Lecture exam 4 17, 18, 22, 23, 24 End of Chapter Review
Which action by a 3-month-old infant would the nurse interpret as an example of Piaget's sensorimotor stage of primary circular reaction? Deliberately placing the thumb into the mouth Accidentally kicking a ball Searching for an object under a blanket Shaking a rattle
Answer: a The deliberate action of placing the thumb in the mouth elicits a pleasurable effect. Accidentally kicking a ball is not a deliberate action. Searching for objects and shaking a rattle occur at later stages.
When developing treatment plans, which assumption should the nurse consistently make about individual clients within vulnerable populations? Educational levels are minimal. Economic resources are strong. Personal beliefs are important. Support systems are extensive.
Answer: c Personal beliefs of clients within a vulnerable population are always important. They are a key to how people will respond to care that is offered. Educational levels, economic resources, and support systems vary dramatically by individual clients within vulnerable populations.
Which behavior by the young adult patient indicates an understanding of patient education aimed at reducing the health risks for that age group? Smoking only one pack of cigarettes per day Limiting alcohol use to an occasional drink Using drugs found in a roommate's drawer for anxiety Having a relationship with a partner who was threatening in the past
Answer: b Having an occasional drink shows control and moderation. Smoking any amount is damaging, and education for cessation is needed. Using any drugs that are not directly prescribed for the person shows a lack of understanding of the risks of drugs. Staying in a relationship that has been dangerous in the past increases the risk of intimate partner violence.
How is the toddler's need for autonomy best met? The parents' consistently meeting the child's needs Encouraging imaginative play Allowing the child limited choices Promoting experimentation to determine cause and effect
Answer: c The toddler's need for autonomy can best be supported by allowing the child choices within limits. Parents consistently meet the child's needs during the infant period. In later developmental stages, imaginative play is encouraged, and experimentation is promoted to determine cause and effect.
The nurse is caring for a 45-year-old woman who is a breast cancer survivor. What activity associated with her cancer experience will promote this patient's spiritual well-being? Attending church every week Ensuring she follows her medication regimen Genetic testing on family members Speaking about her cancer experience to increase breast cancer awareness
Answer: d Speaking about her experience helps promote meaning and purpose in life. Church attendance does not guarantee time of spiritual reflection related to her breast cancer experience. Treatment and genetic testing assist in physical treatment and risk identification but do not necessarily relate to finding meaning and purpose.
From the nurse's knowledge about the emerging adult according to Arnett's theory, which behavior by a 21-year-old hospitalized male patient is most appropriate for his age group? Talking about college courses that he is taking while working part-time at a restaurant Requesting that his mom be present when his IV line is started Stating that he cares for his disabled father and his 2-year-old daughter Becoming upset that he is not giving back to his community
Answer: a According to Arnett (2006), emerging adults are shifting their choices, and many are unstable; they explore more possibilities and move gradually toward enduring choices. The young adult is often slow in transitioning due to pursuing higher education. This 21-year-old is pursuing education while working part time, which fits within Arnett's theory for this age group. A 21-year-old male would be exhibiting regression if he needed his mom with him during an intravenous (IV) start. Caring for his father and daughter would be more typical of middle adults, who are called the sandwich generation. Giving back to one's community is generativity, which is Erikson's middle adult developmental task.
The nurse has been caring for a patient who just died. The patient's daughter is crying uncontrollably, saying, "She was my best friend. I thought she would make it! I don't know what I am going to do." What is the nurse's best response? Express sympathy and ask if she would like to talk with a chaplain. Give the daughter time to cry in her mother's room alone. Ask the daughter if her father is still living. Inquire if the daughter would like to pray.
Answer: a At crisis times, spiritual advisors or chaplains are the best resource with the expertise to address family members' needs. Leaving the daughter alone or inquiring about her father would not provide the emotional support needed. The nurse should avoid making suggestions to the daughter but instead should seek to identify needs from the daughter's cues.
