Nursing Legal Guidelines and Interventions
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Questions and Answers

In focus charting, what serves as the primary index for nursing documentation?

  • Modified patient problems (correct)
  • Post-care evaluations
  • Documented nursing orders
  • A pre-defined problem list

What is the main objective of quality assurance (QA) in healthcare?

  • To report non-standard care cases to the state
  • To assess care outcomes against set standards (correct)
  • To provide training on documentation quality
  • To evaluate employment applications for nurses

Which process involves the assessment of a nurse's professional practice by his or her peers?

  • Incident reporting
  • Peer review (correct)
  • Quality assurance
  • OBRA compliance

Which documentation format commonly utilizes the acronym SOAPE?

<p>Problem-oriented medical records (A)</p> Signup and view all the answers

Who typically holds the legal ownership of a hospitalized patient's medical record?

<p>The institution or hospital (A)</p> Signup and view all the answers

If an individual nurse's practices are under review, what type of process would that be?

<p>A peer review (B)</p> Signup and view all the answers

When using SOAPE format in medical documentation, what purpose does the 'S' serve?

<p>Subjective data (D)</p> Signup and view all the answers

In the context of a patient's medical records, where does legal ownership typically reside for those receiving care in a private office setting?

<p>The healthcare provider (A)</p> Signup and view all the answers

Which of the following provides universal guidelines for appropriate nursing interventions?

<p>Standard of care (A)</p> Signup and view all the answers

An LPN/LVN is asked to administer an IV chemotherapeutic agent. Which legal framework should be consulted first?

<p>Nurse practice act (D)</p> Signup and view all the answers

A nurse neglects to irrigate a feeding tube as prescribed, resulting in patient harm. This action could be legally classified as:

<p>malpractice (D)</p> Signup and view all the answers

Which of the following has been established to legally protect patient expectations regarding health care services?

<p>Self-Determination Act (C)</p> Signup and view all the answers

What is the primary purpose of nurse practice acts?

<p>To define and limit the scope of nursing practice (B)</p> Signup and view all the answers

If a nurse acts in a prudent manner, what does that imply?

<p>The nurse does what is considered careful and/or wise practice (A)</p> Signup and view all the answers

What is the key difference between negligence and malpractice?

<p>Malpractice refers to professional negligence, while negligence is generally a broader term (D)</p> Signup and view all the answers

An established standard of care provides which form of guidance to practicing nurses?

<p>Legal guidelines for the appropriateness of performance (A)</p> Signup and view all the answers

A healthcare professional reports a case of suspected elder abuse in good faith. What protection does this afford them?

<p>Protection from liability related to the report. (B)</p> Signup and view all the answers

What is the most effective way a nurse can minimize the risk of a lawsuit?

<p>By consistently providing compassionate and competent nursing care. (D)</p> Signup and view all the answers

A nurse is caring for a patient with a documented DNR order. What action constitutes the nurse's primary legal responsibility?

<p>To adhere to and follow the stipulations of the DNR order. (C)</p> Signup and view all the answers

A nurse has strong ethical objections to abortion and is assigned to assist with the procedure. What is the most appropriate course of action for the nurse?

<p>To request an alternative assignment without abandoning care for the patient. (A)</p> Signup and view all the answers

A new nurse is concerned about the scope of their practice. What resource is most helpful in determining the tasks they are allowed to perform?

<p>The specific standards of the nursing care profession. (D)</p> Signup and view all the answers

Which statement accurately describes the adoption of nurse practice acts in the United States and Canada?

<p>All state, provincial, and territorial legislatures have adopted nurse practice acts. (B)</p> Signup and view all the answers

When a nurse follows a physician's order that results in harm to the patient, which of the following is true?

<p>The nurse should have questioned the order and may be held liable. (B)</p> Signup and view all the answers

What is the primary goal of a nurse when acting as a patient advocate?

<p>To represent the patient's needs and ensure their care is appropriate. (A)</p> Signup and view all the answers

What is the nurse's responsibility concerning the nurse practice act within their region?

<p>The nurse must know the nurse practice act that is in effect for their geographic region. (C)</p> Signup and view all the answers

A nurse is having difficulty caring for a patient. What is one of the things they should do?

