PNR 104 EXAM 2 QUESTIONS AND
CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY
GRADED A+
QUESTIONS AND ANSWERS
Steps of the nursing process in order. ANSWER - Assessment, nursing dx, planning,
implementation, and evaluation
Assessment and nursing DX. ANSWER - RN's are responsible for this part of the
nursing process
Data Collection. ANSWER - LPN's main role in nursing process
Documentation of the plan. ANSWER - Should be constructed right after the
admission database is collected. Must be readily available to each nurse who is
assigned to the patient. (Reviewed & updated once every 24 hrs.)
Problem solving process steps. ANSWER - define the problem clearly, consider all
possible alternatives as solutions to the problem, consider the possible outcomes for
each alternative, predict the likelihood of each outcome occurring, choose the best
alternative with the fewest undesirable outcomes.
A medical diagnosis is never included in a nursing diagnosis. ANSWER - True
(example: stroke, MI)
Nursing diagnosis =. ANSWER - problem + etiology +signs and symptoms
Etiology. ANSWER - causes of the problem
, Defining characteristics. ANSWER - characteristics that must be present for a
nursing DX
Constructing a nursing care plan. ANSWER - assess the pt, analyze the data, identify
nursing problems, prioritize, make goals, write expected outcomes, and choose
interventions.
purposes of charting. ANSWER - written record of history, treatment, care, claims
for reimbursement, and evidence in court
6 main methods of documentation. ANSWER - source-oriented (narrative) charing,
problem oriented medical record charting (POMR) focus charting, charting by
exception, computer assisted charting, and case management system charting.
source oriented charting (narrative). ANSWER - narrative notes are phrases and
sentences written without any standardized structure. benefits of this method are
that it gives info on pt condition in chronological order, indicates pt baseline for each
shift, and includes aspects of all steps in the nursing process
POMR. ANSWER - focuses of patient status, emphasizing a problem solving
approach. contains 5 steps - the data base, problem list, plan, progress note, and the
discharge summary. This format is known as a SOAP(IE) note.
s- subjective o - objective a- assessment p- plan i- implementation e- eval
focus charting. ANSWER - similar to POMR but it substitutes focus for the problem.
3 parts to this form of documentation are D - data A- action R- response (DAR)
Advantage is that it keeps all relevant data to a problem in one place.
Charting by exception. ANSWER - decreases lengthy narrative entries to reduce
repetition of data.
computer assisted charting. ANSWER - electronic health record (EHR)
CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) ALREADY
GRADED A+
QUESTIONS AND ANSWERS
Steps of the nursing process in order. ANSWER - Assessment, nursing dx, planning,
implementation, and evaluation
Assessment and nursing DX. ANSWER - RN's are responsible for this part of the
nursing process
Data Collection. ANSWER - LPN's main role in nursing process
Documentation of the plan. ANSWER - Should be constructed right after the
admission database is collected. Must be readily available to each nurse who is
assigned to the patient. (Reviewed & updated once every 24 hrs.)
Problem solving process steps. ANSWER - define the problem clearly, consider all
possible alternatives as solutions to the problem, consider the possible outcomes for
each alternative, predict the likelihood of each outcome occurring, choose the best
alternative with the fewest undesirable outcomes.
A medical diagnosis is never included in a nursing diagnosis. ANSWER - True
(example: stroke, MI)
Nursing diagnosis =. ANSWER - problem + etiology +signs and symptoms
Etiology. ANSWER - causes of the problem
, Defining characteristics. ANSWER - characteristics that must be present for a
nursing DX
Constructing a nursing care plan. ANSWER - assess the pt, analyze the data, identify
nursing problems, prioritize, make goals, write expected outcomes, and choose
interventions.
purposes of charting. ANSWER - written record of history, treatment, care, claims
for reimbursement, and evidence in court
6 main methods of documentation. ANSWER - source-oriented (narrative) charing,
problem oriented medical record charting (POMR) focus charting, charting by
exception, computer assisted charting, and case management system charting.
source oriented charting (narrative). ANSWER - narrative notes are phrases and
sentences written without any standardized structure. benefits of this method are
that it gives info on pt condition in chronological order, indicates pt baseline for each
shift, and includes aspects of all steps in the nursing process
POMR. ANSWER - focuses of patient status, emphasizing a problem solving
approach. contains 5 steps - the data base, problem list, plan, progress note, and the
discharge summary. This format is known as a SOAP(IE) note.
s- subjective o - objective a- assessment p- plan i- implementation e- eval
focus charting. ANSWER - similar to POMR but it substitutes focus for the problem.
3 parts to this form of documentation are D - data A- action R- response (DAR)
Advantage is that it keeps all relevant data to a problem in one place.
Charting by exception. ANSWER - decreases lengthy narrative entries to reduce
repetition of data.
computer assisted charting. ANSWER - electronic health record (EHR)
