Semester 1 Unit 2 Exam
What are 4 sources from which to gather data for patient assessment?
-Client -Family -Client's Physical state -Medical records CFPM Cats Find Plenty of Mice
What is CPOE and what does it do?
-Computerized Provider Order Entry -Patient care is entered directly into computer to reduce errors and time
What are the 4 main areas for assessing a patient or caregiver for their LEARNING needs?
-Physical characteristics (nature of illness, dexterity) -Psychological characteristics (anxiety, depression, self-efficacy) -Sociocultural characteristics (health literacy, cultural background, economic resources) -Learner characteristics (individual learning needs, readiness to learn, language skills) PPSL Pumpkin Pumpkin Spice Latte
When faxing health information, what needs to happen to be HIPAA compliant?
-Receiver must be present -Cover letter
Cultural norms Culture value Same gender preference These are examples of ____, and should be obtained in the ______ phase of health assessment.
-Subjective data -Data collection
What are 2 key attributes of patient education?
-The teaching is planned -The goal of teaching is to meet objectives
A "readiness for" diagnosis has how many parts?
1
What type of nursing diagnosis is a wellness diagnosis? ie: Patient comes in and says, "My dad has CHF, I'm here to see for myself." What will the nursing diagnosis look like?
1-part nursing diagnosis: "Readiness for CHF patient education"
Which step of Maslow's Hierarchy of Needs involves: Sleep Sex
1. Physiological
List Maslow's Hierarchy of Needs in order
1. Physiological 2. Safety 3. Love 4. Esteem 5. Self-actualization PSLEA Pumpkin Spice Latte Every Afternoon
A "risk for" diagnosis has how many parts?
2
What type of nursing diagnosis indicates a potential problem?
2-part nursing diagnosis ie: ""Constipation R/T immobility due to recent surgery"
What type of nursing diagnosis requires nursing implementations be indicated, or else a problem will occur?
2-part nursing diagnosis: a potential problem is identified by risks, but no evidence yet
Which step of Maslow's Hierarchy of Needs involves: Employment Resources Family Health Privacy
2. Safety
Which step of Maslow's Hierarchy of Needs involves: Friendship Family Sexual intimacy
3. Love/belonging
Which step of Maslow's Hierarchy of Needs involves: Achievement Respect of others Respect by others
4. Esteem
What type of nursing diagnosis takes priority because it indicates an actual problem?
A 3-part nursing diagnosis ie: "Constipation R/T immobility due to recent surgery AEB distended, tender abdomen and pt. states, "I haven't moved my bowels in 3 days"
What are the levels of US preventative services task force grading for evidence?
A = recommends B = recommends C = selectively recommends D = recommends against I = insufficient evidence
What is the difference between a medical diagnosis and a nursing diagnosis?
A medical diagnosis is just the name, ie: "Asthma", but a nursing diagnosis describes the issue from the patient's point of view, ie: "Asthma with shortness of breath"
What describes how a patient is responding to diseases and disorders?
A nursing diagnosis
"Ineffective airway clearance" vs "asthma" would be an example of what?
A nursing diagnosis vs a medical diagnosis
How does the Iowa model transcend mere nursing care? (Select all that apply.) a. It includes formalized internal feedback loops. b. Its triggers can have their origins practically anywhere. c. It generates change in practice solely through research. d. It implies a layer of policy development. e. It addresses multiple disciplines' impacts on quality.
A, B, D, E a. It includes formalized internal feedback loops. b. Its triggers can have their origins practically anywhere. d. It implies a layer of policy development. e. It addresses multiple disciplines' impacts on quality.
The nurse is conducting a review of the literature for pain management techniques. Which of the following should the nurse consider when conducting research that yields solid EBP? (Select all that apply.) a. Search the literature to uncover evidence to answer the question. b. Evaluate the outcome. c. Use the nursing process to evaluate evidence. d. Evaluate the evidence found. e. Develop an answerable question. f. Develop a question that has not been answered. g. Apply the evidence to the practice situation.
A, B, D, E, G a. Search the literature to uncover evidence to answer the question. b. Evaluate the outcome. d. Evaluate the evidence found. e. Develop an answerable question. g. Apply the evidence to the practice situation.
Which organization defines nursing informatics as "A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice."?
ANA
What is defined as: "An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient."
Adverse event
Which learning domain involves changing or influencing attitudes?
Affective
In what step of the nursing process do nurses make any needed modifications to interventions?
After evaluation
When doing CPR, what comes first?
Airway (ABC = airway breathing circulation)
An assessment of functional ability should involve who?
All healthcare professionals on the patient's team
We should always assess patients bilaterally, except when doing what?
Apical pulse (we only have one heart)
The nurse is explaining the nursing process to a student nurse. Which step of the nursing process would include interpretation of data collected about the client? -Diagnosis -Evaluation -Assessment -Implementation
Assessment
What part of ADPIE takes into consideration biophysical, psychological, psychosocial, sociocultural, spiritual, and environmental factors?
Assessment
Which step of the nursing process involves the nurse interviewing a client about a current health problem and obtaining the client's vital signs? -Assessment -Diagnosis -Planning -Evaluation
Assessment
The types of assessments we learned are comprehensive, focused, and emergency. These are very different from what?
Assessment techniques
Which statements are true about the Iowa model of EBP? (Select all that apply.) a. It addresses utilization of research findings at an individual level. b. It addresses the relevance of the question to the organization. c. Individual nurses enact an Iowa decision tree when they examine risk management data. d. It identifies triggers capable of posing hazard or benefit. It reiterates that innovators embrace change far earlier than laggards.
B, D b. It addresses the relevance of the question to the organization. d. It identifies triggers capable of posing hazard or benefit. It reiterates that innovators embrace change far earlier than laggards.
How does a nurse demonstrate culturally competent care?
By conducting a cultural assessment
Who is most at risk for developmental issues?
Children
Lack of funding Lack of standardization Privacy laws Lack of uniform approach to numbers These are all barriers to what?
Clinical informatics
Which domain of informatics does nursing informatics fall under?
Clinical informatics
What guides nurses to question current practices and consider when guidelines need to be updated based on current evidence?
