NUR 121, CHAPTER 4, PREPU
The nurse is admitting a 38-year-old male client to the oncology unit whose religious background is different from her own. The nurse is assessing how the client's religion may affect his health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care? "I am a Christian and believe in Jesus. What does your religion believe?" "Do you have any dietary restrictions that we should know about?" "Will your religion allow us to give you blood if you need it?" "What can we do to help you meet any religious needs you may have?"
"What can we do to help you meet any religious needs you may have?" Explanation: The nurse should always respect the client's religious beliefs and ask if he has any religious needs that may affect his health care. Comparing the client's beliefs to those of the nurse is inappropriate. Asking general questions about the client's religion would not identify other aspects of his religion that might affect his health care. A too narrow focus on only dietary restrictions or specific medical treatments will not give the nurse enough information to develop an inclusive plan of care.
A 44-year-old female client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which of the following values? Urine output of 1500 ml in 24 hours An elevated hematocrit level An elevated urine specific gravity Oral intake of 1500 ml in 24 hours
Urine output of 1500 ml in 24 hours Explanation: A balance between intake and elimination of fluids is an essential physiological need. Disruption in the water balance in the body results in either dehydration or edema. Measuring the fluid intake and output can determine the client's hydration status. A 24-hour urine output of 1500 is normal (range 1000 to 3000 ml/day) and indicates sufficient fluid intake to produce a normal urine output. An elevated hematocrit and urine specific gravity indicate that the client is dehydrated. An oral intake alone is not an indicator of adequate hydration
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 Participate in religious rituals Evolve psychologically over time Maintain order and safety
Occupy specific positions Explanation: The family is a social group whose members share common values, occupy specific positions, and interact with each other over time.
The nurse is assessing a family parented by a 60-year-old grandmother and her 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? Lack of knowledge about child safety Increased financial concerns Child abuse and neglect Conflict between family members
Increased financial concerns Explanation: Many single parent families are headed by women. Single parents often have special problems and needs, including financial concerns and role shifts (i.e., having the roles of both parents). Single-parent families are not less knowledgeable about child safety than other family types, nor is there a higher incidence of child abuse, neglect, or conflict among family members.
A nurse who is using DuVall's conceptual framework to assess a family with two parents and three children must first determine the Family's economic status Stresses within the family Age of the oldest child Parent's developmental stage
Age of the oldest child Explanation: DuVall's framework, essentially based on the individual life cycle, demonstrated that families move through a series of eight developmental stages. These stages are based on the developmental stage of the oldest child in the family, and they address marriage, childbearing, preschool years, school years, adolescent years, young adulthood, middle-aged parents whose children have left home, and aging parents.
Which of the following theorists supports the developmental framework of family assessment? Minuchin Duvall Satir Bowen
Duvall Explanation: Duvall supports the developmental framework of family function. Minuchin, Satir, and Bowen are nurses whose family nursing theory is based on systems theory.
Once physiologic needs are met, nurses can concentrate on meeting self-actualization needs of patients. What are examples of self- actualization needs according to Maslow's hierarchy of needs? (Select all that apply.) A nurse attains a master's degree in nursing by going to school in the evening. A nurse refers a patient's spouse to an Al- Anon group meeting. A student nurse takes a course in communication to improve her ability to relate to patients. A nurse raises the side rails on the bed of a patient at risk for falls. A nurse administers insulin to a diabetic patient. A nurse subscribes to several nursing journals to stay abreast of developments in the profession.
A nurse attains a master's degree in nursing by going to school in the evening. A student nurse takes a course in communication to improve her ability to relate to patients. A nurse subscribes to several nursing journals to stay abreast of developments in the profession. Explanation: The highest level on the hierarchy of needs is self- actualization needs, which include the need for individuals to reach their full potential through development of their unique capabilities. A nurse referring a client's spouse to an Al-Anon group meeting would be an example of addressing self-esteem, Level 4. A nurse raising the side rails on the bed of a client at risk for falls would be Level 2, safety and security. A nurse administering insulin to a diabetic client would be Level 1, physiological needs. A nurse going to school to attain a higher degree, or improving one's knowledge would be self-actualization, Level 5, examples.
A home health care nurse who works in a low- income community assesses the risk factors for patients being serviced. What is an example of a community risk factor? A woman finds out that she is genetically inclined to develop crippling arthritis. An 80-year-old man is at risk for falls in his home due to clutter in his hallways and stairways. Children are kept inside the home on a sunny summer day because of lack of recreational opportunities. A child is born with severe intellectual disability.
