411 Chapter 2

____________ prevention involves avoiding the disease or condition before it occurs through health promotion activities, environmental protection, and specific protection against disease or injury.

primary

A 13-year-old client who is newly diagnosed with type 1 diabetes is being discharged home with home care follow-up. What is the most appropriate goal for the nurse to select related to the nursing diagnosis of Health-Seeking Behaviors related to Skills Needed to Continue Home Care?

Client will self-administer insulin injections using appropriate technique.

The nurse is asked to present an educational event to the local Junior League. While planning for the event, what is most important for the nurse to do?

knows the needs of the audience

A nurse encourages both partners in a lesbian family to come into the examining room with the newborn during a well-baby check. What type of nursing is the nurse practicing?

transcultural nursing

A nurse is addressing a group of women on the issue of women's health during their reproductive years. Which reason does the nurse provide regarding the need for comprehensive, community-centered care to women during this time period?

women health care needs change with their reproductive goals

ways to prevent the incidence of neural tube defects in her fetus

take folic acid supplements each day.

Key element when providing family-centered care

communicate specific health information

The nurse is caring for a child from a different culture. Which statement(s) by the nurse demonstrates an understanding of how culture impacts a client? Select all that apply.

"Culture can impact who a client chooses to see for health care needs." "Culture can impact the diet a client follows." "A client's cultural beliefs can impact spirituality and/or religion." "A client's cultural beliefs should be incorporated into the care a client receives.

A nurse is teaching an 18-year-old client about circumcision care for her second baby. Which statement made by the nurse would be most appropriate to assess the client's learning ability?

"I note you're having problems with reading the information. Will you tell me about this?"

Advocacy for the client is an important aspect of community-based nursing. What is one way a nurse can advocate for a child client?

Assisting the family to apply for Medicaid or other forms of health care reimbursement

the nurse is working with a same-sex couple, both of whom have children from previous relationships. Although the couple have no plans of marrying, they view their relationship as monogamous and long-term. Which family structure would apply to this family? Select all that apply.

Gay or lesbian family Cohabitation family Blended family

A labor and birth nurse is admitting an adolescent client with her mother. The client appears to be upset, and the nurse wants to find out why. How should the nurse proceed? Select all that apply.

Make note of the client's and parent's nonverbal expressions. Maintain eye contact throughout the discussion. During the discussion maintain an open posture, with arms uncrossed.

The mother of a child who has been diagnosed with a chronic lung condition has asked what the implications are for her child's future. After providing education to the parent, which statements indicates the need for additional teaching? Select all that apply.

"Since this condition is not related to my child's level of intelligence, it will not impact her performance in school." "Social maturity is not likely to be impacted with a chronic lung condition."

The nurse is caring for a child. The nurse is trying to ensure that the family's cultural practices are supported. Which statement by the nurse indicates a lack of understanding regarding cultural competence?

"Since your child is only 8, I doubt that your child has any cultural practices we need to be aware of."

A pregnant woman reports she does not see the value in attending prepared childbirth classes because she plans to have an epidural to manage the discomfort from the contractions. What information should be included in responses by the nurse? Select all that apply.

"There are many different topics included in prepared childbirth classes aside from pain management." "Preparation for labor and birth can enhance your experience and coping abilities." "You can learn tools to assist you in the labor process both before and after your epidural."

When a pregnant client explains to the nurse that strawberries cause birthmarks, what is the nurse's best response?

"Wow, that's very interesting. Where did you learn that?"

A client follows traditions of the Chinese culture. The client is 7 weeks' pregnant and admitted with vaginal bleeding. During admission, the client tells the nurse, "This is all my fault. I never should have raised my arms above my head." Which response by the nurse is mostappropriate?

"You sound concerned. Let's talk about potential causes of miscarriage."

The home care nurse visits a client who is 32 weeks' gestation on bed rest and reporting a severe headache. Which intervention should the nurse implement first?

Assess the client's vital signs and conduct a quick, focused assessment.

A nurse is visiting the home of a mother and her newborn. The woman's family members are present when the nurse arrives. What is the nurse's best approach to the situation?

Assess the family members' interactions with the newborn and one another.

A 40-year-old pregnant client tells her nurse that she would like to give birth in a birthing center because she wants several friends and family members to be there and will have more freedom at the center. What would be the most important factor for the nurse to point out when discussing this option with the client?