<p>Ask for clarification or additional help from colleagues. (B)</p> Signup and view all the answers

In what ways can a medical record be utilized in litigation?

<p>As proof of adherence to standards, evidence of omission of care, and documentation of time lapses. (C)</p> Signup and view all the answers

What is the legal status of information contained in a medical record once it is used in court?

<p>It becomes a public record. (B)</p> Signup and view all the answers

An emergency department nurse shares private patient information with a colleague during lunch. Which legal violation did they commit?

<p>HIPAA violation and invasion of privacy. (B)</p> Signup and view all the answers

A nurse fails to monitor a patient's respiratory status after administering a narcotic analgesic, leading to intubation. What is required for the nurse to be held liable for malpractice?

<p>A breach of duty and a direct causation of harm. (D)</p> Signup and view all the answers

Which of the following is NOT a potential use of the medical record in a court of law?

<p>Evidence of the defendant's character as a person (C)</p> Signup and view all the answers

A nurse asks a patient, 'What time do you take your insulin?' Which type of question is this?

<p>Closed question (B)</p> Signup and view all the answers

When a patient has an endotracheal tube placed, which nursing diagnosis is most appropriate?

<p>Impaired verbal communication (D)</p> Signup and view all the answers

A nurse reviews a patient's progress, examining if interventions were appropriate and if the expected outcomes were achieved. Which phase of the nursing process is the nurse demonstrating?

<p>Evaluation (D)</p> Signup and view all the answers

Which of the following is an example of an open-ended question?

<p>How does this pain affect your daily life? (D)</p> Signup and view all the answers

A nurse assesses a patient's vital signs and medical history, which step of the nursing process is this?

<p>Assessment (B)</p> Signup and view all the answers

Which statement best describes the purpose of the planning phase in the nursing process?

<p>To establish goals and outcomes of care (D)</p> Signup and view all the answers

What would be the most appropriate intervention for a patient with impaired verbal communication due to an endotracheal tube?

<p>Encourage the patient to use communication board (A)</p> Signup and view all the answers

During the evaluation phase, a nurse notes that a patient has not met the expected outcomes. What is the next appropriate action?

<p>Modify the care plan (D)</p> Signup and view all the answers

Which question encourages an unlimited response?

<p>What are you most looking forward to in Europe? (C)</p> Signup and view all the answers

Which statement accurately reflects the role of eye contact in communication?

<p>Eye contact can be a source of both effective communication and miscommunication. (D)</p> Signup and view all the answers

What can be inferred from extended eye contact?

<p>Implies aggression or heightened anxiety. (D)</p> Signup and view all the answers

Which action does NOT exemplify active listening?

<p>Nodding frequently while the patient speaks. (A)</p> Signup and view all the answers

What is the primary goal of passive listening in a therapeutic setting?

<p>To indicate to the patient that you are paying attention. (D)</p> Signup and view all the answers

In which scenario is the nurse NOT using passive listening?

<p>The nurse is providing an in-depth summary and feedback of the patients statements. (B)</p> Signup and view all the answers

What does the phrase 'extended eye contact' mean in the context of this information?

<p>Eye contact maintained for a prolonged period of time. (A)</p> Signup and view all the answers

What is a key difference between active and passive listening?

<p>Active listening involves full attention, interpretation, and feedback; passive listening indicates that that the listener is listening without interpreting. (A)</p> Signup and view all the answers

Flashcards

Standards of care

Guidelines that define the appropriate actions for nursing interventions, accepted as legal standards for proper performance.

Nurse Practice Acts

Laws that define and limit the scope of nursing practice in each state.

Advocacy in Nursing

A nurse is responsible to advocate for their patients by defending their rights and needs to ensure they receive proper care.

Malpractice

Actions or omissions that result in harm to a patient due to a breach of professional duty.

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Negligence

Failure to meet a legal duty that results in harm to another.

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American Nurses' Association (ANA) Code of Ethics

A set of guidelines that define ethical conduct and responsibilities for nurses.

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Regulation of Practice

The process of reviewing and evaluating a nurse's practice to ensure it meets professional standards.

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Patient's Bill of Rights

A set of legal rights that patients have regarding their health care.