Children are kept inside the home on a sunny summer day because of lack of recreational opportunities. Explanation: A key component of the question is the term community. The most basic definition of a community is a specific population or group of people living in the same geographic area under similar regulations and having common values, interests, and needs. The only option above that addresses community is where children are kept inside the home on a sunny summer day because of lack of recreational opportunities. Each of the other options are focused on individuals which is not the direction of the question.
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 Maintain open communication Strengthen the marital relationship Maintain a supportive home environment
Adjustment to retirement Explanation: Developmental tasks for families with adolescents and young adults include balancing teenagers' freedom with responsibility, maintaining supportive home base, and strengthening marital relationships. Adjusting to retirement is a developmental task for families with older adults.
A community is defined as a social group that may or may not share common geographic boundaries yet interact because of Similar school districts Economic interests Common interests Political beliefs
Common interests Explanation: Community is defined as a social group, whose members may or may not share common geographic boundaries, yet who interact because of common interests or shared values to meet the needs within a larger society. A community assessment allows the nurse the opportunity to understand the community.
You are the community-based nurse who acts as case-manager for a small town about 60 miles from a major health care centre. What is the most important factor of community-based nursing for you be knowledgeable about? Eligibility requirements for services. Community resources available to patients. Transportation costs to the health care centre. Possible charges for any services provided.
Community resources available to patients. Explanation: A community-based nurse must be knowledgeable about community resources available to patients as well as services provided by local agencies, eligibility requirements, and any possible charges for the services. The other answers are incorrect because they are not the most important factor for a community-based nurse to be knowledgeable about.
The charge nurse is assigning client care for the upcoming shift. Which is the priority evaluation when performing this task? Determine the level and intensity of client care needed according to physical and psycho-social factors. Consider the educational level and experience of the nursing staff. Calculate the number of staff scheduled to work the oncoming shift. Examine the departmental budget to determine the financial consequences of staffing patterns.
Determine the level and intensity of client care needed according to physical and psycho-social factors. Explanation: Level and intensity of client care based on physical and psycho-social factors is the priority evaluation when using Maslow's hierarchy of needs. While the other options may impact staffing, these are not the priority when making client care assignments.
A client who was admitted to a drug treatment centre 3 days ago is boasting to the other residents that he used drugs for 2 years, and that his former employer never suspected that he was using drugs. Which action, if taken by the nurse, would be most appropriate for this client? Ask the client to give a short talk in group about drug abuse. Ask the client to mentor another client at the drug treatment centre. Insist that the client not talk about his past drug abuse. Have the client assume responsibility for the cleanliness of the dayroom.
Have the client assume responsibility for the cleanliness of the dayroom. Explanation: Having the client assume responsibility for the cleanliness of the dayroom would increase his sense of belonging and meet his basic need for acceptance of others without affecting the other clients. Asking the client to mentor another client is not appropriate at the start of treatment. Insisting that the client not talk about his past drug abuse would discourage therapeutic communication and trust between the nurse and the client.
The nurse is conducting a home assessment and suggests that the client's family remove scatter rugs from the home and increase the lighting. Which basic human need is being addressed by the nurse's suggestions? Physiologic Self-actualization Safety and security Self-esteem
Safety and security Explanation: Making changes in the home environment, such as removing scatter rugs and increasing lighting, promotes the safety of the family members. Physiologic needs include basic bodily functions, such as oxygen, water, and food. Self-esteem needs include the need for an individual to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments. Self-actualization includes the need for individuals to reach their full potential through development of their unique capabilities.
A nurse is caring for an adolescent who lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address? Love and belonging needs Safety and security needs Self-actualization needs Self-esteem needs
Self-esteem needs Explanation: The options listed are stages of Maslow's hierarchy of needs. The adolescent would have issues and concerns in the self-esteem stage. Self-esteem needs would include fear, sadness, loneliness, and accepting self; all would be appropriate with this client. Love and belonging would focus on the sociocultural aspect and would include areas such as relationships with others, communications with others, support systems, being part of a community, and feeling loved by others. Safety and security would focus on the environmental aspect and would include areas such as housing and community/ neighborhood to name a few. Self-actualization needs are in the intellectual and spiritual dimension and would include areas such as thinking, learning, decision making, values, beliefs, and helping others.
