Question 1

A classification system is used to categorize the details of the clinical encounter. Which of the following does a classification system not do?

Accepted Answer

Classification systems are designed for aggregating data for various purposes such as determining costs, outcomes, and reporting health statistics, rather than capturing the detailed documentation of specific items at the point of care. This level of detail is typically managed by coding systems.

Question 2

The impact of standardized terminology throughout the U.S. health care system has grown exponentially. Medicare and Medicaid have begun to offer financial incentives to health care providers to promote adoption and meaningful use of interoperable health information systems and a qualified health record. Which of the following statements best describes meaningful use?

Accepted Answer

Meaningful use refers to the use of certified electronic health record (EHR) technology in a way that improves the quality, safety, and efficiency of patient care. The goal is to exchange clinical structured data in a manner that is accurate and complete to improve patient care in a cost-efficient way. This includes using EHRs to capture and share patient information, implementing clinical decision support tools, and engaging patients in their own care. Medicare and Medicaid incentive programs encourage providers to adopt and demonstrate meaningful use of certified EHR technology.

Question 3

Which of the following is a nursing classification designed to document the six steps of the nursing process across the care continuum?

Accepted Answer

The Clinical Care Classification (CCC) System is a nursing classification designed to document the six steps of the nursing process across the care continuum. The International Classification of Nursing Practice (ICNP) and NANDA International Nursing Diagnoses are classifications for nursing diagnoses, while NANDA-I Taxonomy II is another version of NANDA nursing diagnoses, none of which necessarily document the six steps of the nursing process across care continuum.

Question 4

Gonzalez is scheduled to undergo a hip replacement after he slipped on an icy step. During the preoperative phase, the nurse begins to enter the assessment findings into the database. Which of the following standardized terminologies will the nurse most likely use?

Accepted Answer

The PeriOperative Nursing Data Set (PNDS) is specifically designed for the preoperative, intraoperative, and postoperative phases of surgery. It includes standardized terminology for assessment, interventions, and outcomes related to surgical care. The Omaha System is a general purpose terminology system used in community health settings. NANDA-I and ICNP are both nursing diagnosis classification systems, but they do not specifically address perioperative care.

Question 5

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?

Accepted Answer

The American Nurses Association (ANA) recognizes standardized terminologies that are crucial for documenting nursing care across settings. These terminologies must support outcome identification, diagnosis, and include nursing process data elements. Outcome identification is essential for evaluating patient progress. Diagnosis is necessary for identifying patient problems that nursing care can address. Nursing process data elements ensure that the terminology can capture the full scope of nursing care, from assessment through evaluation. Problem solving and decision making, while important in nursing, are not specifically mentioned as criteria for terminology approval by the ANA.

Question 6

The use of which of the following is a means of ensuring the data collection is accurate and valid?

Accepted Answer

Using standardized terminology ensures that all data collected is clearly defined and understood in the same way by all individuals involved in the data collection process. This helps eliminate confusion and inconsistencies in data collection, which can lead to inaccurate and invalid results. While tablets, barcoding, and handheld devices may also be useful tools in data collection, they do not directly address the issue of ensuring accuracy and validity of the data being collected.

Question 7

Standard terminologies have been scientifically investigated for their effectiveness and impact on patient care. The use of standard terminologies can, therefore, facilitate the use of which of the following?

Accepted Answer

The use of standard terminologies facilitates evidence-based practice and decision support rules. Standard terminologies help standardize clinical data and make it easier to analyze and make decisions based on that data. This, in turn, supports evidence-based practice and decision support rules. Multiple support languages, consumer informatics, and computer literacy may also be facilitated by the use of standard terminologies, but they are not directly related to the impact on patient care.

Question 8

______________________________ is a globally recognized controlled health care vocabulary that provides a common language for electronic health applications.

Accepted Answer

The answer of ______________________________ is a globally recognized controlled health...

Question 9

Which of the following answers depicts the use of the ANA recognized nursing classifications to codify data?

Accepted Answer

The ANA recognized nursing classifications are used to codify data during the nursing process, such as assessments, problems, interventions, and outcomes. This ensures that the nursing data is accurately captured and can be easily retrieved when needed. The other options do not accurately depict the use of ANA recognized nursing classifications.

Question 10

Which of the following terminologies have been approved by the American Nurses Association?

Accepted Answer

The American Nurses Association (ANA) has approved several terminologies to support nursing practice, including the Nursing Management Minimum Data Set (NMMDS), Nursing Minimum Data Set (NMDS), Alternative Billing Codes (ABC Codes), Clinical Care Classification (CCC), and North American Nursing Diagnosis International (NANDA-I). These terminologies are recognized for their significance in documenting nursing care, facilitating the collection of nursing data, and enhancing communication among healthcare professionals.

Question 11

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?

Accepted Answer

The head nurse emphasized that the Clinical Care Classification (CCC) System facilitates patient care documentation at the bedside, suggesting that the system improves the accuracy and efficiency of documenting patient care. While lab values may be a component of documentation, the system does not specifically focus on their collection and dissemination. Similarly, improved patient outcomes may be a potential benefit of the system, but this was not the primary point highlighted by the head nurse. The Clinical Care Classification (CCC) System does disclose standardized nursing terminologies, but this was not the primary value emphasized during the orientation.

Question 12

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?

Accepted Answer

The answer of Terminologies can be incorporated within the electronic...

Question 13

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?

Accepted Answer

The answer of The ANA has recognized the Omaha System...

Question 14

The Omaha System has a multitude of functions. The system can store data describing problems, symptoms, modifiers, interventions, and outcomes. One of the benefits of the stored data is which of the following?

Accepted Answer

The stored data in the Omaha System can be used to research quality and effectiveness, making it a valuable tool for evaluating healthcare interventions and outcomes. The system does not necessarily decrease services to the elderly, allow patient input of data, or decrease time spent with data collection (although it may streamline the process).

Question 15

The use of standardized nursing terminology will result in better ______________________ among the interdisciplinary team.

Accepted Answer

The answer of The use of standardized nursing terminology will...

Question 16

The use of SNOMED CT within electronic health records has multiple benefits. Which of the following are considered benefits of SNOMED CT?

Accepted Answer

The answer of The use of SNOMED CT within electronic...

Question 17

_______________________________________ is standardized classification of interventions that describes the activities that nurses perform.

Accepted Answer

The answer of _______________________________________ is standardized classification of interventions that...

Question 18

Which of the following can be used to document the elements of the nursing process within the care plan?

Accepted Answer

The answer of Which of the following can be used...

Question 19

Which of the following terms is defined as structured and controlled languages that have been developed according to terminology development guidelines?

Accepted Answer

Standardized terminologies are structured and controlled languages that follow terminology development guidelines. These terminologies are used in health care to ensure consistent and accurate documentation of patient data in electronic health records (EHRs), as well as for communication among health care professionals. Examples of standardized terminologies include SNOMED CT, LOINC, and ICD-10-CM. Health care standards, health care terminology, and health information standards may all be related to standardized terminologies, but they are not the same thing.

Question 20

Clinical terminologies consist of concepts that support which of the following facets of health care?

Accepted Answer

Clinical terminologies support all of the mentioned facets of health care. They provide standardized vocabulary to describe diagnostic studies, history and physical examinations, visit notes, ancillary department information, and outcomes measures. This helps to ensure accuracy, consistency, and interoperability of health data across various settings and systems.

Quiz 15: The Role of Standardized Terminology and Languages in Informatics