When the nurse is establishing goals for a community health initiative, which strategy is most important to incorporate in the planning process? Collaboration with key stakeholders Help from professional interpreters Location of schools and businesses Gender of primary care providers
Answer: a Collaboration with key stakeholders is critical to effective goal planning in a community. Valuing the ideas of stakeholders increases support for initiatives and has the potential to increase participation and improve outcomes. Help from professional interpreters, the location of schools and businesses, and the gender of health care providers are factors to be considered after goals are established and interventions are being considered for a specific target population.
A teenage girl faces a long hospitalization after surgery. How can the girl's continued development be fostered? Encourage her to write her feelings in a journal. Divert her attention by playing video games. Encourage her to work on craft projects. Make sure her parents are constantly by her side.
Answer: a Teenagers are capable of abstract thought and often find it helpful to verbalize their feelings either by talking or by journaling. Diverting her attention by playing video games and encouraging her to work on craft projects are measures that may be used to help her pass the time but are not methods of fostering teen development. A teen usually does not wish parents to be at his or her side constantly and may want some private time away from them.
Which interventions are considered helpful to assist nurses coping with the unexpected death of a patient for whom they cared for many weeks? (Select all that apply). Attending a Code Lavender with unit colleagues Journaling personal reflections surrounding the death of the patient Scheduling to work to a different shift than the one regularly worked Arranging a consultation with the unit manager to discuss a possible unit transfer Setting aside time for relaxation activities such as painting, gardening, or exercising
Answer: a, b, e Attending a Code Lavender, journaling personal reflections, and setting aside time for relaxation activities are all considered helpful strategies for nurses coping with loss and stress. Scheduling to work different shifts and discussing a possible unit transfer are both forms of avoidance that may result in increased stress and delayed grieving.
The mother of a 5-month-old infant is concerned because her child is not yet sitting on his own. What is the nurse's best response to her concerns? Informing the mother that this is not normal and recommending further evaluation Telling the mother that this is normal development for a 5-month-old Encouraging the mother to do sit-ups with the child to encourage muscle development Asking the mother if the child had any trauma at birth
Answer: b 7-month-olds will first sit with help and then sit on their own. A 5-month-old is not expected to sit alone. Although sit-ups may help muscle development, the child's neurologic system must develop enough to maintain a sitting position. Asking about birth trauma is not necessary, because the child is not exhibiting delayed development. Asking about birth trauma would cause alarm and is not related to the child's ability to sit.
What is the best method for the public health nurse to determine whether community members are involved in outdoor physical activity? Meet with the parents of high school children. Complete a windshield survey of the community. Evaluate the number of community health club members. Check the local health statistics for the incidence of obesity.
Answer: b A windshield survey will allow the nurse to observe whether people are walking or engaged in physical activity. It also will help the nurse identify single- or multiple-family private and public housing units; health, safety, and social services agency availability; and other essential community attributes. Meeting with parents, evaluating health club membership, or obesity statistics will not assess the concern of the prevalence of outside physical activity.
While assessing a patient for domestic violence, the nurse knows that which statement is true regarding domestic violence? It is a health risk factor only during young adulthood. It occurs across socioeconomic levels and cultural boundaries. Young women aged 20 to 24 have the lowest incidence of rape and sexual assaults. Women are the only victims of domestic violence whom nurses should be concerned about.
Answer: b All socioeconomic levels are affected by domestic violence. It is a health risk for adults of all ages from young to older adulthood. Young women have the highest rate of rape and sexual assault. Women are not the only victims of domestic violence. Men also may be victims of domestic violence and sexual assaults, although they are less likely to report it or to seek care.
A 1-year-old child grabs an Easter egg and attempts to throw it across the room. The nurse knows that the child is exhibiting which scheme according to Piaget? Adaptation Assimilation Accommodation Equilibration
Answer: b Assimilation occurs when the child attempts to use a new object in the same fashion as for a more familiar object. Adaptation is the process of adjusting schemes to new applications. Accommodation occurs when the child understands that the object is different from a more familiar object and cannot be used in the same way. Equilibration occurs when a balance is achieved between the old understanding and the new.
In using the PLISSIT model, what is the first action initiated by the nurse? Present basic information about sexual functioning. Ask permission to begin the sexual assessment. Inquire about any medications the patient is taking. Ask the patient about sexual activity and practices.
