Chapter 4: Health of the Individual, Family, and Community

The nurse receives an 8-year-old client in the pediatric unit following a tonsillectomy. Which assessment finding requires immediate intervention by the nurse?

The client makes a rattling noise when breathing through the mouth.

A nurse is caring for a family consisting of three middle-aged adults. Which examples describe developmental tasks of this type of family structure? Select all that apply.

The family must maintain ties with younger and older generations. -The family must prepare for retirement.

A new graduate nurse asks a nurse manager working at the community health center, "I've heard people talk about community health nursing and community-based nursing. Is there a difference?" Which response by the nurse manager would be appropriate?

"Community health nursing involves care for entire populations whereas community-based nursing focuses on individuals and families in that population."

A nurse is working as part of a group to address factors within the community affecting the health of the families in that community. Which area would the nurse identify as playing a role in contributing to altered health status? Select all that apply.

-Limited number of institutions providing health care -Overlapping of industrial zones with residential zones -Small number of recreational opportunities for adults and children

A client is admitted to the emergency department following a tornado in which multiple people were killed or injured. The nurse applies direct pressure to an open wound on the client's thigh while assuring the client that the weather has cleared. Which of Maslow's basic human needs is the nurse addressing with the actions? Select all that apply.

-Physiologic -Safety and security

Nursing, as a profession, has long held the belief that providing nursing care to an individual patient means providing nursing care to the entire family. What does this mean when put into a holistic framework of patient care?

Active participation by individuals and families in health promotion is integral to this framework of patient care.

A nurse is caring for a client diagnosed with pancreatitis. Which is a priority need for nursing management of this client?

Acute pain in the abdomen

A nursing student's parents are both physicians. The nursing instructor may feel the student has

Been socialized in healthcare

What is an example of a community risk factor?

Children are kept inside on a sunny day due to a lack of recreational opportunities.

A community is defined as a social group that may or may not share common geographic boundaries yet interact because of

Common interests

A client says, "I live in a small community on the northwest side of the city." Why does the nurse consider it significant that the client reports living in a community rather than a neighborhood?

Community indicates people who share similar characteristics.

The nurse is planning interventions to promote the health of a family with young children. Which family task does the nurse need to consider when planning interventions?

Coping with loss of energy and privacy

A nurse is assessing a family and identifying where the family is in the family life cycle. During this assessment, the nurse applies Duvall's theory. Which theory forms the basis for Duvall's theory?

Erikson's theory of psychosocial development

The nurse in the adolescent in-patient psychiatric unit is interviewing the family of a 16-year-old client admitted for depression and threatened suicide. What assessment information is most essential for the nurse in determining the affective and coping function of the family?

Family patterns of communication

A community health nurse is providing care to several farming families in a rural community. Which concept would be most important for the nurse to integrate into the plans of care for these families?

Family structures may change over time.

The nurse is assessing a family parented by a 60-year-old grandmother and three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families?

Increased financial concerns

A young couple who have been married less than a year are having difficulty with adjusting to parenting. What is a contributing factor to this level of maladjustment?

Limited time in learning to be a marital partner

A nurse is providing care to a client who is feeling lonely and isolated. In an effort to develop a trusting nurse-client relationship, the nurse exhibits a caring attitude, ensures the client's privacy, and spends time with the client to promote therapeutic communication. The nurse is meeting which category of client needs?

Love and belonging

The nurse assesses a client who is postoperative day 1 following a total abdominal hysterectomy. Assessment data includes blood pressure (BP) 150/88 mm Hg, heart rate (HR) 100 beats/min, respiratory rate (RR) 22 breaths/min with a pain scale of 8 on a scale of 1 to 10. The abdominal dressing is clean, dry, and intact. The client's prescriptions indicate ambulation today. Which is the priority nursing action?

Medicate the client for pain as prescribed by the health care provider.

A family that consists of two homosexual parents and three children living in the same house is an example of which type of family?

Nuclear

A nurse in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of the head, and multiple 1-cm round scabs and blisters on the upper back. The parents state that their child sustained the injuries by falling out of a high chair. What is the best action for the nurse to take?

Report the suspected child abuse to Child Protective Services.

The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which is an individual need?

Safety

Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family?

Socialization

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?

The father is an engineer and the mother is an elementary school teacher.

Which statement is true regarding Friedman's theory of family-centered nursing care?

The role of the family is essential in every level of nursing practice.

The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action?

Wash the nurse's hands before and after the dressing change.

The nurse in the pediatric unit is caring for a 10-year-old client admitted with dehydration and diarrhea after eating chicken contaminated with Salmonella bacteria. What action taken by the nurse would be the most effective in preventing the spread of the infectious microorganism?

Washing hands before and after providing the client care

A Spanish-speaking client is admitted to the emergency department with a urinary tract infection and is experiencing a stress response from hospitalization. What is the priority nursing intervention?

contact a translator

A comprehensive definition of family is that it is a social group with members who share common values, interact over time, and

occupy specific positions.

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

sit with the client and ask them about their feelings

A nurse is caring for a 78-year-old client who has been hospitalized following a stroke. Which nursing action has the highest priority for this client?

Measuring the client's intake and output during recovery

During the nurse's admission interview the client says, "I don't get too much rest because I am in nursing school and work full time to support myself and my kids." The nurse classifies this statement as an issue at which level of Maslow's basic needs?

