THEORY EXAM 3 NU 136 GALEN QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS VERIFIED LATEST UPDATE

THEORY EXAM 3 NU 136 GALEN QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS VERIFIED LATEST UPDATE Terms in this set (49) What are the 5 steps in the nursing process? Assessment Diagnosis Planning Implementation Evaluation What is the assessment portion of the nursing process used for? data collection what is the nursing diagnosis portion of the nursing process used for? analyzing the data what is the planning portion of the nursing process used for? the steps to resolve the health problem present what is the implementation portion of the nursing process used for? carrying out the steps of the planning portion what is the evaluation portion of the nursing process used for? to assess the patients respose to the treatment How often is the nursing care plan updated? every 24 hours what are the three charecteristics of an expected outcome? realistic, attainable, and have a set timeline Who should have access to the patients records? only those who are directly involved in the patients care What is source-oriented or narrative charting? organized according to the source of the information What is problem-oriented medical record charting (POMR)? 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)? follows the nursing process and uses nursing diagnosises while placing the plan of care within the nurses progress notes What is focused charting? focuses only on the direct health problems of the patient What is charting by exception? 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)? a computerized comprehensive record of a patient's history and care across all facilities and admissions What is a computerized provider order entry (CPOE)? an efficent and effective way for any orders put in through the system to be automatically sent to the appropriate clinical areas for action