Answer: b Before initiating discussion via the PLISSIT model, the nurse should first seek permission to have the conversation with the patient. All the other listed steps occur, but only after permission is obtained.
A client with metastatic cancer shares with the clinic nurse that he has only days or weeks to live. What type of community service would be most appropriate for the nurse to suggest to this client? Home health care Hospice care Forensic care Acute care
Answer: b Hospice care provides specialized care for people who are dying. It may take place in a person's home or community facility. Home care is less specialized. Forensic and acute care would not be appropriate for this client.
What action would be most appropriate for the home care nurse to take if an intrinsic factor appears to be contributing to a client's illness? Report the presence of multiple insects in the home to the health department. Document the intrinsic factor in the client's electronic health record. Explore the possible impact of changing jobs for stress reduction. Discuss the danger of having multiple throw rugs with the client.
Answer: b Intrinsic factors include variables such as genetics, age, gender, and ethnic group. These should be documented in the client's electronic health record so their impact can be taken into consideration in assessing the client's health status. The presence of insects and throw rugs in a client's home and where the client works are extrinsic factors.
The nurse is performing a health assessment on a 15-year-old female patient. Which is the best way to obtain accurate information regarding her sexual activity? Ask the mother about the girl's sexual activity. Privately ask the girl about her sexual activity. Warn the girl about the dangers of sexual activity. Ask the girl if she wants birth control.
Answer: b Privately asking the girl about her sexual activity in an open and nonjudgmental fashion is the best way to obtain accurate information. Asking the mother about the girl's sexual activity may be embarrassing for the teen and her mother and may not provide accurate information. Warning the girl about the dangers of sexual activity is making a judgment. It is important to provide a nonjudgmental approach with teens. The teen may have additional questions about sexuality beyond the topic of birth control, so it is important to approach the teen in a manner that encourages open discussion.
When a patient is beginning a regimen of an antidepressant medication, which information should the nurse include in the medication teaching as it pertains to sexuality? "Your partner will be pleased because your sexual functioning is going to improve." "You may find that your desire for sex will decrease while on this medication." "Your skin will probably become supersensitive to touch, so you may need to change your activity during sex." "You will be unable to have an erection while taking your antidepressants."
Answer: b Reduced sexual desire can be a side effect of antidepressant use. Skin sensitivity and erectile dysfunction are not side effects. Improved sexual function is not a specific effect of antidepressant administration.
A 2-year-old child insists on having a drink of water and having a story read to him and says, "Good night, sleep tight" at bedtime every night. The nurse knows the child is exhibiting which type of behavior? Controlling Ritualism Obsession Compulsion
Answer: b Ritualism offers the toddler a sense of security and comfort. The child is not trying to control his behavior with the ritual. Obsession and compulsion are terms commonly used in patients in older age groups and describe maladaptive behaviors.
When teaching female reproduction to a group of high school students, the nurse uses what term to indicate the cessation of a woman's menstrual activity? Menarche Menopause Premenstrual syndrome Menstrual dysfunction
Answer: b The definition of menopause is the cessation of a female's menstrual activity. Menarche is the onset of menstruation. Premenstrual syndrome is a set of specific symptoms that occur before the monthly menstrual cycle. Menstrual dysfunction refers to altered patterns of menstruation associated with various disorders.
Which intervention should the college health clinic nurse implement as a secondary prevention strategy to identify students at risk for diabetes? Nutrition education on high-protein food availability Promotion of registration in fitness classes Blood glucose screening at the health fair Administration of prescribed insulin
Answer: c Blood glucose screening is the only secondary prevention strategy listed. Education and promotion of fitness classes are primary prevention strategies, and administering insulin is a tertiary prevention intervention.
What is the most important aspect of providing spiritual care in nursing practice? Call a chaplain. Complete the FICA spiritual assessment and refer as needed. Recognize situations and patient behaviors indicating a spiritual need. Spend some time in self-reflection.
