978-0132574952 Chapter 15 Part 1

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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

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

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

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

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

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