Nurs 222 Chapter 4 CoursePoint
An adolescent confides in the school nurse that the adolescent is arguing daily with her mother and often wonders whether her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health? 1) A psychosocial risk factor 2) A lifestyle risk factor 3) A developmental risk factor 4) A biologic risk factor
A psychosocial risk factor
A family that consists of two homosexual parents and three children living in the same house is an example of which type of family? 1) Nuclear 2) Extended 3) Blended 4) Single-parent
Nuclear
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? 1) Cutting up food and opening drink containers for the client 2) Providing the mother the phone number for the poison control center 3) Seeking input from the client regarding preferences for a snack 4) Assisting the client to validate feelings regarding treatment options
Providing the mother the phone number for the poison control center
A nurse in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of the head, and multiple 1-cm round scabs and blisters on the upper back. The parents state that their child sustained the injuries by falling out of a high chair. What is the best action for the nurse to take? 1) Document the suspected child abuse in the child's health care record 2) Report the suspected child abuse to Child Protective Services 3) Refer the child and the family to social services for follow-up 4) Ask the physician to question the parents about the suspected child abuse
Report the suspected child abuse to Child Protective Services
A client is admitted to the emergency department following a tornado in which multiple people were killed or injured. The nurse applies direct pressure to an open wound on the client's thigh while assuring the client that the weather has cleared. Which of Maslow's basic human needs is the nurse addressing with the actions? Select all that apply. Physiologic 1) Safety and security 2) Love and belonging 3) Self-esteem 4) Self-actualization
1) Physiologic 2) Safety and security
A nurse is assessing a family and identifying where the family is in the family life cycle. During this assessment, the nurse applies Duvall's theory. Which theory forms the basis for Duvall's theory? 1) Erikson's theory of psychosocial development 2) Freud's psychoanalytic theory 3) Kohlberg's theory of moral development 4) Piaget's theory of cognitive development
Erikson's theory of psychosocial development
A client comes to the health center for a follow-up visit. Assessment reveals that the client is experiencing problems ambulating and moving about due to degenerative joint disease; in addition, the client is feeling isolated due to the limitations in mobility. The client also reports feeling anxious about the future related to the mobility issues and being unable to fulfill the role as the major provider. Which need would the nurse identify as the priority? 1) Mobility 2) Role change 3) Anxiety about the future 4) Feelings of isolation
Mobility
A community health nurse is providing care to several farming families in a rural community. Which concept would be most important for the nurse to integrate into the plans of care for these families? 1) The traditional nuclear family structure is the current norm 2) Family structures may change over time 3) All family types have similar problems regardless of their structure 4) The extended family structure has fewer issues that impact family functions
Family structures may change over time
The epidemiology nurse finds a lower occurrence of influenza cases in a section of a large metropolitan city. Further research reveals higher influenza immunization rates in that section of the city. The nurse determines which probable cause for this occurrence? 1) Immunizations are given at no cost in the area 2) Persons living in the area are better educated 3) Immunization has become a community norm 4) There are fewer tobacco users in this section of town
Immunization has become a community norm
Which are stressors that affect the health of the family? 1) Many job opportunities with adequate income 2) Family members who live in the same geographic location 3) Public transportation present throughout the community 4) Inadequate childcare services
Inadequate childcare services
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? 1) Limited time in learning to be a marital partner 2) Economic difficulties associated with parenting 3) Involvement from significant others 4) Stress of education, job, and parenting
Limited time in learning to be a marital partner
A nurse is caring for a 78-year-old client who has been hospitalized following a stroke. Which nursing action has the highest priority for this client? 1) Ensuring that the client has family and friends visit 2) Helping the client to fill out an advanced directive form 3) Finding a safe environment for the client on discharge 4) Measuring the client's intake and output during recovery
Measuring the client's intake and output during recovery
The nurse is caring for an 85-year-old client hospitalized for dehydration. The nurse notices that the client is shivering and takes the client's temperature. The nurse notes an oral temperature of 97.8°F (36.6°C). The client also reports being "chilly." Which nursing action is most appropriate? 1) Notify the physician 2) Offer the client an extra blanket 3) Increase the client's oral fluid intake 4) Assess the client's respiratory rate
Offer the client an extra blanket
A nurse is working as part of a group to address factors within the community affecting the health of the families in that community. Which area would the nurse identify as playing a role in contributing to altered health status? Select all that apply. 1) Limited number of institutions providing health care 2) Small number of recreational opportunities for adults and children 3) Low incidence of violent crimes in the community 4) Overlapping of industrial zones with residential zones 5) Absence of air pollution
1) Limited number of institutions providing health care 2) Small number of recreational opportunities for adults and children 3) Overlapping of industrial zones with residential zones
The nurse is taking care of a client who is scheduled for a mastectomy. The client tells the nurse that the client is apprehensive about the operation and asks the nurse to read a passage from the Koran to help prepare the client for surgery. Which action by the nurse is the most appropriate? 1) Read the Koran passage to the client 2) Gently inform the client that nurses cannot practice religion with clients 3) Ask the client whether it would be okay to call a minister to pray with client 4) Attempt to find someone on staff who is the same religion as the client
Read the Koran passage to the client
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? 1) Socialization 2) Physical 3) Reproductive 4) Affective and coping
Socialization
A nurse working with patients in a community is aware that which is a true statement related to environmental factors in that community? 1) Barriers to accessing health care within a community may include lack of transportation 2) The quality of air and water are relatively consistent when comparing urban and rural environments 3) Environmental factors focus on the harmful effects on an individual's health 4) Lack of health insurance is a negative environmental factor affecting one's access to health care
Barriers to accessing health care within a community may include lack of transportation
A nursing student's parents are both physicians. The nursing instructor may feel the student has 1) Been educated in healthcare 2) Been socialized in healthcare 3) Difficulty in changing her attitudes 4) Defined her future
Been socialized in healthcare
A nurse is planning education on self-administration of insulin to the client and the client's family members. The client asks the nurse why the family members are also included in the teaching. What should the nurse's response be? 1) "Family members can take you to the hospital if any emergency occurs." 2) "Family members are a point of contact and are able to check on your progress." 3) "Family members are at risk of developing diabetes mellitus in the future." 4) "Family members are equally involved in planning and implementation of care."
