC: NCLEX Client Needs: Safe and Effective Care Environment: Management of Care
5. A student explains to a classmate using an electronic database that the scope note describes
a. best searching strategies for this topic.
b. how far back in time the topic is covered.
c. the breadth of scope of the topic searched.
d. the definition of the term being searched.
ANS: D
The scope note contains a definition of the term being searched.
The scope note does not describe the best searching strategies for a topic.
The scope note does not describe how far back in time citations for this topic go.
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