Answer: c Changes in spiritual needs happen in the moment, and it is critical for nurses to recognize when a spiritual need arises. The FICA tool is not sensitive to daily changes in spiritual need. Calling a chaplain may be an appropriate intervention when the need arises. Nurses should integrate self-reflection in their own spiritual practices to find meaning in their life experiences, but that is not the most important aspect of providing spiritual care.
Which term indicates a mental health disorder that is frequently seen in older adults? Schizophrenia Bipolar disorder Depression Posttraumatic stress disorder (PTSD)
Answer: c Depression is one of the psychiatric illnesses appearing most frequently in the older adult population. Schizophrenia typically is seen in younger adult populations. Bipolar disorder is usually identified before age 65 years. PTSD can be seen in any age group and usually is related to previous experience of a traumatic event.
For which person seen at a physician's office appointment would patient and family education be most critical? A 24-year-old male patient with a cold virus and on no medications A 45-year-old male patient on metformin for type 2 diabetes for the past 3 years A 75-year-old female patient just prescribed the anticoagulant warfarin A 40-year-old male asthmatic patient diagnosed 10 years ago and on albuterol
Answer: c Educating the patient and family members to the side effects of anticoagulant warfarin and its potential for bleeding is a critical part of care for the 75-year-old female patient. A 25-year-old male patient is young, and his immune system has the potential to fight off a cold virus. Education about a cold versus the flu would be helpful but is not critical. A middle adult who has had diabetes and has been maintained on this medication for 3 years would have had education when he was first started on the medication. A patient who has been using asthmatic medication for the past 10 years is likely to be knowledgeable about the medication from previous use.
Which group is referred to as the sandwich generation? Older adults who are caretakers for their elderly parents Younger adults who are reexamining their life choices Middle adults who are caretakers for multiple generations of their family Younger adults who are changing employment constantly
Answer: c Middle adults who are caretakers for multiple generations of their family tend to be sandwiched in between the needs of children, grandchildren, and elderly parents, all of whom need their attention and care. This situation can lead to many health and financial problems for the middleadult. Although older adults caring for their elderly parent also may experience significant stresses, they would not be called the sandwich generation unless they also were caring for younger members of their family. Younger adults may change jobs or middle adults may reexamine choices they have made, but these factors do not reflect the concept of the sandwich generation.
The nurse is caring for a religious patient who is going to surgery the next day. The patient states that she is afraid and asks the nurse to pray with her, although the nurse is not religious. What is the most appropriate response by the nurse? "I am not confident praying, but I will think about you tomorrow." "I need to take care of other patients right now, but I will be back." "I am uncomfortable praying. May I call the chaplain for you?" "I don't do that. Nurses are not allowed to do that at our hospital."
Answer: c Offering to call the chaplain because the nurse is uncomfortable praying is the best option. Avoiding the subject or focusing on the nurse's feelings or needs is not appropriate and will not provide for the patient's stated spiritual need.
Which statement by a patient best illustrates reflection on a spiritual need? "My husband told me what to do about this situation, and I'm sure he's right." "There is little I can do now to change my circumstances. I just need to adapt." "I need to think a little more about how I feel about undergoing this treatment." "Whatever the physician wants to do is fine. I don't have much of an option."
Answer: c Reflection requires intentional thought about a situation to determine how it affects or is affected by the person's beliefs and values. Simply having someone tell the person what to do is not reflection. Adopting a fatalistic attitude or accepting the decision of a physician without inquiry are not reflection either.
How do people who participate in organized religion differ from nonreligious people? Religious people are healthier than spiritual people. Religious people are more spiritual than nonreligious people. Religious people express their spirituality through faith traditions. Religious people have spiritual practices, whereas nonreligious people do not have spiritual practices.
Answer: c Religious people express their beliefs through faith traditions. Research has not indicated that religious people are healthier or more spiritual than those who do not participate in organized religion. Nonreligious people may practice various spiritual disciplines.
While performing a physical assessment on a female patient, the nurse finds several bruises on the patient's inner thighs that are in various stages of healing and suspects that the patient may be a victim of sexual abuse. What should be the nurse's first action? Refer the patient to a sexual counselor. Tell the patient about the safe house for women. Ask the patient to describe how she got the bruises. Report the abuse immediately to the proper authorities.