Clinical judgment
What is an integral aspect of safe implementation of evidence-based practice (EBP)?
Clinical judgment
What is defined as: "An interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response."
Clinical judgment
What is defined as: "An iterative process of noticing, interpreting, and responding - reasoning in transition with a fine attunement to the patient and how the patient responds to a nurse's actions."
Clinical reasoning
Which learning domain involves increasing knowledge?
Cognitive
What are the 3 learning domains?
Cognitive Psychomotor Affective (CPA)
What are the 3 learning domains that describe how the learner will be engaged?
Cognitive (knowledge) Phsychomotor (skill) Affective (changes)
What is a process of interaction between people in which symbols are used to create, exchange, and interpret messages about ideas, emotions, and mind states?
Communication
What is a detailed health history and physical exam of all body symptoms?
Comprehensive assessment
H.J., a 74-year-old black man, is a retired army military officer. His wife of more than 50 years passed away 4 years ago. He has 4 daughters and 2 sons who are all grown and married. He has 14 grandchildren with a great-grandchild on the way. His son brought him to the health care provider today because he is concerned his father has been more forgetful and is losing weight. H.J. has a history of coronary artery disease that is being managed with metoprolol XL (Lopressor) and aspirin. 1.What level of assessment do you need to perform?
Comprehensive: Because H.J. presents with a set of vague symptoms that could be related to a number of disorders or life processes, a comprehensive assessment, including a detailed health history using a functional health pattern format and physical examination, is needed.
What is a cognitive process used for analysis of an issue or problem, that is not situated or specific to a given patient, nurse, or care context?
Critical thinking
_______ involves accepting a patient's beliefs about health and healthcare while sharing information, encouraging them to succeed and strengthening the patient's coping skills.
Culturally competent care
"The diagnosis and treatment of human response to actual or potential health problems or life processes." This is the focus of what?
Data collection in nursing
The nurse asks an unlicensed assistive personnel (UAP) to provide an ice pack to a client. Which nursing function does this represent? -Implementation -Case Management -Delegation -Interprofessional teamwork
Delegation
What assessment tool is used for children and infants?
Denver II
What is defined as: "The sequence of physical, psychosocial, and cognitive developmental changes that take place over the human life span."
Development
____ is based on the timing and sequence of tasks, generally organized by age groups.
Development
What is defined as: "A plateau of developmental change or cessation in development."
Developmental arrest
What is defined as: "An individual's stage of development or ability to independently achieve an outcome". Ex: epiphyseal plate closure, stage of cognitive development, ability to perform abstract reasoning
Developmental level
What is defined as: "An ability or specific skill that most individuals can accomplish in a certain age range."
Developmental milestone
What is defined as: "An individual who has accomplished a developmental milestone but lost the ability to perform it, usually due to significant stressor."
Developmental regression
What is denied as: "A unique set of skills to be mastered at each developmental stage across the lifespan for the individual to cope with the environment."
Developmental tasks
What is defined as: "An individual who does not accomplish milestones within a specified age range, or a critical period, signifying that an essential element of neurologic and/or cognitive maturation has not occurred."
Developmentally delayed
What is defined as: "The process by which initially formed cells and structures become specialized."
Differentiation
What is the preferred source of data for a nursing assessment?
Directly from patient
What term describes the functional/structural disturbance that a patient has?
Disease
What is a goal for health organization in relation to nursing informatics?
EHR: Electronic Health Record
What is a rapid history and exam of a patient while maintaining vital functions, usually done in life-threatening situations?
Emergency assessment
Replicability Reliability Validity Publicly available Understandable Usable These attributes are important for what?
Evidence
What is defined as: "Information (in the form of personal or documented testimony or the production of material objects), tending or used to establish facts in a legal investigation."
Evidence
The "Iowa Model" is a flow chart for implementing what?
Evidence-based practice
What is defined as: "A problem-solving approach to clinical decision-making that combines the best available scientific evidence with best available patient and practitioner experiential evidence toward optimal healthcare outcomes."
Evidence-based practice (EBP)
What does the acronym ISBARR relate to and what does it stand for?
Facilitating communication in nursing: Identify Situation Background Assessment Recommendation Read back/repeat
What is defined as: "Two or more individuals who depend on one another for emotional, physical, and economic support."
Family
What is defined as: "Interrelationships between and among individual family members or 'the forces at work within a family that produce particular behaviors or symptoms'."
Family dynamics
What is an abbreviated health history and examination, used to evaluate the status of previously identified problems and monitor for signs and symptoms of new problems?
Focused assessment
In assessing ______ you should identify populations at risk and risk factors, complete an assessment (self-report, physical exam, screening tools such as Katz Index, etc.), and plan and deliver individualized care.
Functional ability
The goal of ______ is for the client to be capable of performing daily activities safely and maintaining health and well-being.
Functional ability
What is defined as: "The cognitive, social, physical, and emotional ability to carry on the normal activities of life."
Functional ability
H.J., a 74-year-old black man, is a retired army military officer. His wife of more than 50 years passed away 4 years ago. He has 4 daughters and 2 sons who are all grown and married. He has 14 grandchildren with a great-grandchild on the way. His son brought him to the health care provider today because he is concerned his father has been more forgetful and is losing weight. H.J. has a history of coronary artery disease that is being managed with metoprolol XL (Lopressor) and aspirin. 3. Based on your assessment, you are concerned about H.J.'s functional abilities and decide to evaluate him further. What types of functional screening tools would be appropriate for H.J.?
Functional screening tools that are appropriate for H.J. include those that evaluate activities of daily living, instrumental activities of daily living, gait impairment, social domain, and cognition and affect. KATZ, SPICES
What must be done before the physical examination?
General survey
What is defined as: "A lag in multiple neurocognitive development areas - speech and language, gross and fine motor skills, and personal and social development."
Global delay
What is a social assessment done on adolescents?
HEADSS Home Education Activities Drugs Sexuality Suicide
What ensures that healthcare organizations collect the right data in a common format?
HIPAA
Which client situation will the nurse address first on priority basis of Maslow's hierarchy of needs? -Feels like is leading a worthless life. -Has multiple fainting episodes due to lack of proper nutrition. -Shows signs of lack of interest in carrying out social interaction. -Conveys to the nurse thatis estranged from all family members.
