Theory Exam 3 NU 136 Galen Questions and Answers(A+ Solution guide)

Theory Exam 3 NU 136 Galen What are the 5 steps in the nursing process? - Answer -Assessment Diagnosis Planning Implementation Evaluation What is the assessment portion of the nursing process used for? - Answer -data collection what is the nursing diagnosis portion of the nursing process used for? - Answer -analyzing the data what is the planning portion of the nursing process used for? - Answer -the steps to resolve the health problem present what is the implementation portion of the nursing process used for? - Answer -carrying out the steps of the planning portion what is the evaluation portion of the nursing process used for? - Answer -to assess the patients respose to the treatment How often is the nursing care plan updated? - Answer -every 24 hours what are the three charecteristics of an expected outcome? - Answer -realistic, attainable, and have a set timeline Who should have access to the patients records? - Answer -only those who are directly involved in the patients care What is source -oriented or narrative charting? - Answer -organized according to the source of the information What is problem -oriented medical record charting (POMR)? - Answer -charting the focuses on the patient's status with an emphasis on the problem -solving approach What is problem identification, interventions, and evaluation charting (PIE)? - Answer -follows the nursing process and uses nursing diagnosises while placing the plan of care within the nurses progress notes What is focused charting? - Answer -focuses only on the direct health problems of the patient What is charting by exception? - Answer -the assumption that all standards of practice are carried out and met with a normal or expected response What is computer -assisted charting or an electronic health record (EHR)? - Answer -a computerized comprehensive record of a patient's history and care across all facilities and admissions What is a computerized provider order entry (CPOE)? - Answer -an efficent and effective way for any orders put in through the system to be automatically sent to the appropriate clinical areas for action What is case management system charting? - Answer -organizing patient care through an episode of illness so that clinical outcomes are achieved within an expected time frame and at a predictable cost What do you never do when documenting on a computer? - Answer -walk away with the screen opened and unlocked What does accuracy in documentation mean? - Answer -being specific and definite in using words or phrases that convey the meaning you wish expressed What is brevity in documentation? - Answer -sentences are not neccessary, but abbreviations, acronymns, and symbols are acceptable What do you need to be sure of when providing written documentation? - Answer -it is always legible and complete What time do all medical staff use? - Answer -military time