Answer: c The nurse's first action is to gather more data that can confirm or negate the suspicion of sexual abuse. The other actions also could be appropriate after additional information is obtained.
What is the best activity for a hospitalized school-age child to encourage continued appropriate development? Watching favorite television shows for 2 hours per day Keeping a journal of feelings while in the hospital Working on a paint-by-number project that can be completed in an afternoon Playing a favorite video game each afternoon
Answer: c The school-age child is in Erikson's stage of industry. He needs to work on projects that build a sense of accomplishment. A painting project that can be completed in one afternoon gives a sense of accomplishment. Although the other options are activities, they do not contribute to the primary developmental task of the school-age child—developing a sense of industry.
The nurse knows that which patient is an example of the Wear-and-Tear Theory of Aging? A patient who is dying of cancer at age 35 A 55-year-old who runs half-marathons A patient with depression and suicidal thoughts who is 65 An 88-year-old with heart failure, kidney failure, and osteoarthritis
Answer: d Dr. Weisman believed that aging occurred because of overuse and abuse to body and cells, and that this takes place on the cellular and organ systems level. An 88-year-old with multiple body system failure and damage would be exhibiting signs of wear and tear. A 35-year-old patient dying of cancer would not have overuse. A 55-year-old running in half marathons is not exhibiting wear and tear, although signs of overuse may emerge later in life. A 65-year-old person with depression is not exhibiting wear and tear. Emotional stressors are only one group of factors that can lead to aging and are not a component of the Wear-and-Tear Theory of Aging.
A preschooler's mother is concerned because her child behaves in a mean fashion toward her younger brother. The mother states, "She acts like she has no sympathy for him!" What is the nurse's best response? "She is very young to exhibit sibling rivalry." "What does her brother do to her to make her act this way?" "Do you fight at home? She is probably imitating you." "Preschoolers are not capable of putting themselves in another's place."
Answer: d A characteristic of preschool thought is that it is egocentric. That is, preschoolers are not yet able to see a situation from another's point of view. Sibling rivalry commonly appears in the preschool period. The brother's behavior has no bearing on the mother's expressed concern. The child is not necessarily imitating adult behavior but is displaying appropriate developmental characteristics.
Which statement is the best resource for the nurse to use when determining appropriate nursing care for a transsexual patient? Gender identity is altered by acute psychosis. Sexual attraction is to individuals of both genders. Gonadal gender, internal organs, and external genitals are contradictory. Anatomy associated with sexual identity is not consistent with gender identity.
Answer: d A transsexual's sex organs do not match gender identity. Being a transsexual is not a psychosis. Transsexuals usually are attracted to persons of the gender opposite their own gender identity. Gonadal gender and internal and external organs are not in contradiction.
The nurse is caring for a 16-year-old boy receiving chemotherapy for testicular cancer. He says that his parents are religious and left a cross next to his bed for "good luck." What is the most appropriate response by the nurse? "Would you like to talk with a chaplain?" "Sounds like you are not very religious." "How well do you get along with your parents?" "What helps you get through tough times?"
Answer: d Asking an open-ended question is the best response that the nurse can make to this patient's comment. It will encourage the patient to share what he thinks would be most supportive at this time. Asking the patient if he would like to talk with a chaplain is incongruent with his comment about having a cross for good luck. Sharing that he does not sound religious is judgmental, and asking about his relationship with his parents is changing the subject.
A 75-year-old male patient reports decreased frequency of sexual intercourse, although he does not express dissatisfaction or difficulty. He seems a little embarrassed by the discussion but is engaged and asks some questions. Which nursing diagnosis does the nurse determine is most appropriate for this patient? Impaired Sexual Functioning Disturbed Body Image Difficulty Coping Lack of Knowledge
Answer: d Because the patient can discuss the topic of reduced sexual frequency without expressing difficulty or dysfunction, manages any embarrassment, is engaged in the conversation, and is able to ask questions, the most appropriate nursing diagnosis is Lack of Knowledge. The nurse would develop a care plan to include age appropriate discussion topics and/or patient education materials focused on the patient's physical condition, social situation, and his questions. The patient's collective behaviors do not describe Impaired Sexual Functioning, Disturbed Body Image, or Difficulty Coping.