Has multiple fainting episodes due to lack of proper nutrition.
What should be done with infants and children during examination to minimize crying/issues?
Have parents and caregivers assist
What is defined as: "The state of complete physical, mental, and social well-being and not merely the absence of disease, or infirmity."
Health
The purpose of _____ is to collect subjective and objective data to determine client's overall functioning.
Health assessment
What is defined as: "A systematic, dynamic way to collect and analyze data about a client, including not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well."
Health assessment
What is the process of enabling people to increase control over and to improve their health?
Health promotion
What is defined as: "A discipline in which health data are stored, analyzed, and disseminated through the application of information and communication technology."
Healthcare informatics
Whose role is it to converse with tech staff about hardware, software, communication, data, representation, and security?
IN (informatic nurse) and INS (informatic nurse specialist)
Which step in the research process is similar to the assessment step of the nursing process? -Analyzing the results -Conducting the study -Developing hypothesis -Identifying the problem
Identifying the problem
What term describes the symptoms a patient experiences?
Illness
The nurse is performing nursing care therapies and including the client as an active participant in the care. Which step in the nursing process is involved in this situation? -Planning -Implementation -Assessment -Evaluation
Implementation
What step of the nursing process includes delegation?
Implementation
Which component of the nursing process includes tasks that can be delegated? -Planning -Evaluation -Assessment -Implementation
Implementation
Which phase of nursing process can involve delegation?
Implementation
Which step in the nursing process would involve promoting a safe environment for the client? -Implementation -Planning -Assessment -Diagnosis
Implementation
What step of the nursing process is based on evidence?
Implementation (nursing interventions)
What is defined as: "The science that ecompasses information science and computer science to study the process, management, and retrieval of information."
Informatics
What are physical exam techniques that are used? (4)
Inspection Palpation Percussion (tapping - advanced nurses only) Auscultation (listening to heart/lung) IPPA
Management of developmental problems involves what?
Interdisciplinary collaboration (nursing, medicine, PT, OT, psych, counseling, nutritional intervention, speech, audiology, assistive tech)
Education level Literacy level Social/family support Developmental level Culture These factors can all affect what?
Learner readiness for patient education
What is defined as: "The emergence of personal, behavioral, or adultlike physical characteristics or a 'ripening.'"
Maturation
Disturbances in mood, environmental stimuli, relationships between people communicating, and interpersonal states are all examples of what?
Metacommunication
What consists of factors that compromise the context of the message in communication?
Metacommunication
Should patient data ideally be gathered from one or multiple sources?
Multiple sources
What is defined as: "An error of commission (incorrect care) or omission (failed to provide care) that could have harmed the patient, but serious harm did not occur as a result of chance, prevention, or mitigation."
Near miss event
Are nurses allowed to write a medical diagnosis, such as "asthma" or "bronchitis"?
No
False assurance Giving advice Changing the subject Probing questions Why and how questions Yes and no questions Using cliches These are all examples of what?
Non-therapeutic communication
Lack of time, competing priorities, availability of a conductive environment, availability of materials, confidence, and perception of importance are common barriers to what?
Nurse teaching
What is defined as: "A clinical judgement about the patient in response to an actual or potential health problem."
Nursing Diagnosis
What is a problem-solving approach to identifying and treating client's problems, and describes how we think, identify, and differentiate outcomes?
Nursing Process
Data collection Preparing the client History and physical exam These are components of what?
Nursing assessment
What aids these 3 things: -Facilitates evidence-based practice -Reduces errors in healthcare -Enables compilation of electronic health record
Nursing informatics
What is defined as: "A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice."
Nursing informatics
What is a 5-step process based on the scientific process?
Nursing process
What is an important concept to address with patients (it is embedded throughout the program)?
Nutrition
What type of data is measurable and comes from what the nurse assesses and finds?
Objective
General survey and physical examination are examples of what?
Objective data
The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? -Determine the mother's readiness to learn. -Observe the mother feeding the infant. -Ask the mother if she understands. -Develop a basic teaching plan.
Observe the mother feeding the infant.
What is the process of helping people learn health related behaviors so that they can incorporate these behaviors into their every day life?
Patient education
Educational materials that are at too high of a level, language difficulties, and culturally inappropriate materials are common barriers to what?
Patient learning
Not believing what is taught will be helpful, not believing in the ability to learn the material, and lack of social support are common barriers to what?
Patient motivation
What is defined as: "A disorder involving significant developmental delay in many milestones, usually identified by 3 years of age."
Pervasive development disorder (PDD)
Genetics and nutritional status can affect ______ in children.
Physical development
What is defined as: "An increase in cell number and size that results in an increase in overall size or weight of the body or any of its parts."
Physical growth
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? -Implementation -Evaluation -Assessment -Planning
Planning
H.J., a 74-year-old black man, is a retired army military officer. His wife of more than 50 years passed away 4 years ago. He has 4 daughters and 2 sons who are all grown and married. He has 14 grandchildren with a great-grandchild on the way. His son brought him to the health care provider today because he is concerned his father has been more forgetful and is losing weight. H.J. has a history of coronary artery disease that is being managed with metoprolol XL (Lopressor) and aspirin. 4.What nursing diagnoses and problems do you feel exist for H.J.?
Potential nursing diagnoses and problems for H.J. may include: Risk for falls Activity intolerance Fatigue Impaired skin integrity Impaired physical mobility Impaired nutritional status Social isolation
What is generally cheaper and more easily accessible than disease management?
Primary PREVENTION of disease before it occurs
What is considered the first line of defense for health and wellness?
Primary prevention
What type of prevention involves immunizations?
Primary prevention
What type of prevention involves patient education?
Primary prevention
What type of data comes from patient and is non-measurable?
Primary subjective
Who is accountable for medication safety?
Provider Pharmacist Nurse all 3
Which learning domain involves developing or improving a skill?
Psychomotor
What type of research is defined as: "Focused on a person's experience and uses of textual, or non-numeric, data, such as interviews, surveys, or questionnaires."
Qualitative research
What type of research is defined as: "Focused on the testing of a hypothesis through objective observation and validation."
