CoursePoint+ Foundations of Nursing Ch. 4: Health of the Individual, Family, and Community

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?

Self-esteem needs

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

A couple with adolescent children is most likely to focus on which of the following developmental tasks?

Strengthening marital relationships 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 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 states, "I don't discuss money matters with my wife because I don't want her to worry."

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 nursing student asks the instructor to explain what a community is. Which statement by the instructor would be inappropriate?

"Communities have few effects on the health of the individuals that live there."

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 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.

An adolescent confides in the school nurse that she is arguing daily with her mother, and she often wonders if 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

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 working with patients in a community is aware that which of the following is a true statement related to environmental factors in that community?

Barriers to accessing health care within a community may include lack of transportation. Environmental barriers to accessing health care within a community include lack of transportation, distance to services, and location of services.

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

Been socialized in healthcare

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

Common interests

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 of the following factors is the primary influence on this aspect of the family's health?

Community health care structure

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 psychosocial factors.

Which of the following theorists supports the developmental framework of family assessment?

Duvall

According to Archer, what are the three general types of communities?

Emotional, structural, and functional

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 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

The nurse assesses a client who is postoperative day 1 following a total abdominal hysterectomy. Assessment data includes BP 150/88 mm Hg, HR 100/bpm, RR 22/min with a pain scale of 8 out of 1-10. The abdominal dressing in clean, dry, and intact. The client's orders indicate ambulation today. Which is the priority nursing action?

Medicate the client for pain.

The family is a social group whose members share common values, occupy specific positions, and interact with each other over time. Which of the following is considered the basic unit of human society?

Family

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 Explanation: The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. When assessing the family of a depressed client for affect and coping function, it is helpful for the nurse to be aware of the family's communication style. This information can help identify family difficulties and teaching points that could benefit the client and the family.

The nurse is implementing care for several clients. Which of the following clients 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. The nurse who provides privacy for the client and family during times of prayer is helping the client to reach self-actualization, the highest level on the hierarchy.

A home health care nurse who works in a low-income community assesses the risk factors for clients being serviced. What is an example of a community risk factor?

Children are kept inside the home on a sunny summer day because of lack of recreational opportunities.

Which nursing diagnosis is the priority according to Maslow's hierarchy of basic needs?

Constipation related to decreased mobility

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

Measuring the client's I&O during recovery

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

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.

An 85-year-old man is being transferred from his house to a nursing home by his wife. What is the first action the nurse should take to help reduce the stress of relocation on the client?

Assess the client's usual lifestyle and daily activities. Assessment of the client's usual lifestyle and daily activities to incorporate them into his new life at the nursing home is the first action the nurse should take.

A nurse is evaluating a child for new onset of bedwetting. Which nursing action is the priority?

Collect a urine sample for the prescribed urinalysis (UA). To prioritize client care, a nurse will consider the client's physical needs as a priority, and address other psychosocial needs as secondary. In this instance, collecting a urine sample is an assessment, looking for a physical cause of the bedwetting. This would be done prior to implementation of orders, such as administration of medication and sending the child to radiology. Since asking the parent about stressful situations at home is psychosocial, it is not the priority.

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

Patient care dealing with nutrition and metabolism should include which factors? Select all that apply.

- knowledge about the value of the food pyramid - understanding food preferences of clients from the Jewish community - information on the client's financial status related to meal provisions - ability of the client to prepare food at home

The nurse is assessing a client diagnosed with early-onset Alzheimer's disease. The spouse states that it is making them uncomfortable to be the sole care provider due to the degree of lifestyle changes that will be required. Which factors will be a priority issue when assessing for a risk of caregiver role strain? Select all that apply.

- Past history of poor relationship between caregiver and care receiver - Inexperience with giving care to others - Caregiver as the spouse

Which client requires priority intervention when providing care on a medical-surgical unit?

A postsurgical 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?

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

A community has a lead smelting factory that is contaminating the air. According to Higgs and Gustafson, the community health nurse must

Assist in the protection of members

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

Which action by the nurse demonstrates the nurse's efforts to meet the client's self-actualization needs?

The nurse arranges for the client's clergy to visit after visiting hours.

