NFDN 1002 MIDTERM UPDATED EXAM ALL
QUESTIONS AND ANSWERS SURE A+
Intrapersonal Communication - ✔✔communication with oneself
✔✔Interpersonal Communication - ✔✔between two or more people
✔✔Transpersonal Communication - ✔✔interaction that occurs within a person's spiritual
domain
✔✔SOAP Charting - ✔✔S= Subjective data (how the patient feels)
O= Objective data (results of physical exam, vital signs, etc)
A= Assessment (what is the patient's status)
P= Plan (does the plan stay the same or is change needed?)
✔✔SOAPIE Charting - ✔✔I= Intervention (what did the nurse do?)
E= Evaluation (what is the patient outcome following the intervention?)
✔✔PIE Charting - ✔✔P= Patient problems (teaching needs and discharge planning
needs, identified during initial assessment of the patient)
I= Interventions carried out for each specific nursing diagnosis
E= Evaluate the outcomes of the interventions
, ✔✔DAR - ✔✔Data: information that supports the focus
Action: the nursing intervention
Response: how the patient responds to the intervention and the outcome
✔✔Focus Charting - ✔✔Eliminates the word "problem" and uses the term "focus"
Includes patient's condition, nursing diagnosis, s&s, or significant event or change in
condition
Organized using DAR
✔✔Source-Oriented Charting - ✔✔Most common
Information is organized & presented according to its source
There are separate sections for the doctor's notes, the nurse's notes, the respiratory
therapist notes, etc
Read through all the sections & piece together the data
✔✔Charting by Exception - ✔✔Chart only when there is a significant change or finding
different from the norm
Otherwise use standardized flow sheets, nursing database, SOAP progress notes and
care plans
CBE use narrative format
Alerts staff to something unusual that has occurred with the patient
Presumes that unless documented otherwise, all standards have been met with a
normal response
✔✔A.C. - ✔✔before meals
✔✔P.C. - ✔✔after meals
✔✔NKA - ✔✔No known allergies
✔✔NPO - ✔✔Nothing per mouth
✔✔HOB - ✔✔Head of bed
✔✔W/C - ✔✔wheelchair
✔✔SOB - ✔✔Shortness of breath
✔✔PRN - ✔✔As needed
✔✔TPR - ✔✔temperature, pulse, respiration
✔✔Written Orders - ✔✔Physically written by the physician on the chart
QUESTIONS AND ANSWERS SURE A+
Intrapersonal Communication - ✔✔communication with oneself
✔✔Interpersonal Communication - ✔✔between two or more people
✔✔Transpersonal Communication - ✔✔interaction that occurs within a person's spiritual
domain
✔✔SOAP Charting - ✔✔S= Subjective data (how the patient feels)
O= Objective data (results of physical exam, vital signs, etc)
A= Assessment (what is the patient's status)
P= Plan (does the plan stay the same or is change needed?)
✔✔SOAPIE Charting - ✔✔I= Intervention (what did the nurse do?)
E= Evaluation (what is the patient outcome following the intervention?)
✔✔PIE Charting - ✔✔P= Patient problems (teaching needs and discharge planning
needs, identified during initial assessment of the patient)
I= Interventions carried out for each specific nursing diagnosis
E= Evaluate the outcomes of the interventions
, ✔✔DAR - ✔✔Data: information that supports the focus
Action: the nursing intervention
Response: how the patient responds to the intervention and the outcome
✔✔Focus Charting - ✔✔Eliminates the word "problem" and uses the term "focus"
Includes patient's condition, nursing diagnosis, s&s, or significant event or change in
condition
Organized using DAR
✔✔Source-Oriented Charting - ✔✔Most common
Information is organized & presented according to its source
There are separate sections for the doctor's notes, the nurse's notes, the respiratory
therapist notes, etc
Read through all the sections & piece together the data
✔✔Charting by Exception - ✔✔Chart only when there is a significant change or finding
different from the norm
Otherwise use standardized flow sheets, nursing database, SOAP progress notes and
care plans
CBE use narrative format
Alerts staff to something unusual that has occurred with the patient
Presumes that unless documented otherwise, all standards have been met with a
normal response
✔✔A.C. - ✔✔before meals
✔✔P.C. - ✔✔after meals
✔✔NKA - ✔✔No known allergies
✔✔NPO - ✔✔Nothing per mouth
✔✔HOB - ✔✔Head of bed
✔✔W/C - ✔✔wheelchair
✔✔SOB - ✔✔Shortness of breath
✔✔PRN - ✔✔As needed
✔✔TPR - ✔✔temperature, pulse, respiration
✔✔Written Orders - ✔✔Physically written by the physician on the chart