Quantitative research
What type of studies are considered the "gold standard" of research?
Randomized, controlled, double-blind
The goal of _____ is to improve the quality of care among patients. A nurse must implement interventions while meeting standards provided by them.
Regulatory agencies
What approach uses algorithms and clear-cut guidance, implying that there is only one right decision, and prioritizes best practices rather than individual patient-centered care?
Rules-based or Standards-based
What is defined as: "Freedom from accidental injury; involving the establishment of operational systems and processes that minimize the likelihood of errors and maximizes the likelihood of intercepting them when they occur."
Safety
Which consideration would the nurse emphasize to the parent of a toddler-age client when selecting toys? -Creativity -Safety -Appropriateness -Evidence
Safety
A pregnant client is tested for gestational diabetes. This is an example of what?
Secondary prevention
A prostate exam is an example of what?
Secondary prevention
The goal of ____ is to cure, or at least limit disability, or delay the advancement of any disease.
Secondary prevention
The goal of ____ is to reduce the impact of injury that has occurred despite primary prevention interventions.
Secondary prevention
The purpose of ____ is to identify and promptly treat an early state of disease process.
Secondary prevention
What type of prevention involves genetic testing and PAP smears?
Secondary prevention
What type of prevention involves screening of any kind?
Secondary prevention
What type of data comes from family members or support system and is non-measurable?
Secondary subjective
A client involved in an accident says, "I have a dream of conquering the world's highest mountain range." According to Maslow's hierarchy of needs, to which level of need does the given scenario refer? -Physiology needs -Self-esteem -Self-actualization -Safety and security
Self-actualization
Which step of Maslow's Hierarchy of Needs involves: Problem solving Lack of prejudice Acceptance of facts
Self-actualization
What is defined as: "An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." ie: loss of limb
Sentinel event
Which definition is correct to explain the nursing process? -Procedures used to implement client care -Sequences of steps used to meet the client's needs -Activities employed to identify a client's problem -Mechanisms applied to determine nursing goals for a client
Sequences of steps used to meet the client's needs
What is SPICES used for and what does it stand for?
Skin Problems eating Incontinence Confusion Evidence of falls Seep disturbance Risk factors for older adults
What do all client outcomes created in the planning phase of ADPIE need to be?
Specific Measurable Attainable Realistic Timed
What are 2 ways in which linguistic communication can occur?
Speech and writing
Are primary and secondary data subjective or objective?
Subjective
What is similar to the nursing process in that it has the same steps (ADPIE) and (also like the nursing process) can be used as a set of checkpoints that do not always flow in sequential order?
Teaching process
What is defined as: "The knowledge and use of tools, machines, materials, and processes to help solve human problems."
Technology
Who inspects and reviews a variety of areas within each organization in relation to technology and informatics?
The Joint Commission
In addition to the rights of delegation, what else should you consider when delegating a task?
The acuity of the patient
To provide patient safety, we must use screening tools adopted by what?
The facility we are working at
H.J., a 74-year-old black man, is a retired army military officer. His wife of more than 50 years passed away 4 years ago. He has 4 daughters and 2 sons who are all grown and married. He has 14 grandchildren with a great-grandchild on the way. His son brought him to the health care provider today because he is concerned his father has been more forgetful and is losing weight. H.J. has a history of coronary artery disease that is being managed with metoprolol XL (Lopressor) and aspirin. 2.How will your assessment be different from the assessment performed by the health care provider?
The health care provider will use the assessment to diagnose any medical conditions determine treatment. As a nurse, you will use your assessment to evaluate H.J.'s health status or responses to any actual or potential health problems or life processes.
Who is responsible for the implementation of the task when it is delegated by the nurse?
The nurse who delegated
What phase of the nursing process prioritizes the nursing diagnosis?
The planning phase (when you are developing client outcomes)
When delegating a task, you must consider the rights of what?
The rights of delegation
What is important to document about assessment data?
The source (subjective, objective, primary, secondary)
What is the purpose of a patient interview during the data collection phase of a health assessment?
To obtain a health history
When thinking in terms of Maslow's Hierarchy of Needs, if options are to help patient with toileting or feed patient, what would be first?
Toileting Both are physiological, but toileting is priority
What does an assessment include? (6)
Vital signs (temp, pulse, respiration, blood pressure) O2 saturation Pain
What is defined as: "A positive state of health that is continually changing."
Wellness
What is defined as: "An active process through which people become aware of, and make choices toward, a more successful existence."
Wellness
A "risk for" diagnosis is an example of what type of exam?
Wellness checkup
Can nurses act independently to create a diagnosis and r/t Wwithout doctor's orders?
Yes
If a patient requests a bath before breakfast, do you allow it? (Thinking in terms of Maslow's Hierarchy of Needs)
Yes, patient preference comes first as long as it doesn't contradict Maslow's.
A student nurse is studying clinical judgment theories and is working with Tanner's Model of Clinical Judgment. How can the student nurse best generalize this model? a. A reflective process where the nurse notices, interprets, responds, and reflects in action b. One conceptual mechanism for critiquing ideas and establishing goal-oriented care c. Researching best practice literature to create care pathways for certain populations d. Assessing, diagnosing, implementing, and evaluating the nursing care plans
a. A reflective process where the nurse notices, interprets, responds, and reflects in action
A home care nurse receives a physician order for a medication that the patient does not want to take because the patient has a history of side effects from this medication. The nurse carefully listens to the patient, considers it in light of the patient's condition, questions its appropriateness, and examines alternative treatments. What is the nurse's best action? a. Call the physician, explain rationale, and suggest a different medication. b. Consult an experienced nurse on whether there are other similar treatments. c. Hold the drug until the physician returns to the unit and can be questioned. d. Question other staff as to the physician's acceptance of nursing input.
a. Call the physician, explain rationale, and suggest a different medication.