A patient who had a hysterectomy 3 days ago says to the nurse, "I no longer feel like a real woman." Which response by the nurse would be most appropriate? "Don't worry about that. The feeling will probably go away." "You should talk to your doctor about how you feel." "I don't blame you. I would feel like half a woman also." "I hear your concern. Tell me more about your feelings."
Answer: d Providing an opportunity for communication with an open-ended response encourages the patient to discuss concerns. Telling the patient not to worry is dismissing those concerns and will hamper discussion. Agreeing with the patient also is nontherapeutic and does not foster dialogue. Telling the patient to talk with the doctor stops the chance of conversation and reduces the nurse's role in helping the patient express feelings.
The outpatient clinic nurse develops a plan of care focusing on diet, exercise, and glucose monitoring for a preteen recently diagnosed with early-onset type 2 diabetes. On what type of interventions has the nurse based the client's care plan? Primary Proactive Secondary Tertiary
Answer: d The nurse has incorporated tertiary interventions, because the client has already been diagnosed with an illness. Tertiary interventions are implemented once a disease occurs, to prevent further deterioration.
When caring for patients who are Jewish, how best can the nurse address their religious needs? Order a kosher diet. Allow time for prayer before each meal. Ask about religious holidays, particularly religious practices around the Sabbath. Ask about religious practices affecting care.
Answer: d There are a variety of levels of observance within the Jewish community. It is best to ask patients about what practices will affect their care. Do not assume that all persons of faith are equally observant of religious traditions.
Which factor(s) is/are likely to influence the transition from adolescence to adulthood? (Select all that apply.) Cultural beliefs Societal values Personal beliefs and expectations Governmental rules Societal expectations
Answers: a, b, c Cultural beliefs, societal values, and personal beliefs and expectations are all factors that influence an individual's transition into adulthood. Although governmental rules may influence certain societal values and beliefs, they are not directly responsible for the transition through adulthood. Coté (2006) states that little is socially expected during this time, so routes to adult roles and responsibilities are highly diverse.
Whom should the school nurse engage in discussion when conducting a needs assessment related to the high incidence of obesity in the school system? (Select all that apply.) Parents Students School staff Community members Firefighters and police
Answers: a, b, c, d To address the concern regarding obesity, the nurse will need to engage each of these groups, as well as school administrators and teachers, to gain insight into the needs and identify resources. The nurse could form a task force with representatives of each group to work on necessary interventions to address the high incidence of obesity. It would not be necessary for the nurse to speak with firefighters or police in this case.
When an injury to a child is suspicious for abuse, which is/are important to document? (Select all that apply.) Size and location of bruising Distinguishing characteristics of injuries Height and weight of the child Time of last meal General state of health of the child
Answers: a, b, c, e The size and location of the bruising, distinguishing characteristics of injuries, height and weight of the child, and the general state of health of the child all are considerations in determining possible child abuse or neglect. The exact location and the nature of the injury are important to document. A child who has been abused over time may be small and have other health problems stemming from the abuse. The time of the last meal may be important information but usually is not related to suspected abuse.
The nurse is caring for a group of older adults. Which patient(s) in this group is/are exhibiting normal signs of aging? (Select all that apply.) The patient with knee pain and wrinkles around the eyes The patient who needs reading glasses and states that the food tastes bland The patient who is confused and does not know the current year The patient who states that constipation is an increasing problem The patient who is showing signs of depression and hopelessness
Answers: a, b, d Normal aging includes signs of decline in many organ systems. Knee pain, skin wrinkles, need for reading glasses, decline in taste buds, and constipation all can occur with aging. Normal aging does not include dementia or depression, even though these can both be diagnosed in the older adult population.