A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for patients in this developmental stage? Setting up parenting classes Providing alcohol and drug information Screening for congenital defects Providing sex education
Setting up parenting classes Explanation: Duvall (1977) identified critical family developmental tasks and stages in a family life cycle. Duvall's theory, based on Erikson's theory of psychosocial development, states that all families have certain basic tasks for survival and continuity as well as specific tasks related to developmental stages throughout the life of the family. The question asks about a community clinic that serves mostly families with young children and the priority intervention for clients in this developmental stage. Setting up parenting classes is the only answer that address the stated developmental stage. Families with adolescents and young adults would be at the appropriate developmental stage for providing sex education and alcohol/drug information. The community clinic would not focus on screening for congenital defects.
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 Physical Reproductive Affective and coping
Socialization Explanation: Through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving. Incorporating religious beliefs, values, and attitudes is an example of socialization. Physical functions of the family include providing a safe, comfortable environment necessary for growth and development, rest, and recuperation. The reproductive function of the family is raising children. The affective and coping function of the family involves providing emotional comfort to family members.
The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual? Physical dimension Environmental dimension Sociocultural dimension Emotional dimension
Sociocultural dimension Explanation: Communication is essential for interaction with others and is an example of the sociocultural dimension. Housing and community are examples of the environmental dimension. The emotional dimension includes fear, sadness, loneliness, and acceptance of self.
A couple with adolescent children is most likely to focus on which of the following developmental tasks? Strengthening marital relationships Establishing a mutually satisfying marriage Adjusting to retirement Coping with loss of energy and privacy
Strengthening marital relationships Explanation: The couple in a family with adolescents and young adults likely has a developmental task to strengthen marital relationships. Establishing a mutually satisfying marriage and coping with the loss of energy and privacy are tasks for a couple with young children. Adjusting to retirement is a developmental task for older adults.
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. The family celebrates Hanukkah and Passover with special meals. The family consults their rabbi and synagogue members during times of stress. The family members vacation together every year at a beach resort.
The father is an engineer and the mother is an elementary school teacher. Explanation: The occupations of the parents provide financial support for the family and contribute to the socioeconomic status of the family. Affiliation with a religious organization can be a source of social support during stressful times, which can promote adaptive coping for the family. Cultural and religious activities of the family define values and beliefs important to family members. Recreational activities, such as vacationing together, promote interaction of family members.
Which client requires priority intervention when providing care on a medical-surgical unit? a newly admitted client who is upset due to new cancer diagnosis an older adult client who is yelling and angry with family members a post-surgical client who is feeling dizzy with a heart rate of 45/bpm a client with a blood pressure of 98/40 mm Hg who needs to ambulate to the bathroom
a post-surgical client who is feeling dizzy with a heart rate of 45/bpm Explanation: According to Maslow, the first-level physiologic needs are the most important. They are the activities necessary to sustain life, such as breathing, circulation, and eating. Using Maslow and ABCs to help prioritize care of clients, the nurse needs to see the client experiencing acute problems with circulation and a heart rate of 45/bpm. All other client problems are not the priority at this time.
You are the nurse caring for a patient newly diagnosed with diabetes and you are developing a holistic plan of care. You know that for this plan of care to be successful it must what? Take into account the cost of care. Connect families, friends and the environment. Provide a connection between medicine and nursing. Address the disease but also incorporate the mind, body, and spirit.
Address the disease but also incorporate the mind, body, and spirit. Explanation: A holistic plan of care seeks to balance and integrate the use of crisis medicine, advanced technology along with the mind, body and spirit which are incorporated though the use of the nursing process. Option A is incorrect; taking into account the cost of care is only one facet of a holistic picture. Option B connecting families, friends and the environment is important but mind, body and spirit define holism. Option C is incorrect, a holistic plan of care may provide a connection between medicine and nursing but it does not define it.
A home health nurse is visiting the Goldstein family after the recent death of their matriarch. She observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. She asks Mr. Goldstein's cousin what is happening, and he says, "We are Jewish, and the family is 'Sitting Shiva' for my aunt." This family is fulfilling which family function? Economical function Physical function Affective and coping functions Socialization function
Affective and coping functions Explanation: This family exhibits the function of affective and coping by observing the ritual of "Sitting Shiva." By observing this Jewish, seven-day period of mourning for first degree relatives (husband, wife, parent, or child) the family provides emotional comfort to family members, helps to establish their identity, and maintains it in times of stress. Economical function provides financial aid to family members. Physical function provides a safe, comfortable environment necessary for growth and development. Through socialization the family teaches values, attitudes, and provides feedback, and with the function of reproduction the family produces and raises children.