"Family members are equally involved in planning and implementation of care."
The community offers physician offices, a county health department, a community hospital, an assisted living facility, two nursing homes, and hospice. The nurse recognizes that these agencies represent which type of community factor? 1) Social support systems 2) Protection and safety agencies 3) Environmental factors 4) Community healthcare structure
Community healthcare structure
A client says, "I live in a small community on the northwest side of the city." Why does the nurse consider it significant that the client reports living in a community rather than a neighborhood? 1) Neighborhoods are, by definition, smaller units within a community 2) Community indicates people who share similar characteristics 3) Communities are defined by geography 4) Neighborhoods meet basic human needs, where communities do not
Community indicates people who share similar characteristics
A nurse is assessing a family with adolescents. The family consists of a father, mother, a 13-year-old son, a 14-year-old son from a previous marriage, and a 16-year-old daughter. Which statement by the parents would lead the nurse to suspect a potential risk factor for altered health with this family? 1) "Our 16-year-old just seems to butt heads with us at every turn." 2) "We've taught our kids to be assertive when appropriate." 3) "All of us have faced problems along the way but we've worked them out." 4) "We've encouraged our kids to talk to us about sex and sexually transmitted infections."
"Our 16-year-old just seems to butt heads with us at every turn."
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. 1) The family must adjust to the cost of family life 2) The family must maintain ties with younger and older generations 3) The family must prepare for retirement 4) The family must adjust to loss of spouse 5) The family must support moral and ethical family values 6) The family must cope with loss of energy and privacy
1) The family must maintain ties with younger and older generations 2) The family must prepare for retirement
A nurse is developing a plan of care for a client to meet the client's self-actualization needs. The nurse would focus on which area as most important? 1) Emphasizing the client's strengths 2) Addressing the client's problems 3) Reducing fear 4) Promoting socialization
Emphasizing the client's strengths
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? 1) Notify the healthcare provider of the client's condition 2) Assist the client out of bed to walk in the hall 3) Medicate the client for pain 4) Remove the abdominal dressing and assess the incision
Medicate the client for pain
Which theorist supports the developmental framework of family assessment? 1) Minuchin 2) Duvall 3) Satir 4) Bowen
Duvall
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? 1) Families are caretakers even when the patient is not acutely ill 2) It is necessary for the nurse, patient and the patient's family to integrate the physical and emotional environment of the patient 3) Active participation by individuals and families in health promotion is integral to this framework of patient care 4) This model is congruent with the philosophy of traditional patriarchal medicine
Active participation by individuals and families in health promotion is integral to this
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? 1) Adjustment to retirement 2) Maintain open communication 3) Strengthen the marital relationship 4) Maintain a supportive home environment
Adjustment to retirement
The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which is an individual need? 1) Safety 2) Education 3) Socialization 4) Political
Safety
A nurse is implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing? 1) Physiologic 2) Safety and security 3) Love and belonging 4) Self-esteem
Safety and security
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? 1) Safety and security 2) Self-esteem 3) Love and belonging 4) Self-actualization
Safety and security
Which action by the nurse demonstrates the nurse's efforts to meet the client's self-actualization needs? 1) The nurse teaches the client's family members how to administer the client's tube feeding. 2) The nurse facilitates a family meeting to elicit support for the client's return to home following a stroke. 3) The nurse caring for a Native American/First Nations client arranges for the client's medicine man to perform a healing ceremony. 4) The nurse arranges for the client's clergy to visit after visiting hours.