A nurse is caring for a patient in a long-term care facility who has not been sleeping well. She notes that the patient is new to the facility, has been refusing therapy, and is also not eating well. The nurse interprets this to mean that the patient has been having trouble adjusting. The nurse decides to meet with the patient's care team. The team decides to assess the patient's willingneNss to participate in group recreational activities. The patient agrees to participate. After 1 week, the nurse reevaluates the plan of care and notes that the patient has been sleeping much better. Which of the following terms best describe processes used in the nurse's plan? (Select all that apply.) a. Clinical judgment b. Evidence-based practice c. The nursing process d. Collaborative care planning e. Positive reward process
a. Clinical judgment c. The nursing process d. Collaborative care planning
Which are exemplars of the health informatics concept? a. Clinical research informatics b. Hardware and software c, Privacy and security d. Standard terminology
a. Clinical research informatics (the others are considered aTtriBuTeS not exemplars. Ok giddens.)
Aspects of safety culture that contribute to a culture of safety in a healthcare organization include which component? a. Communication b. Fear of punishment c. Malpractice implications d. Team nursing
a. Communication
The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment? a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment b. Height, weight, body mass index (BMI), vital signs assessment c. Sleep assessment, energy assessment, memory assessment, concentration assessment d. Health and well-being, amount of community volunteer time, working outside the home, and ability to care for family and house
a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment
A new graduate nurse is working with an experienced nurse to chart assessment findings. The new nurse notes that the physical therapist wrote on the chart that the patient is lazy and did not want to participate in assigned therapies this AM. The experienced nurse asks the new nurse what may be going on here. What is the best explanation for this statement? a. Data on the chart can sometimes be documented in a biased manner. b. Data on the chart changes as the patient's condition changes. c. Data on the chart is usually accurate and can be verified from the patient. d. Reading the chart is not a wise use of time as this can be time consuming and tedious.
a. Data on the chart can sometimes be documented in a biased manner.
When discussing the purposes of healthcare informatics with a nurse during orientation, the nurse educator would be concerned if the nurse orientee stated that which is one purpose of informatics? a. Develop a cognitive science. b. Improve disease tracking. c. Improve the health provider's work flow. d. Increase administrative efficiencies.
a. Develop a cognitive science.
A new nurse appears to be second-guessing herself and is constantly calling on the other nurses to double-check their plan of care or rehearse what they will say to the doctor before she call on the patient's behalf. This seems to be annoying some of the nurse's coworkers. What is the nurse manager's best response? a. Explain to coworkers that this is a characteristic of critical thinking and is important for the new nurse to improve reasoning skills. b. Agree with the staff and have someone follow and work more closely with a preceptor. c. Have a talk with the nurse and suggest asking fewer questions. d. Tell the staff that all new nurses go through this phase, and ignore their behavior.
a. Explain to coworkers that this is a characteristic of critical thinking and is important for the new nurse to improve reasoning skills.
The nurse is assessing a patient's functional abilities and asks the patient, "How would you rate your ability to prepare a balanced meal?" "How would you rate your ability to balance a checkbook?" "How would you rate your ability to keep track of your appointments?" Which tool would be indicated for the best results of this patient's perception of their abilities? a. Functional Activities Questionnaire (FAQ) b. Mini Mental Status Exam (MMSE) c. 24hFAQ d. Performance-based functional measurement
a. Functional Activities Questionnaire (FAQ)
A nurse has committed a serious medication error and has reported the error to the hospital's adverse medication error hotline as well as to the unit manager. The manager is a firm believer in developing critical thinking skills. From this standpoint, what action by the manager would best nurture this ability in the nurse who made the error? a. Have the nurse present an in-service related to the cause of the error. b. Instruct the nurse to write a paper on how to avoid this type of error. c. Let the nurse work with more experienced nurses when giving medications. d. Send the nurse to refresher courses on medication administration.
a. Have the nurse present an in-service related to the cause of the error.
A nurse is conducting a therapeutic session with a patient in the inpatient psychiatric facility. Which remark by the nurse would be an appropriate way to begin an interview session? a. How shall we start today? b. Shall we talk about losing your privileges yesterday? c. Let's get started discussing your marital relationship. d. What happened when your family visited yesterday?
a. How shall we start today?
When planning to evaluate a patient's satisfaction with a teaching activity, what is the most appropriate strategy? a. Include a survey instrument. b. Observe for level of skill mastery. c. Present information more than one time. d. Provide for a return demonstration.
a. Include a survey instrument.
The nurse and the patient are conversing face to face. What communication technique is being demonstrated? a. Linguistic b. Paralinguistic c. Explicit d. Metacommunication
a. Linguistic
When there is evidence that supports a screening for an individual patient but not for the general population, the nurse would expect the United States Preventive Services Task Force Grading (USPSTF) to be what? a. No recommendation for or against b. Recommends c. Recommends against d. Strongly recommends
a. No recommendation for or against
Which feature distinguishes nursing diagnoses from medical diagnoses? Select all that apply. a. Nursing diagnoses involve the client when possible b. Nursing diagnoses are based on results of diagnostic tests and procedures c. Nursing diagnoses are identification of a disease condition in the client d. Nursing diagnoses involve the sorting of health problems within the nursing domain e. Nursing diagnoses involve clinical judgment about the client's response to health problems
a. Nursing diagnoses involve the client when possible d. Nursing diagnoses involve the sorting of health problems within the nursing domain e. Nursing diagnoses involve clinical judgment about the client's response to health problems
The nurse administrator is doing a study that entails gathering data about new employees over a 10-year period. Which research method would be the best one to use for this type of study? a. Quantitative longitudinal cohort b. Qualitative longitudinal c. Qualitative interview d. Qualitative case study
a. Quantitative longitudinal cohort (other examples are quantitative, only qualitative can be longitudinal or cohort studies)
The evaluation phase of the should include which of the following? (Select all that apply.) a. Reassessment b. Compare baseline and current condition c. Implement interventions d. Occur at end of shift e. Apply only to nursing care
a. Reassessment b. Compare baseline and current condition
A staff nurse reports a medication error due to failure to administer a medication at the scheduled time. What is the charge nurse's best response? a. We'll conduct a root cause analysis. b. That means you'll have to do continuing education. c. Why did you let that happen? d. You'll need to tell the patient and family.
a. We'll conduct a root cause analysis.
A nurse is planning to assess the structure of a family. Which question should the nurse ask? a. Who lives with you in this home? b. Who does the grocery shopping? c. Who provides support in your family? d. How old are the members of your family?
a. Who lives with you in this home?