A nurse in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of his head, and multiple 1-cm round scabs and blisters on his upper back. The parents state that their child sustained the injuries by falling out of his high chair. What is the best action for the nurse to take? Document the suspected child abuse in the child's health care record. Report the suspected child abuse to Child Protective Services. Refer the child and the family to social services for follow up. Ask the physician to question the parents about the suspected child abuse.
Report the suspected child abuse to Child Protective Services. Explanation: The physical function of the family is to provide a safe environment necessary for growth and development. The child's injuries (fractured femur with head injury and 1-cm round scabs and blisters on the upper back) suggest physical abuse by slamming the child into a wall while holding on to his leg, along with cigarette burns. All suspected cases of abuse must be reported to the appropriate agency or authority. Failure to report suspected child abuse is considered nursing negligence. Documenting "suspected abuse" in the client's record is inappropriate. Only the objective physical findings and observations should be documented. Referring the family for follow-up care to social services does not satisfy the legal obligation to report the suspected crime of child abuse to the proper authorities. Asking the physician to question the parents about the suspected abuse can jeopardize the child's safety by alienating the parents and creating distrust between the parents and the healthcare providers.
The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs? Safety and security Self-esteem Love and belonging Self-actualization
Safety and security Explanation: Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as moving and ambulating patients. Assisting the patient to ambulate ensures that the patient will not experience a fall.
The nursing instructor is discussing holistic health care with her nursing students. The instructor talks about the different factors the nurse must consider when creating a holistic plan of care. What are these factors? (Mark all that apply.) The patient's physical environment The patient's developmental life stage The patient's emotional context The patient's conceptual integration of life The patient's physiologic health condition
The patient's developmental life stage The patient's emotional context The patient's physiologic health condition Explanation: It is the nurse's conceptual integration of the physiologic health condition within the emotional and social context, along with the patient's developmental life stage, that allows for the development of a holistic plan of nursing care. The patient's physical environment and their "conceptual integration of life" are not factors the nurse would take into account when creating a holistic plan of care.
Which of the following statements 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 family is composed of independent members who live and function individually. The focus on health should be directed at improving the health of the sickest member of the family. Illness of one family member strengthens the roles of the sick member in the family structure.
The role of the family is essential in every level of nursing practice. Explanation: Friedman and associates identified the importance of family-centered nursing care, based on four rationales. First, the family is composed of interdependent members who affect one another. If some form of illness occurs in one member, all other members become part of the illness. Second, a strong relationship exists between the family and the health status of its members; therefore, the role of the family is essential in every level of nursing care. The third rationale is that the level of health of the family and, in turn, each member can be significantly improved through health-promotion activities. Finally, illness of one family member may suggest the possibility of the same problem in other members; through assessment and intervention, the nurse can assist in improving the health status of all members.
Which are stressors that affect the health of the family? Many job opportunities with adequate income. Family members who live in the same geographic location. Public transportation present throughout the community. Well-funded school systems and inadequate childcare services.
Well-funded school systems and inadequate childcare services. Explanation: Inadequate childcare services is a major stressor for many families. Communities that offer many job opportunities tend to have low unemployment. Families that have adequate income to meet the needs of the family tend to have higher health. Public transportation facilitates access to healthcare. Other family members who live nearby are a source of support. Well-funded school systems promote education within the community, which positively impacts the health of the community.
The nurse is taking care of a female client who is scheduled for a mastectomy. The client tells the nurse that she is apprehensive about the operation and asks the nurse to read a passage from the Koran to help her prepare herself for surgery. Which action by the nurse is the most appropriate? Read the Koran passage to the client. Gently inform the client that nurses cannot practice religion with clients. Ask the client if she would like to call a minister to pray with her. Ask if someone else on staff is the same religion as the client.
Read the Koran passage to the client. Explanation: Recognizing that Maslow's self-actualization need is a spiritual and intellectual dimension of a client is viewing the client as a whole person with a spiritual dimension just like physiological, safety and security, love and belonging, and esteem needs. Reading a religious passage to a client is not practicing a religion, and asking to call a minister or another staff member to address this spiritual need is deferring the client's needs to someone else
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? A client enrolls in art class after recovering from major surgery. A nurse arranges for a teenage client to have visits from school friends. Grab bars are installed in a client bathroom to facilitate safe showering. A nurse identifies strengths in a client who is scheduled for a mastectomy.
