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Nursing Fundamentals

Legal and Ethical Aspects of Nursing Communication Vital Signs Nursing Process Documentation
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What are the 2 basic categories of law

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Which type of law affects society in general or as a whole

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Spoken or written statements made maliciously and on purpose that may injure a person's reputation

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A malicious or untrue writing about a person brought to other's attention

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Malicious or untrue spoken words about another person

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Voice, Eye Contact, Physical Appearance, Gestures and Posture are types of what kind of communication

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What are the 3 styles or types of communication

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What is one of the most difficult therapeutic communication skill to master

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Lip Reading, Sign Language, Word or Picture Cards and Communication Boards are all examples of what

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18 inches to 4 feet away from a person comprises what zone

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Vital signs include what

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What is the normal/average rate of respiration for an older adult

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When taking a temperature with a tympanic thermometer, where would it be placed

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What is the normal/average pulse rate for an adult

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What does the apical pulse represent

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What are the 5 steps involved in the nursing process

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What is another term for subjective data

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What is another term for objective data

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When performing an assessment, grouping related cues together is called

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What are the 4 main types of nursing diagnoses

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The form on the chart where the nurse records their observations, care given and patient's responses

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Methods of Recording Data

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In what year did Congress pass The Health Insurance Portability and Accountability Act (HIPAA)

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Who owns the original copy of a patient's medical record

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Which accreditation agency specifies guidelines for documentation

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Criminal and Civil
Criminal
Defamation
Libel
Slander
Nonverbal
Assertive, Unassertive and Aggressive
Listening
Alternative Methods of Communication
The Personal Zone
Temperature, Pulse, Respirations, BP and Pain Level
12-18 per minute
Ear
60-100 per minute
The actual beating of the heart
Assess, Diagnose, Plan and Identify Outcomes, Implement and Evaluate
Symptoms
Signs
Data Clustering
Actual, Risk, Syndrome and Wellness
Nursing Notes
Traditional Charting, Problem-Oriented Medical Record (POMR), Focus Charting Format and Charting by Exception
1996
The physician or institution
The Joint Commision (TJC)





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