Which actions describe the primary scope of practice of a public health nurse? (Select all that apply.) Assesses populations within the community Emphasizes health promotion and disease prevention using evidence-based strategies Focuses on individual, setting specific care. Collaborates with community stakeholders to assure that essential health services are available to the community. Promotes health policies to protect health
Answers: a, b, d, e Public health nurses focus primarily on population-focused practice as opposed to individually focused care. Population-focused care is aimed at health promotion and disease prevention. Assessment, policy development, and ensuring essential services are provided are the three core functions of public health.
When a patient reports having dyspareunia, which questions are appropriate for the nurse to ask? Select all that apply. "Have you talked with your partner about this discomfort?" "Have you had these spasms since you became sexually active?" "Has your health care provider offered any treatment measures? "Does the bleeding continue longer than 5 days?" "Do your breasts swell up large enough for you to need a larger bra?"
Answers: a, c Dyspareunia is painful intercourse. The sexual partner should be made aware of this to foster understanding and adjustment of sexual practices, and the health care provider should be aware, so potential treatment measures can be offered. Spasms, bleeding, and breast swelling are not associated with this condition.
A nurse assigned to the neonatal intensive care unit (NICU) has spent most of a day working with a critically ill infant, with the mother standing by. The infant experiences a cardiac arrest and does not survive. The mother spends an hour crying and holding the baby, saying good-bye. Which spiritual care interventions are most appropriate for the nurse to implement? (Select all that apply.) If desired, briefly hold the baby to say good-bye after the mother leaves. Follow procedures to prepare the body for transport to the morgue. Visit the mother the next day to see how she is doing. Call the family spiritual adviser or the chaplain. Ask the mother if you could call a family member or friend to be with her.
Answers: a, d, e It is important for nurses to take time to say "good-bye" to patients with whom they have developed a relationship. In this case, it would be appropriate for the nurse to hold the infant briefly, if desired, after the family has left before preparing the body for the morgue. With consent, the mother needs to be surrounded by appropriate persons to provide spiritual support, including a chaplain, family members, and friends. Although it is critical that the nurse follow procedures in preparing bodies for the morgue, it is not considered spiritual care. Visiting the mother after her loss could be viewed as a violation of professional boundaries, especially for a nurse who worked with the family for only a day.
Which intrinsic factors would be of major concern to the nurse when the community has an outbreak of pertussis? (Select all that apply.) Age Gender Ethnic group Cultural background Immunization status
Answers: a, e Age and immunization status would be of most concern because people who have not had a pertussis vaccine could be a source of potentially fatal infection in infants. In the case of pertussis vaccination, gender ethnicity and cultural background are not of particular concern.
Which step(s) can nurses and health care providers take to remove barriers to identifying and treating victims of domestic violence? (Select all that apply.) Call the police. Ask about abuse. Ask for proof of domestic violence. Screen for domestic violence with all patients. Disregard reported abuse in spouses.
Answers: b, d Screening for domestic violence with all patients and asking about abuse will help identify patients who may be victims. Calling the police is a step that may be taken when abuse is confirmed but is not a step in identifying victims. Taking this step will be decided on with the involvement of both health care providers and the patient. Asking for proof may cause the victim to mistrust the health care provider. Never disregard a report of abuse. Abusers often are related to or married to the victim.
When teaching a patient about surgical procedures for birth control, the nurse would include which methods? Select all that apply. Diaphragm Vasectomy Hormone injection Tubal ligation Oral contraceptives
Answers: b, d Vasectomy and tubal ligation are surgical procedures for birth control. The diaphragm is a mechanical barrier, oral contraceptives are absorbed through the gastrointestinal tract, and hormones in injections are absorbed systemically.
For which reasons are patients unlikely to introduce the topic of sex with health care providers? Select all that apply. Most patients have few, if any, questions or problems relating to this topic. They are too embarrassed to discuss the topic of sex with a health care provider. Female patients prefer to discuss problems with female health care providers. They assume that health care professionals know little about sexual functioning. They are concerned that the health care professionals will be judgmental.
Answers: b, e Embarrassment to discuss a personal subject and fear of being judged can cause the patient to avoid introduction of the topic. Gender is not a consideration in this question, and it cannot be generalized that patients have few questions or problems on any topics. Health care professionals are generally considered to be knowledgeable in subject matters associated with health and illness.