Physiologic

In caring for a client, the nurse recognizes which as the primary educational and support structure for an individual?

Family members

The mother of three young children makes the following statements to the nurse working in community health. Drag and drop each statement in the order of priority from Maslow's basic priorities to Maslow's more complex priorities. Use all options.

1."Sometimes we run out of food the day before I get paid." 2."There have been two murders in our neighborhood in the last year." 3."My teenage son is so quiet. He works and goes to school all the time and doesn't have time for friends." 4."I keep my kids' clothes clean, but we don't have money for the latest styles." 5."I try to get along with our neighbors, but they are from a strange culture with weird ideas."

A nurse is planning education on self-administration of insulin to the client and the client's family members. The client asks the nurse why the family members are also included in the teaching. What should the nurse's response be?

"Family members are equally involved in planning and implementation of care."

An adolescent confides in the school nurse that the adolescent is arguing daily with her mother and often wonders whether her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health?

A psychosocial risk factor

The nurse has developed a strong therapeutic relationship with an electrician who sustained severe burns while working on an industrial site. Which action by the nurse most directly addresses the client's self-actualization needs?

Discussing the client's strengths and dialoguing about body image

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate?

limit the family visits to once daily

A client comes to the health center for a follow-up visit. Assessment reveals that the client is experiencing problems ambulating and moving about due to degenerative joint disease; in addition, the client is feeling isolated due to the limitations in mobility. The client also reports feeling anxious about the future related to the mobility issues and being unable to fulfill the role as the major provider. Which need would the nurse identify as the priority?

Mobility

The nurse enters the client's room in the acute care unit immediately after the client experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take?

Position the client in a side-lying position.

The nurse is caring for an 85-year-old client hospitalized for dehydration. The nurse notices that the client is shivering and takes the client's temperature. The nurse notes an oral temperature of 97.8°F (36.6°C). The client also reports being "chilly." Which nursing action is most appropriate?

Offer the client an extra blanket.

The nurse is aware that basic client needs must be met before a client can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a client after physiologic needs have been met?

Grab bars are installed in a client bathroom to facilitate safe showering.

A nurse is assessing a family with adolescents. The family consists of a father, mother, a 13-year-old son, a 14-year-old son from a previous marriage, and a 16-year-old daughter. Which statement by the parents would lead the nurse to suspect a potential risk factor for altered health with this family?

"Our 16-year-old just seems to butt heads with us at every turn."

Which theorist supports the developmental framework of family assessment?

Duvall

The nurse is admitting a 38-year-old client to the oncology unit whose religious background is different from the nurse's own. The nurse is assessing how the client's religion may affect the client's health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care?

"What can we do to help you meet any religious needs you may have?"

The nurse is reviewing the health care records of several families from the health care clinic. Which families should the nurse identify as being at risk for factors affecting their health? Select all that apply.

A family that uses herbal medicine -A family that is headed by a single mother -A family that fasts for religious purposes -A family that is vegan -A family that receives public assistance

Which intervention performed by the nurse is most appropriate for assisting a client in meeting safety and security needs based on Maslow's hierarchy of needs?

Providing the mother the phone number for the poison control center

A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for clients in this developmental stage?

Setting up parenting classes

In conjunction with the client, the nurse has set the following client outcomes. Which client outcome reflects Maslow's level of self-esteem needs?

The client will verbalize feelings of increased confidence in performing a finger-stick blood sugar.

The nurse is implementing care for several clients. Which client is the nurse helping to reach the highest level of Maslow's hierarchy of basic human needs?

The nurse provides privacy for the client and family during times of prayer.

A family assessment of a father, mother, and four children has suggested the presence of several risk factors. Which aspect of the family's structure and function would be considered a psychosocial risk factor?

The parents have a tumultuous relationship, with frequent separations in the past.

The parents of a blended family have a baby boy age six months who is due for immunizations. The clinic closest to their home has recently closed, and they feel intimidated by the prospect of going to the large, university hospital near their home. Which type of factor is the primary influence on this aspect of the family's health?

Community health care structure

When providing care to a client, the nurse prioritizes the client's needs. Which intervention would the nurse employ to meet the client's physiological needs? Select all that apply.

Assessing the client's skin color -Weighing the client -Promoting a high-fiber diet

The epidemiology nurse finds a lower occurrence of influenza cases in a section of a large metropolitan city. Further research reveals higher influenza immunization rates in that section of the city. The nurse determines which probable cause for this occurrence?

Immunization has become a community norm.

A nurse working with patients in a community is aware that which is a true statement related to environmental factors in that community?

Barriers to accessing health care within a community may include lack of transportation.

The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include?

Adjustment to retirement

A nurse is implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing?

Safety and security

A nurse is caring for an adolescent who has just lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address?

Self-esteem needs

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?

Sociocultural dimension

A nurse is caring for a client newly diagnosed with diabetes mellitus and developing a holistic plan of care. For this plan of care to be successful, it must what?

Address the disease but also incorporate the mind, body, and spirit.

A community-based nurse acts as a case manager for a small town about 60 miles from a major healthcare center. What is the most important factor of community-based nursing for this nurse to be knowledgeable about?

Community resources available to clients