Birthing centers do not always have pediatricians on staff if the newborn has special needs.

The nurse is preparing to teach a class on cultural differences to a group of clients from the community. Which principle of culture will the nurse consider while planning the class information?

Each generation learns about culture from family and the community

A nursing instructor is teaching the class about community-based nursing. The instructor determines the session is successful when the students correctly choose which activity as an example of tertiary prevention?

Ensuring the client attends physical therapy after orthopedic surgery

A 4-year-old adopted child has begun to ask questions about when she was born. Which suggestions by the clinic nurse would be considered the most appropriate answer for this child related to her birth? Select all that apply.

Explain to the child that she grew inside another woman, but after the birth she was given to her adoptive mom and dad to raise. Avoid criticizing the biological parents but reinforce how much the adoptive mom and dad love them.

The nurse is assessing an infant girl at her first well-baby visit. The nurse also observes the actions of the 6-year-old brother and parents who share that she was the best anniversary present they received this year. Which type of family will the nurse conclude these individuals represent?

Nuclear

Which concept characterizes transcultural nursing?

Planning care compatible with the client's health belief system

The nursing instructor is teaching a session on the increase of health care costs associated with the advancement of modern technology. The instructor determines the session is successful when the students correctly choose which focus of community-based health care that has been implemented to combat the increased cost?

Preventing disease and its sequelae

A 19-year-old pregnant adolescent who experienced a rape has arrive in the emergency department in active labor with no prenatal care. The nurse caring for the client should assess for which potential adverse health problem?

STI's

A nurse is developing a plan of care for a client of Muslim faith. Which action demonstrates an understanding of providing culturally competent care?

The client is asked if there are any meal preferences to be included in the care plan.

The community health nurse is seeing a mother and newborn for the first home visit. Which information best indicates an understanding of visiting clients in their home?

The home visit is a way of monitoring the well-being of all family members.

The nurse is planning the discharge education session of a postpartum client who recently moved to the United States from Vietnam. What questions would the nurse plan to ask to ensure learning will take place? (Select all that apply.)

What is the family's religious belief? Does the family have social support system? Who is the authority figure in the family? Who will be the person caring for the newborn at home?

A nurse is addressing a group of women on the issue of women's health during their reproductive years. Which reason does the nurse provide regarding the need for comprehensive, community-centered care to women during this time period?

Women's health care needs change with their reproductive goals

A community health nurse is actively involved in various community projects. The nurse is providing a secondary prevention activity by organizing which event?

a skin cancer screening fair

_____________ literacy is the ability to read, understand, and use health care information

health

A client with hypertension tells her nurse that she would like to use an herbal substance (CAM) to lower her blood pressure instead of taking the antihypertensive medication. The nurse should:

advise the client to speak with her primary care provider about combining herbal substances with her medication.

A woman in active labor begins to recite a lullaby to "call the baby outside." Which action by the nurse caring for this woman is most appropriate at this time?

allow the client to perform a ritual

A woman is in the second stage of labor, 8-cm dilated and 90% effaced. She keeps very quiet without expressing any outward signs of pain. Which intervention by the nurse would be mostappropriate in this situation?

allow the women to labor according to her cultural beliefs

When a woman is admitted to the labor-and-delivery unit, her husband says he is going to work and asks you to call when the baby is born. Your best response to this husband would be to

ask him if he knows that he can stay with his wife during labor.

A home care nurse is planning care for a 29-week gestation client pregnant with triplets on bed rest to reduce the chance for preterm labor. Which tasks can the nurse delegate to the home care assistant? Select all that apply.

assist the client with a bed bath prepare lunch for the client

A community-based nurse has a different set of skills than those of counterparts who work in a hospital. Community-based nurses also face unique issues and challenges. What is one of the unique aspects of community-based nursing?

autonomous

Which action should a nurse perform to avoid disrupting family routine when visiting to provide home care?

avoid coming during mealtimes

The home care nurse is conducting an environmental assessment of an apartment home prior to the dismissal of a child with a wheelchair. Which finding on the environmental assessment would be the priority concern for the nurse?

bunk beds in the clients room

A home care nurse has just completed a home assessment for a client and notes that there are no working smoke detectors in the upstairs of the home. The client states that her husband just lost his job and they cannot afford to purchase them. Which is the most appropriate referral for the nurse to initiate?