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Mandatory Reporting Laws

Mandatory reporting laws protect healthcare professionals from legal consequences when they report certain conditions, like communicable diseases or gunshot wounds, in good faith.

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How to Avoid a Lawsuit

Providing high-quality, compassionate care reduces the risk of lawsuits. It demonstrates competence and a commitment to patient well-being.

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DNR Orders

A nurse must always follow a valid DNR order, even if they personally disagree with it.

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Ethics & Patient Care

If a nurse has ethical objections to a procedure (e.g., abortion), they can request to be assigned to a different task. However, abandoning the patient isn't acceptable.

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What are Standards of Care?

Standards of care provide guidelines for nurses, outlining what should and shouldn't be done for patients. They help ensure consistent and safe care.

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Medical Record

A legal document containing a patient's medical history, treatments, and care plans. Used for legal purposes.

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Invasion of Privacy

Sharing information about a patient without their consent, even if it's true.

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HIPAA (Health Insurance Portability and Accountability Act)

A legal document outlining the privacy and security of patient health information.

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Defamation

Making a false statement that harms someone's reputation.

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Slander

Spreading harmful lies about someone verbally.

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Libel

Spreading harmful lies about someone in writing.

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Focus Charting

A method of documentation that uses patient problems as the organizing principle. Instead of a problem list, modified patient problems serve as the index for nursing documentation.

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Quality Assurance (QA)

A department within a healthcare organization, primarily responsible for evaluating the quality of care provided against established standards.

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Peer Review

A process of evaluating the professional performance of a nurse. Typically done by a group of fellow nurses.

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SOAPE Documentation

A documentation format using the acronym SOAPE. This format helps organize medical records.

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Incident Reporting

An in-house department that investigates and reports on incidents that occur within the healthcare facility.

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Problem-Oriented Medical Record (POMR)

A method of documentation that organizes information around specific patient problems.

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Who owns the patient's medical record?

The healthcare provider or institution, not the patient, owns the medical record.

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Closed Question

A type of question that requires a specific, usually short and straightforward answer. It limits the patient's response and often needs only one or two words. Example: "What time do you take your insulin?"

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Open-Ended Question

A type of question that encourages a detailed and in-depth response. It provides freedom for the patient to express their thoughts and feelings. Example: "How do you feel about having diabetes?"

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Assessment

The first step in the nursing process, where the nurse gathers information about the patient's health status through observation, interviewing, and physical assessment.

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Diagnosis

The second step in the nursing process, where the nurse analyzes the gathered assessment data to identify patient problems and prioritize their needs.

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Planning

The third step in the nursing process, where the nurse develops a plan of care based on the identified patient problem. This includes setting goals, choosing appropriate interventions, and documenting the plan.

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Implementation

The fourth step in the nursing process, where the nurse puts the planned interventions into action. This involves providing direct patient care, monitoring progress, and collaborating with other healthcare professionals.

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Evaluation

The final step in the nursing process, where the nurse evaluates the effectiveness of the interventions in achieving the desired outcomes. This involves monitoring the patient's progress, reassessing needs, and making necessary adjustments to the plan.

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Patient Problem

A statement used in nursing documentation to describe a patient's current health status. It should be specific, measurable, achievable, relevant, and time-bound.

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Active Listening

The ability to comprehend and interpret the meaning behind a message, going beyond just hearing the words.

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Verbal Feedback

Expressing your understanding of the message you've heard, ensuring the sender knows you got it.

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Extended Eye Contact

Eye contact that is too intense or prolonged, potentially making the other person uncomfortable or even feeling threatened.

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Passive Listening

A form of listening where the receiver provides minimal verbal or nonverbal cues to show they are paying attention.

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Nonverbal Listening Cues

The process of using nonverbal cues like nodding, leaning in, and maintaining eye contact to demonstrate attention and understanding.

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Communication

A specific type of interaction where the receiver focuses on understanding the sender's message and showing them their message was received.

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Active Communication

A form of communication where the receiver actively participates in the conversation, seeking clarification or asking questions to ensure full understanding.

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Active Listening Strategies

Using a variety of techniques to demonstrate attentiveness, including summarizing, reflecting, and asking open-ended questions to ensure understanding.