The nurse arranges for the client's clergy to visit after visiting hours
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? 1) Love and belonging needs 2) Safety and security needs 3) Self-actualization needs 4) Self-esteem needs
Self-esteem needs
The nurse enters the client's room in the acute care unit immediately after the client experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take? 1) Reorient the client to person, place, and time 2) Notify the physician 3) Position the client in a side-lying position 4) Document the type of seizure in the client's health record
Position the client in a side-lying position
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? 1) Setting up parenting classes 2) Providing alcohol and drug information 3) Screening for congenital defects 4) Providing sex education
Setting up parenting classes
A family assessment of a father, mother, and four children has suggested the presence of several risk factors. Which aspect of the family's structure and function would be considered a psychosocial risk factor? 1) The parents have a tumultuous relationship, with frequent separations in the past 2) The mother has a history of heavy alcohol use 3) The family lives in a small apartment in a poor neighborhood with high crime rates 4) The family's electricity has been cut off at various times due to nonpayment
The parents have a tumultuous relationship, with frequent separations in the past
A client who was admitted to a drug treatment center 3 days ago is boasting to the other residents about using drugs for 2 years, and that the former employer never suspected the drug use. Which action, if taken by the nurse, would be most appropriate for this client? 1) Ask the client to give a short talk in group about drug use. 2) Ask the client to mentor another client at the drug treatment center. 3) Insist that the client not talk about the past drug use. 4) Have the client assume responsibility for the cleanliness of the dayroom.
Have the client assume responsibility for the cleanliness of the dayroom
The nurse is assessing a family parented by a 60-year-old grandmother and three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families? 1) Lack of knowledge about child safety 2) Increased financial concerns 3) Child abuse and neglect 4) Conflict between family members
Increased financial concerns
A nurse is providing care to a client who is feeling lonely and isolated. In an effort to develop a trusting nurse-client relationship, the nurse exhibits a caring attitude, ensures the client's privacy, and spends time with the client to promote therapeutic communication. The nurse is meeting which category of client needs? 1) Physiologic 2) Safety and security 3) Love and belonging 4) Self-esteem
Love and belonging
A 44-year-old client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which values? 1) Urine output of 1500 mL in 24 hours 2) An elevated hematocrit level 3) An elevated urine specific gravity 4) Oral intake of 1500 mL in 24 hours
Urine output of 1500 mL in 24 hours
A community-based nurse acts as a case manager for a small town about 60 miles from a major healthcare center. What is the most important factor of community-based nursing for this nurse to be knowledgeable about? 1) Eligibility requirements for services 2) Community resources available to clients 3) Transportation costs to the healthcare center 4) Possible charges for any services provided
Community resources available to clients
Which nursing diagnosis is the priority according to Maslow's hierarchy of basic needs? 1) Constipation related to decreased mobility 2) Anxiety related to inability to cope with pending prognosis 3) Impaired Social Interaction related to disturbed body image 4) Risk for Falls related to unsteady gait following stroke
Constipation related to decreased mobility
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? 1) Coping with loss of energy and privacy 2) Moving from the family home 3) Maintaining ties with younger and older generations 4) Balancing teenagers' freedom with responsibility
Coping with loss of energy and privacy
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? 1) Responsibilities of the adolescent 2) Employment history of the parents 3) Family patterns of communication 4) Environmental hazards in the home
Family patterns of communication
Which statement is true regarding Friedman's theory of family-centered nursing care? 1) The role of the family is essential in every level of nursing practice. 2) The family is composed of independent members who live and function individually. 3) The focus on health should be directed at improving the health of the sickest member of the family. 4) 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
The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual? 1) Physical dimension 2) Environmental dimension 3) Sociocultural dimension 4) Emotional dimension
Sociocultural dimension
A home health nurse is visiting a family after the recent death of their matriarch. The nurse 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. The nurse asks what is happening, and is told, "We are Jewish, and the family is 'Sitting Shiva'." This family is fulfilling which family function? 1) economical function 2) physical function 3) effective and coping functions 4) socialization function
effective and coping functions
What is an example of a community risk factor? 1) A client is genetically inclined to develop crippling arthritis. 2) An 80-year-old client is at risk for falls at home due to clutter in the hallways and stairways. 3) Children are kept inside on a sunny day due to a lack of recreational opportunities. 4) A child is born with a severe intellectual disability.
Children are kept inside on a sunny day due to a lack of recreational opportunities
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? 1) A client enrolls in art class after recovering from major surgery 2) A nurse arranges for a teenage client to have visits from school friends 3) Grab bars are installed in a client bathroom to facilitate safe showering 4) 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
The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family? 1) The father is an engineer and the mother is an elementary school teacher. 2) The family celebrates Hanukkah and Passover with special meals. 3) The family consults their rabbi and synagogue members during times of stress. 4) The family members vacation together every year at a beach resort.
The father is an engineer and the mother is an elementary school teacher
