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Hebda, Handbook of Informatics, 5/e Test Bank
Chapter 15
Question 1
Type: MCSA
Which of the following terms is defined as structured and controlled languages that have been developed
according to terminology development guidelines?
1. Standardized terminologies
2. Health care standards
3. Health care terminology
4. Health information standards
2006).
Rationale 2: Standardized terminologies are structured and controlled languages that have been developed
according to terminology development guidelines and have been approved by an authoritative body (HIMSS,
2006).
Rationale 3: Standardized terminologies are structured and controlled languages that have been developed
according to terminology development guidelines and have been approved by an authoritative body (HIMSS,
2006).
Rationale 4: Standardized terminologies are structured and controlled languages that have been developed
according to terminology development guidelines and have been approved by an authoritative body (HIMSS,
2006).
Global Rationale:
Cognitive Level: Remembering
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Communication and Documentation
Learning Outcome:
Question 2
Type: MCSA
The use of which of the following is a means of ensuring the data collection is accurate and valid?
Hebda, Handbook of Informatics, 5/e Test Bank
Copyright 2012 by Pearson Education, Inc.
1. Standardized terminology
2. Tablets
3. Bar coding
4. Handheld devices
Question 3
Type: FIB
The use of standardized nursing terminology will result in better ______________________ among the
interdisciplinary team.
Hebda, Handbook of Informatics, 5/e Test Bank
Copyright 2012 by Pearson Education, Inc.
Standard Text:
Correct Answer: communication
Rationale : The use of coded standardized terminology for nurses is vital to bedside nursing and to the nursing
profession. It is essential because it enables consistent use of terminologies across clinical settings and specialists.
The use of standardized nursing terminology will result in better communication to the interdisciplinary team,
increase the visibility of nursing interventions, enhance data collection used to evaluate and analyze patient care
outcomes, and support greater adherence to standards of care. Further, the use of standardized nursing
terminology can be used to assess nursing competency. Health care facilities are required to demonstrate the
competency of staff for the Joint Commission. The nursing interventions delineated in standardized terminologies
can be used as a means by which to assess nurse competency in the performance of these interventions
(Rutherford, 2008).
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Communication and Documentation
Learning Outcome:
Question 4
Type: MCMA
The American Nurses Association established criteria for recognizing standardized terminologies. The
terminologies must meet established criteria to be approved. Which of the following are instrumental in the
approval process?
Standard Text: Select all that apply.
1. Outcome identification
2. Diagnosis
3. Problem solving
4. Decision making
5. Nursing process data elements
Question 5
Type: MCMA
Which of the following terminologies have been approved by the American Nurses Association?
Standard Text: Select all that apply.
1. Nursing Management Minimum Data Set (NMMDS)
2. Nursing Minimum Data Set (NMDS)
3. Alternative Billing Codes (ABC Codes)
4. Clinical Care Classification (CCC)
5. North American Nursing Diagnosis International (NANDA-I)
Question 6
Type: MCSA
Which of the following is a nursing classification designed to document the six steps of the nursing process across
the care continuum?
1. International Classification of Nursing Practice (ICNP)
2. NANDA International Nursing Diagnoses
3. NANDA-I Taxonomy II
4. Clinical Care Classification (CCC) System
Question 7
Type: MCMA
Terminologies can be incorporated within the electronic health record (EHR) thereby improving practice. Which
of the following are considered uses for this technology in health care?
Standard Text: Select all that apply.
1. Classification
2. Reference
3. Point of care
4. Coding
Hebda, Handbook of Informatics, 5/e Test Bank
Copyright 2012 by Pearson Education, Inc.
5. Denial of claims
Question 8
Type: FIB
______________________________ is a globally recognized controlled health care vocabulary that provides a
common language for electronic health applications.
Standard Text:
Correct Answer: SNOMED CT
Hebda, Handbook of Informatics, 5/e Test Bank
Copyright 2012 by Pearson Education, Inc.
Rationale : SNOMED CT is a globally recognized controlled health care vocabulary that provides a common
language for electronic health applications. SNOMED CT is SNOMED CT enables a consistent way of capturing,
sharing, and aggregating health data across specialties and sites of care. The use of SNOMED CT within
electronic health records provides interoperable data collection that can be analyzed and used in the
implementation of evidence-based practice, decision support rules, reporting of quality measures and
administrative billing.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Communication and Documentation
Learning Outcome:
Question 9
Type: MCSA
The ANA has recognized the Omaha System and integrated the terminology into SNOMED CT. Which of the
following best represents the value of the Omaha System?
1. The Omaha System is a problem classification scheme.
2. The Omaha System offers outcome labels.
3. The Omaha System provides nursing diagnoses.
4. The Omaha System provides diagnoses and intervention.
Question 10
Type: MCSA
During the orientation to the renal oncology unit, the head nurse demonstrated the usefulness of the Clinical Care
Classification (CCC) System. Throughout the demonstration, the head nurse discussed the value of the system to
patient care. Which of the following statements best reflects the usefulness of CCC?
1. The Clinical Care Classification (CCC) System facilitates the collection and dissemination of lab values.
2. The Clinical Care Classification (CCC) System offers improved outcomes.
3. The Clinical Care Classification (CCC) System facilitates patient care documentation at the bedside.
4. The Clinical Care Classification (CCC) System discloses standardized nursing terminologies.
Hebda, Handbook of Informatics, 5/e Test Bank
Copyright 2012 by Pearson Education, Inc.
Question 11
Type: MCSA
Which of the following can be used to document the elements of the nursing process within the care plan?
1. The Omaha System
2. The PeriOperative Nursing Data Set
3. Personal health record
4. NANDA-I
Question 12
Type: FIB
_______________________________________ is standardized classification of interventions that describes the
activities that nurses perform.
Standard Text:
Hebda, Handbook of Informatics, 5/e Test Bank
Copyright 2012 by Pearson Education, Inc.