The nurse manager of a pediatric clinic could confirm that the new nurse recognized the purpose of the HEADSS Adolescent Risk Profile when the new nurse responds that it is used to assess for needs related to a. anticipatory guidance. b. low-risk adolescents. c. physical development. d. sexual development.
a. anticipatory guidance.
According to Maslow's hierarchy of needs, in which order would the nurse prioritize actions? 1. Encouraging the client to talk about fears and feelings. 2. Praising the client for administering insulin accurately. 3. Providing a warm bath to the client to promote a good night's sleep. 4. Assisting the client in getting out of bed to join family members for meals. a. 4, 3, 2 and 1 b. 3, 1, 4 and 2 c. 3, 4, 1 and 2 d. 2, 3, 4 and 1
b. 3, 1, 4 and 2
The staff nurse who uses informatics in promoting quality patient care is most likely to access data in which domain? a. Certified clinical information systems (CIS) b. Clinical healthcare informatics c. Public health/population informatics d. Translational bioinformatics
b. Clinical healthcare informatics
To design and implement a decubitus ulcer risk management protocol in the electronic health record, the informatics nurse would first perform which action? a. Build the screens in the electronic health record. b. Determine evidence supporting decubitus ulcer risk management. c. Develop the training program for staff. d. Select the appropriate standardized language.
b. Determine evidence supporting decubitus ulcer risk management.
A nurse has designed an individualized nursing care plan for a patient, but the patient is not meeting goals. Further assessment reveals that the patient is not following through on many items. Which action by the nurse would be best for determining the cause of the problem? a. Assess whether the actions were too hard for the patient. b. Determine whether the patient agrees with the care plan. c. Question the patient's reasons for not following through. d. Reevaluate data to ensure the diagnoses are sound.
b. Determine whether the patient agrees with the care plan.
The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate? a. Are you able to shop for yourself? b. Do you use a cane, walker, or wheelchair to ambulate? c. Do you know what today's date is? d. Were you sad or depressed more than once in the last 3 days?
b. Do you use a cane, walker, or wheelchair to ambulate?
Which tertiary prevention measure should be included in the health promotion plan of care for a patient newly diagnosed with diabetes? a. Avoiding carcinogens b. Foot screening techniques c. Glaucoma screening d. Seat belt use
b. Foot screening techniques
1. The nurse is working with a patient diagnosed with post-traumatic stress disorder related to childhood sexual abuse. The patient is crying and states, "I should be over this by now; this happened years ago." Which response(s) by the nurse will facilitate communication? (Select all that apply.) a. Why do you think you are so upset? b. I can see that this situation really bothers you. c. The abuse you endured is very painful for you. d. Crying is a way of expressing the hurt you're experiencing. e. Let's talk about something else, since this subject is upsetting you.
b. I can see that this situation really bothers you. c. The abuse you endured is very painful for you. d. Crying is a way of expressing the hurt you're experiencing.
A nurse has prepared a dischaNrge teaching plan for an adult patient who is not being compliant. Which strategy should the nurse include to help increase compliance with following discharge instructions? a. Individualized handout b. Instructional videos c. Internet resources d. Self-help books
b. Instructional videos
A patient has been admitted for a skin graft following third degree burns to the bilateral calves. The plan of care involves 3 days inpatient and 6 months outpatient treatment, to include home care and dressing changes. When should the nurse initiate the educational plan? a. After the operation and the patient is awake b. On admission, along with the initial assessment c. The day before the patient is to be discharged d. When narcotics are no longer needed routinely
b. On admission, along with the initial assessment
Which activities would the nurse perform to meet the client's safety and security needs based on Maslow's hierarchy of needs? Select all that apply. a. Provide a cold bath to reduce the client's body temperature. b. Positioning the bed in a low position and keeping the side rails up. c. Monitoring vital signs, such as blood pressure to decrease the risk of falls. d. Observing a client who has suicidal tendencies to prevent adverse incidents e. Collaborating with the family members to provide emotional support for the client post surgery.
b. Positioning the bed in a low position and keeping the side rails up. c. Monitoring vital signs, such as blood pressure to decrease the risk of falls. d. Observing a client who has suicidal tendencies to prevent adverse incidents
At the well-child clinic, how does the nurse correctly teach a mother about health promotion activities and describe immunizations? a. Unique for children b. Primary prevention c. Secondary prevention d. Tertiary prevention
b. Primary prevention
The nurse in the outpatient setting would like to conduct a research study that compares patients who take tramadol (Ultracet) to patients who take oxycodone hydrochloride and acetaminophen (Percocet) for managing back pain. Which quantitative research method should yield the best results? a. Longitude study b. Randomized controlled study c. Systematic reviews/meta-analysis d. Survey study
b. Randomized controlled study
Prior to drug administration the nurse reviews the seven rights, which include right patient, right medication, right time, right dose, right education, right documentation, and what other right? a. Room b. Route c. Physician d. Manufacturer
b. Route
A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) a. Being a woman b. Taking more than six medications c. Having hypertension d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence
b. Taking more than six medications d. Having cataracts e. Muscle strength 3/5 bilaterally f. Incontinence
A mother complains to the nurse at the pediatric clinic that her 4-year-old child always talks to her toys and makes up stories. The mother wants her child to have a psychological evaluation. The nurse's best initial response is to a. refer the child to a psychologist immediately. b. explain that playing make believe is normal at this age. c. complete a developmental screening using a validated tool. d. separate the child from the mother to get more information.
b. explain that playing make believe is normal at this age.
Which of the following is an example of objective data? a. Pain b. Weight c. Dizziness d. Nausea
b. weight
Which statement does not correctly describe Maslow's hierarchy of needs? a. "The hierarchy of basic human needs includes five levels of priority!" b. "The second level includes safety and belonging needs, which involve physical and psychological security." c. "The fourth level contains love and belonging needs, including friendship, social relationships, and cope realistically with situations of life." d. "The final level is the need for self-actualization, which includes the ability to solve problems and cope realistically with situations of life."
c. "The fourth level contains love and belonging needs, including friendship, social relationships, and cope realistically with situations of life."