call the local fire department

the collaborative process of assessment, planning, application, coordination, followup, and evaluation of the options needed to meet an individuals needs is referred to as _________________

case management

A woman with a high-risk pregnancy is on bed rest and is receiving home care from a nurse. The mother expresses anxiety over the possibility of losing the baby, as she has lost a previous pregnancy. She says that receiving visits from her friends and family while at home reduces her anxiety. Which outcome criterion would be the most appropriate pertaining to the home care of this client?

client is able to receive frequent visits from friends and family

What is a key element of providing family-centered care?

communicate specific health information

The nurse is caring for a pregnant woman and her family who are immigrants. Which intervention would be the priority for helping to achieve a successful outcome?

communicating using understandable terms

The nurse is caring for a 7-year-old boy and his family, who are immigrants. Which intervention will most significantly affect the success of the care provided?

communicating with sensitivity and understandable terms

_______________ may be defined as a specific group of people, often living in a defined geographical area, who share a common culture, values, and norms."

community

A home care nurse is visiting a pregnant client from the Arab culture. During the health history the husband frequently answers questions for the client. How should the nurse respond?

continue with the health history

A pregnant woman with premature ruptured membranes is trying to decide whether home care might be the best option for her. Which advantage should the nurse mention to the client that is most pertinent to her condition?

decreased exposure to infection

cultural _________ involve participating in cross-cultural interactions with people from culturally diverse backgrounds.

encounters

A community-based nurse is assessing the needs of a family of four, which includes a physically challenged 9-year-old. Which activity would the nurse prioritize to be an advocate for this family?

establish eligibility for assistive devices for child

A pregnant client is questioning the nurse about the advantages of the various health care options. When providing information about home care and births, which factor should the nurse point out as an advantage?

families can be better kept intact

women tells the nurse she places objects in her environment so that they are in harmony with chi. the nurse interprets this as which of the following

feng shui

the nurse is caring for a Turkish American client. the nurse understands that there could be major cultural differences between her an her client. the nurse contemplates assigning this client to a staff member who is of the same culture as the client. What is the potential consequence

lead to stereotyping of the client

A new mother tells the obstetrical nurse that her mother notices so much has changed in maternity care in recent years. One change she could likely be referring to is:

newborns stay at the mother's bedside with the family as long as it is well

______________ communication, also referred to as body language, includes attending to others and active listening

nonverbal

The nurse is preparing to teach a drug education class at a local elementary school. The nurse is focused on providing which type of care to the community?

primary prevention

The nurse caring for a woman in active labor notices a strange odor coming from some tea the family has brought. When questioned, the woman informs the nurse of herbs they have brewed in the tea to help lower the pain. Which intervention would be considered the mostappropriate for the nurse to take?

research the herbs in the tea and report the findings to the provider

A nurse is working in a community setting and is involved in case management. in which activity would the nurse most likely be involved?

schedule speech and respiratory therapy services

A nurse is caring for a Turkish American client. The nurse understands that there could be major cultural differences between the nurse and the client. The nurse contemplates assigning this client to a staff member who is of the same culture as the client. What is a potential consequence?

stereotyping of the client

homeless client diagnosed with human papillomavirus (HPV) is seen in the maternity clinic requesting a pregnancy test. Which nursing action would be the best example of the secondary level of prevention?

suggest she have a Pap smear

Which nursing plan is a good example of how to incorporate cultural diversity perferences into the labor and delivery unit?

supplying long-sleeved gowns and head scarves for a woman who requests them

When caring for woman who speaks a different language than one's own, the nurse must ask for an interpreter before having the client sign which forms to ensure clarity can be confirmed? Select all that apply.

surgical permit end-of-life care consent to blood transfusions

The home care nurse visited a newly assigned primigravida client with preeclampsia. When conducting the assessment and teaching, the client continued to cry and state she was in disbelief this was happening to her. When should the nurse schedule the second visit with the client?

the next day; the client is not coping well

The obstetrical nurse notes that a Muslim client has not been eating any of the meals supplied to her. Which actions performed by the nurse best demonstrate cultural competence?

the nurse becomes more familiar with the clients meal practices

The emergency nurse is providing care for a pregnant woman admitted with a broken femur, blackened eye, and multiple contusions. She admits her partner is abusive. Which activity would be considered at the tertiary level of prevention?

the nurse contacts the crisis social worker for assistance