The nurse enters the client's room in the acute care unit immediately after he 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 need for oxygen is the most essential of all physiological needs. Aspiration is a risk for the client after a seizure because of lethargy and increased oral secretions. The client will need to be positioned on his side to allow the secretions to drain from his mouth. Immediately following a seizure the client will experience postictal confusion, which usually resolves in 1 hour unless complicated by a head injury or hypoxia. Notifying the physician and documenting the type of seizure are good interventions after the client's airway is secure and breathing is normal.

A nurse is providing family-centered care to clients in a community health care clinic. Which statements about the family unit are accurate? Select all that apply.

- Duvall (1977) identified critical family developmental tasks and stages in the family life cycle. - The nuclear family is composed of two parents and their children. - The family is a buffer between the needs of individual members and society.

The nurse is reviewing the health care records of the Clifford Family who has experienced varying life crises. The nurse identifies which of the following as health risk factors? Select all that apply.

- Grandma Opal Clifford dies at the age of 98. - Shirley Clifford is pregnant at the age of 15. - Mr. Clifford is exposed to asbestos at work.

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.

The nurse is caring for an 85-year-old, female client hospitalized for dehydration. The nurse notices that the patient is shivering and takes the client's temperature. She notes an oral temperature of 97.8°:F (36.6°:C). The client also says that she is "chilly." What action, if taken by the nurse, is most appropriate?

Offer the client an extra blanket. Thermoregulation is a physiological need. The human body functions within a narrow temperature range with an oral temperature of 97.5°: to 99.5°:F (36°: to 38°:C). Homeostatic mechanisms and adaptive responses, such as shivering (to increase body temperature) or sweating (to reduce body temperature), helps to maintain body temperature. Offering the client a blanket is appropriate because the external body covering will increase her low body temperature.

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

Safety

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

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

The nurse receives a client assignment. Which client should the nurse see first?

Client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90%

The nurse has developed a strong therapeutic partnership with a 44-year-old electrician who suffered severe burns while working on an industrial site. Which of the nurse's following actions most directly addresses the patient's self-actualization needs?

Discussing the patient's strengths and dialoguing with him about his body image

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

A family assessment of a father, mother, and four children has suggested the presence of several risk factors. Which of the following aspects 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 home health nurse is making an initial visit to a client's home. During the visit she observes the mother cooking dinner, the father watching television with a child on his lap, and the grandmother in a rocking chair reading the Bible. The nurse recognizes this family structure as which of the following?

Extended family

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

Which are stressors that affect the health of the family?

Well-funded school systems and inadequate childcare services. Explanation: - Inadequate childcare services is a major stressor for many families. Well-funded school systems promote education within the community, which positively impacts the health of the community. - 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.

The nurse is assessing the family structure of the client and determines it is an extended family. Which of the following represent an extended family?

The family is comprised of two parents, three children, and one grandparent.

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.

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?

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.

What is the focus of community based nursing?

Promoting and maintaining the health of individuals and families. This nursing practice focuses on promoting and maintaining the health of individuals and families, preventing and minimizing the progression of disease, and improving quality of life.

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 her hands before and after the dressing change. 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.

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.

A nurse is planning education on self-administration of insulin to the client and his 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."

The community environment affects the well-being of the individual and the family. Which of the following is the health responsibility of the family?

Maintain a healthy lifestyle

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 The nuclear family is also known as the traditional family and is composed of two parents and their children. The parents might be heterosexual or homosexual, are often married or in a committed relationship

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?

Report the suspected child abuse to Child Protective Services. 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.

A nurse has the Petty Family as a client, who consists of a wife, husband, and their 4-year-old daughter. The husband has been unemployed for 8 months, and they lost their apartment. The family has been staying in neighborhood shelters and, on occasion, with the husband's father for a night or two. When evaluating this family, the nurse identifies this family as which type?

A homeless family Explanation: - This family is homeless, which is considered a nontraditional family. - A multigenerational family is one in which several generations or age groups live together in the same household. - A blended family is formed when parents bring unrelated children from previous relationships together to form a new family. - An extended family consists of a relative, such as aunts, uncles, and grandparents, who live in close geographic proximity to each other.