The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service after left knee replacement. Which tool is the best for the nurse to utilize? a. Minimum Data Set (MDS) b. Functional Status Scale (FSS) c. 24-Hour Functional Ability Questionnaire (24hFAQ) d. The Edmonton Functional Assessment Tool
c. 24-Hour Functional Ability Questionnaire (24hFAQ)
Using Maslow's hierarchy of needs, in which order would the nurse prioritize client care? 1. Safety and security 2. Self-esteem 3. Physiological 4. Self-actualization 5. Love and Belonging a. 3, 1, 5, 4 and 2 b. 4, 5, 3, 2 and 1 c. 3, 1, 5, 2 and 4 d. 1, 2, 3, 4 and 5
c. 3, 1, 5, 2 and 4
The nurse is seeking clarification of a statement that was made by a patient. What is the best way for the nurse to seek clarification? a. What are the common elements here? b. Tell me again about your experiences. c. Am I correct in understanding that... d. Tell me everything from the beginning.
c. Am I correct in understanding that...
Collaborative interventions are therapies that involve which of the following? a. More than one health care professional b. Nurse and client c. Client and physician d. Nurse and physician
c. Client and physician
Which nursing action indicates that a nurse is more likely to incur a medication error during medication administration? a. Checks the original medication order on the patient's chart b. Asks the patient to state his/her name and date of birth c. Does not scan the barcode of the patient prior to administering the medication d. Does not provide the patient with a glass of water
c. Does not scan the barcode of the patient prior to administering the medication
A nurse manager is reviewing interrelated concepts to professional nursing. Which concepts should the nurse manager consider when addressing concerns about the quality of health promotion? (Select all that apply.) a. Culture b. Development c. Evidence d. Nutrition e. Health policy
c. Evidence e. Health policy
The application of information processing that deals with the storage, retrieval sharing, and use of healthcare data, information, and knowledge for communication and decision making is the definition of which area? a. Computer science b. Health informatics c. Health information technology d. Nursing informatics
c. Health information technology
A nurse is preparing to implement a teaching plan. Which factor might be considered to be a barrier to patient education? a. Family resources b. High school education c. Hunger and pain d. Need perceived by patient
c. Hunger and pain
What does the "I" in the acronym ADPIE represent? a. Imply b. Intervention c. Implementation d. Interest
c. Implementation
What is the most appropriate resource to include when planning to provide patient education related to a goal in the psychomotor domain? a. Diagnosis-related support groups b. Internet resources c. Manikin practice sessions d. Self-directed learning modules
c. Manikin practice sessions
When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of which aspect of the family? a. Development b. Function c. Political views d. Structure
c. Political views
Which of the following nursing diagnosis statements is correctly formatted? a. Obesity related to overweight as evidenced by patient states feels "fat" b. Acute Pain related to chronic pain as evidenced by overuse of pain medications c. Risk for suicide related to history of suicide attempt, suicidal ideations, recent suicide attempt d. Activity Intolerance related to immobility as evidenced by respirations of 16 and heart rate of 70
c. Risk for suicide related to history of suicide attempt, suicidal ideations, recent suicide attempt
Two women have an established long-term relationship and are attending parenting classes in anticipation of finalizing adoption of a baby. The nurse identifies them as which type of family? a. Cohabiting b. Nuclear c. Same-sex d. Single parent
c. Same-sex
When teaching a patient with a family history of hypertension about health promotion, the nurse describes blood pressure screening as which type of prevention? a. Illness b. Primary c. Secondary d. Tertiary
c. Secondary
To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition.
c. functional status.
The most appropriate response of the nurse when a mother asks what the Denver II does is that it a. can diagnose developmental disabilities. b. identifies a need for physical therapy. c. is a developmental screening tool. d. provides a framework for health teaching.
c. is a developmental screening tool.
The nurse preparing a teaching plan for a preschooler knows that, according to Piaget, the expected stage of development for a preschooler is a. concrete operational. b. formal operational. c. preoperational. d. sensorimotor.
c. preoperational.
A 17-year-old girl is hospitalized for appendicitis, and her mother asks the nurse why she is so needy and acting like a child. The best response of the nurse is that in the hospital, adolescents a. have separation anxiety. b. rebel against rules. c. regress because of stress. d. want to know everything.
c. regress because of stress.
The nurse caring for a patient would identify a need for additional interventions related to family dynamics when a. extended family offers to help. b. family members express concern. c. the ill member demands attention. d. memories are shared.
c. the ill member demands attention.
A sentinel event refers to which situation? a. An event that could have harmed a patient, but serious harm didn't occur because of chance b. An event that harms a patient as a result of underlying disease or condition c. An event that harms a patient by omission or commission, not an underlying disease or condition d. An event that signals the need for immediate investigation and response
d. An event that signals the need for immediate investigation and response
A patient states, <I had a bad nightmare. When I woke up, I felt emotionally drained, as though I hadn9t rested well.= Which response by the nurse would be an example of interpersonal therapeutic communication? a. It sounds as though you were uncomfortable with the content of your dream. b. I understand what you're saying. Bad dreams leave me feeling tired, too. c. So, all in all, you feel as though you had a rather poor night's sleep? d. Can you give me an example of what you mean by a bad nightmare?
d. Can you give me an example of what you mean by a bad nightmare?
The nurse identifies the family with a child graduating from college as having which effect on the family life cycle? a. Minimal impact b. Considered to be a negative impact on the family unit c. Leads to role confusion d. Expectation of role change
d. Expectation of role change
The nurse in the psychiatric unit is involved in a research study for a depression medication. In the study, patients are randomly assigned to one depression medication and the other group is receiving no medication to treat the depression. What method of research are the patients involved with? a. Descriptive b. Correlational c. Quasi-experimental d. Experimental
d. Experimental
To promote safety, the nurse manager sensitive to point of care (sharp end) and systems level (blunt end) exemplars works closely with staff to address which point of care exemplar? a. Care coordination b. Documentation c. Electronic records d. Fall prevention
d. Fall prevention
The nurse is assessing a patient's functional ability. Which patient best demonstrates the definition of functional ability? a. Considers self as a healthy individual; uses cane for stability b. College educated; travels frequently; can balance a checkbook c. Works out daily, reads well, cooks, and cleans house on the weekends d. Healthy individual, volunteers at church, works part time, takes care of family and house
d. Healthy individual, volunteers at church, works part time, takes care of family and house
The nurse is admitting a patient to the medical/surgical unit. Which communication technique would be considered appropriate for this interaction? a. I've also had traumatic life experiences. Maybe it would help if I told you about them. b. Why do you think you had so much difficulty adjusting to this change in your life? c. You will feel better after getting accustomed to how this unit operates. d. I'd like to sit with you for a while to help you get comfortable talking to me.
d. I'd like to sit with you for a while to help you get comfortable talking to me.