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Study Notes

  • Standards of care define permissible and prohibited nursing interventions, serving as legal guidelines for appropriate practice.
  • Nurse practice acts are laws that formally define and limit the scope of nursing practice.
  • Advocacy refers to defending or pleading a cause on behalf of another.
  • Prudent practice involves careful and wise actions.

LPN/LVN and IV Chemotherapy Administration

  • Before administering IV chemotherapy, LPN/LVNs should consult their state's nurse practice act.
  • Standards of care, regulations of practice, and the American Nurses' Association Code are not legal guidelines for this specific intervention.
  • Nurses can be held liable for malpractice if they fail to uphold their legal duty, causing harm.
  • Failure to follow a nurse practice act may support a malpractice claim.
  • Omissions of care, such as failing to perform a necessary procedure, can constitute malpractice.
  • Patient rights are legally protected through documents like the American Hospital Association’s Patient’s Bill of Rights.
  • The Self-Determination Act also protects patient rights.
  • If a nurse acts in good faith to report mandated information (communicable diseases, gunshot wounds) they are protected from liability.

Avoiding Lawsuits

  • Providing compassionate and competent care is the best way to prevent a lawsuit.
  • Malpractice insurance is a prudent measure, but not a guarantee of avoiding a lawsuit.

Do-Not-Resuscitate (DNR) Orders

  • Nurses are legally obligated to follow DNR orders, regardless of personal beliefs.
  • Questioning the health care provider, seeking family advice, or discussing with the patient is not a legal obligation in this situation, despite potential personal conflict.

Ethical Dilemmas in Nursing Practice

  • If a nurse has strong moral objections to a procedure (like an abortion), the most appropriate action is to request another assignment rather than abandoning the patient or protesting.

Nurse Practice Acts and Standards of Care

  • Standards of care define acceptable actions for nursing practice; these are informal guidelines defining the scope.
  • Nurse practice acts are laws defining and limiting the nursing scope formally. Every state and province has these laws.

Medical Records in Litigation

  • Medical records are public documents used in legal proceedings.
  • Records can provide evidence of adherence to standards, omissions of actions, and documentation of time lapses.
  • They are used for both the plaintiff and defendant.

HIPAA Violations and Disclosure of Information

  • Sharing patient information during a lunch break constitutes an HIPAA violation and invasion of privacy.
  • True and verbal disclosure of patient information is not considered slander or libel.

Nurse's Responsibility in Patient Care

  • A nurse's failure to monitor a patient's condition after administering narcotics, leading to deterioration, can be considered malpractice.
  • For liability, the nurse must have deviated from the accepted standard of care.

Documentation in Focus Charting

  • Focus charting uses patient problems, not a problem list, for nursing documentation.

Quality Assurance (QA) in Healthcare

  • QA evaluates care against established standards.

Peer Review

  • Peer review assesses nursing practices by other nurses.

Problem-Oriented Medical Record (POMR)

  • POMR uses SOAPE (Subjective, Objective, Assessment, Plan, Evaluation) format.
  • The healthcare institution or provider owns the records, not the patient.

Question Types in Patient Assessments

  • Closed questions seek specific answers (e.g., "What time do you take your insulin?").
  • Open-ended questions allow for detailed responses (e.g., "Tell me about your support system").

Identifying Patient Problems

  • Assess patient needs and consider the presenting issue, not broader problems. For example, an endotracheal tube usually indicates impaired verbal communication rather than ineffective coping.

Evaluating Patient Care

  • Evaluation involves assessing whether interventions yielded expected outcomes.

Eye Contact in Communication

  • Eye contact is a significant aspect of communication.
  • Misunderstandings can arise from varying interpretations of eye contact; intention does not always equate with outcome.
  • Extended eye contact might signal aggression or raise anxiety.

Active vs. Passive Listening

  • Passive listening involves nonverbal cues (nodding) or verbal acknowledgements.
  • Active listening emphasizes interpretation and feedback.

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Foundations and Adult Health Nursing 9th Edition Test Bank PDF

Description

Explore key concepts related to nursing interventions, legal guidelines, and the responsibilities of LPN/LVNs in IV chemotherapy administration. This quiz covers standards of care, nurse practice acts, and legal liability considerations for nurses. Test your understanding of the prudent practices that ensure safe and effective patient care.

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