Grab bars are installed in a client bathroom to facilitate safe showering. Explanation: According to Maslow, safety and security needs follow basic physiologic needs; therefore, grab bars in a bathroom helps ensure safety in the client's shower. Enrolling in an art class would meet love and belonging, self-esteem, or self-actualization needs. Arranging for a teenager to have friends visit would help in meeting love and belonging needs. Identifying strengths in a client demonstrates self-esteem needs.
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? Cutting up food and opening drink containers for the client. Providing the mother the phone number for the Poison Control Center Seeking input from the client regarding their preferences for a snack. Assisting the client to validate their feelings regarding treatment options.
Providing the mother the phone number for the Poison Control Center Explanation: The nurse is meeting safety needs by providing a mother with the phone number for the Poison Control Center. Cutting up food and opening drink containers for the client would meet the most basic need for food. The nurse seeking input from the client regarding their preferences for a snack is showing respect to the individual and meeting self-esteem needs. When assisting the client to validate their feelings regarding treatment options, the nurse is acknowledging the uniqueness of the client and respects the client's knowledge and feelings in solving problems to attain self-actualization.
The nurse is assigned to take care of a client with rheumatoid arthritis. She notices that the client is wearing a copper bracelet. When she asks him about the bracelet, he says, "I believe that the bracelet will relieve the arthritis pain in my hands." Which action by the nurse is the most appropriate? Respect the client's beliefs associated with the copper bracelet and allow him to wear it. Inform the client that copper bracelets have not been medically proven to relieve arthritis pain. Encourage the client to use anti-inflammatory medication, like ibuprofen (Motrin). Inform the client that he must remove the copper bracelet before taking a shower.
Respect the client's beliefs associated with the copper bracelet and allow him to wear it. Explanation: The client's perception of the change, rather than the actual change itself, is what affects that individual's self-esteem. The nurse can help meet the client's self-esteem needs by respecting his values and beliefs. Wearing a copper bracelet continuously does not interfere with the client's well-being and it need not be removed while taking a shower. Encouraging the client to use medication or telling him that there is no medical reason to use a copper bracelet minimizes the client's beliefs and can undermine his self-esteem.
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? Change the abdominal dressing more frequently. Apply extra gauze dressings to the wound to absorb the drainage. Wash her hands before and after the dressing change. Use sterile gloves to change the abdominal dressing.
Wash her hands before and after the dressing change. Explanation: Physical safety and security means being protected from potential or actual harm. The abdominal dressing with a foul smell indicates the presence of bacteria. It is most important for the nurse to prevent the spread of infection to herself and others and to protect the client. Proper hand washing before and after the dressing change to prevent the spread of infection is a nursing activity that will meet these physical safety needs. Changing the abdominal dressing more frequently, applying extra gauze to absorb the wound drainage, or using sterile gloves to change the dressing will not prevent the spread of infection to other clients or staff.
The nurse provides the mother of a toddler with the phone number for the Poison Control Centre. Which level of Maslow's hierarchy of needs is the nurse addressing? Physiologic needs Self-actualization needs Loving and belonging needs Safety and security needs
Safety and security needs Explanation: The nurse is meeting safety needs by providing a mother with the phone number for the Poison Control Center. Physiologic needs, such as oxygen, food, water, rest, and elimination are the most basic needs essential for life. Love and belonging needs involves satisfactory relationships with others. Self-actualization, the highest level, includes the need of individuals to reach their full potential through development of their unique capabilities
The home health nurse is making an initial assessment visit to a family that consists of two parents and twin 3-year-old boys. During the interview, the nurse is most concerned if the client makes which statement? The father asks the nurse, "Do you mind if my little boy sits on my lap during the interview?" The mother states, "We like to pay cash for the things we need." The father states, "I don't discuss money matters with my wife because I don't want her to worry." The mother states, "This house would be a mess if I didn't clean it every day."
The father states, "I don't discuss money matters with my wife because I don't want her to worry." Explanation: Effective and healthy families exhibit open communication among its members. Protecting the spouse from worry by not discussing money matters stifles communication and jeopardizes the family's affective and coping functions. It is appropriate for a father to provide emotional comfort to his son by allowing him to sit on his lap during the interview. Paying cash is an appropriate way to manage family finances. The mother is stating her personal belief about housework in a clear and open manner.