Which factors which would alert the nurse to negative/dysfunctional family dynamics? a. Aging of family members b. Chronic illness of a family member c. Disability of a family member d. Intimate partner violence
d. Intimate partner violence
A nurse administers an incorrect medication to a patient. In reviewing this medication error, the nurse finds out that incorrect medication was placed in the Pyxis system. What type of error has the nurse committed? a. Latent error b. Blunt end c. Did not follow nursing process d. Latent error resulting in active error
d. Latent error resulting in active error
The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? a. Eating and drinking, personal cleansing and dressing, working and playing b. Toileting, transferring, dressing, and bathing activities c. Sleeping, expressing sexuality, socializing with peers d. Maintaining a safe environment, breathing, maintaining temperature
d. Maintaining a safe environment, breathing, maintaining temperature
The primary healthcare nurse would recommend screening based on known risk factors, because of which action? a. Eliminate the possibility of developing a condition. b. Identify appropriate treatment guidelines. c. Initiate treatment of a condition or disease. d. Make a substantial difference in morbidity and mortality.
d. Make a substantial difference in morbidity and mortality.
A nurse is reviewing concepts related to documentation in the electronic health record. Which statement best represents the concept of "meaningful use"? a. Allows for privacy of information b. Uses individualized log on for access c. Completes charting in a timely manner d. Meets established criteria related to technological use
d. Meets established criteria related to technological use
One of the first nurse researchers to document evidence-based practice for nursing was Florence Nightingale. What did Nightingale incorporate into her practice that made her practice different from her colleagues? a. Nightingale gathered scientific data. b. Nightingale calculated statistics to report her findings. c. Nightingale communicated her findings to powerful others. d. Nightingale based her nursing practice on her findings.
d. Nightingale based her nursing practice on her findings.
When describing patient education approaches, the nurse educator would explain that informal teaching is an approach that involves which quality? a. Addresses group needs b. Follows formalized plans c. Has standardized content d. Often occurs one-to-one
d. Often occurs one-to-one
The nurse educator would identify a need for additional teaching when the student lists which example as a type of learning? a. Affective b. Cognitive c. Psychomotor d. Self-directed
d. Self-directed
A nurse manager is reviewing interrelated concepts to the professional nursing role. Which factor should the nurse manager consider when addressing concerns about the quality of patient education? a. Adherence b. Developmental level c. Motivation d. Technology
d. Technology
The nurse is implementing a plan of care for a patient newly diagnosed with type 2 diabetes mellitus. The plan includes educating the patient about diet choices. The patient states that they enjoy exercising and understand the need to diet; however, they can't see living without chocolate on a daily basis. Using the principles of responding in the Model of Clinical Judgment, how would the nurse proceed with the teaching? a. The nurse explains to the patient that chocolate has a high glycemic index. The nurse then focuses on foods that have low glycemic indexes and provides a list for the patient to choose from. b. The nurse explains that the patient may eat whatever they would like as long as the patient's glucose reading and A1c remain stable. c. The nurse derives a new nursing diagnosis of Knowledge Deficit and readjusts the plan of care to include additional sessions with the registered dietician. d. The nurse examines the patient's daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.
d. The nurse examines the patient's daily glucose log and incorporates the snack into the time of day that has the lowest readings. The nurse then follows up and evaluates the response in 1 week.
The nurse is caring for a patient experiencing an allergic reaction to a bee sting who has an order for diphenhydramine (BenaDRYL). The only medication in the patient's medication bin is labeled BenaZEPRIL. The nurse contacts the pharmacy for the correct medication to avoid what type of error? a. Communication b. Diagnostic c. Preventive d. Treatment
d. Treatment
The nurse manager of a medical/surgical unit wants to increase the use of healthcare technology on the unit and is working with an ANA-certified informatics nurse to reduce which barriers to health information exchange? a. Basic informatics knowledge and skills b. Offering the best set of tools c. Privacy and security policies d. Unit-specific terminology
d. Unit-specific terminology
The nurse in a newly opened community health clinic is developing a program for the individuals considered at greatest risk for poor health outcomes. How should the nurse consider this group? a. Global community b. Sedentary society c. Unmotivated population d. Vulnerable population
d. Vulnerable population
To promote a culture of safety, the nurse manager preparing the staff schedule considers the anticipated census in planning the number and experience of staff on any given shift. Which is the human factor primarily addressed with this consideration? a. Available supplies b. Interdisciplinary communication c. Interruptions in work d. Workload fluctuations
d. Workload fluctuations
Which of the following is an example of subjective data? a. Wound appearance b. Heart Rate c. Temperature d. Anxiety
d. anxiety
To plan early intervention anNd care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b. autism. c. attention-deficit/hyperactivity disorder (ADHD). d. failure to thrive.
d. failure to thrive.
The implementation phase of the nursing process is when you: a. use nursing outcomes classification (NOC). b. record the care plan. c. evaluate the objectives. d. give the nursing care.
d. give the nursing care.
The school nurse talking with a high school class about the difference between growth and development would best describe growth as a, processes by which early cells specialize. b. psychosocial and cognitive changes. c. qualitative changes associated with aging. d. quantitative changes in size or weight.
d. quantitative changes in size or weight.
The most appropriate initial nursing intervention when the nurse notes dysfunctional interactions and lack of family support for a patient would be to a. enforce hospital visiting policies. b. monitor the dysfunctional interactions. c. notify the primary care provider. d. role model appropriate support.
d. role model appropriate support.