NURS: Ch 4 NCLEX

The community health nurse is creating a plan of care for a patient with Parkinson's disease. The patient's spouse has provided care to the patient for the past 5 years and the patient's care needs are increasing. The nurse determines that an appropriate nursing diagnosis for the patient and family is: a) Parental Role Conflict. b) Risk for Caregiver Role Strain. c) Readiness for Enhanced Family Processes. d) Health Seeking Behaviors

b) Risk for Caregiver Role Strain: Long-term care of a family member with a chronic illness may lead to caregiver role strain, so the most appropriate nursing diagnosis is "Risk for Caregiver Role Strain"

A nurse is providing care based on Maslow's hierarchy of basic human needs. For which of the following nursing activities is this approach useful? a) Making accurate nursing diagnoses. b) Establishing priorities of care. c) Communicating concerns more concisely. d) Integrating science into nursing care.

b) Establishing priorities of care. Maslow's hierarchy of basic human needs is useful for establishing priorities of care.

The parents of a blended family have a 6-month-old baby boy 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? a) Economic factors b) Lifestyle influences c) Community healthcare structure d) Family risk factors

c) Community healthcare structure The size, location, and services of healthcare offerings in a geographical area are components of the community healthcare structure and its influence on health. Family functioning, lifestyle and economic considerations are not primary influences on the family's actions.

A 26-year-old member of the armed forces was severely injured while serving overseas and now lives with the effects of a spinal cord injury. The man's wife is now forced to get a job in order to provide care for both him and their young son, since the man was the family's soled wage earner. In addition, the family realizes that they may have to move into the basement of the wife's parents in order to survive financially. The family is at greatest risk of which of the following nursing diagnoses? a) Powerlessness b) Ineffective Coping c) Interrupted Family Process d) Impaired Parenting

c) Interrupted Family Process These events presents the possibility of numerous nursing diagnoses. Paramount among these, however, is the fact that the functioning of the family itself has been fundamentally changed. This presents the risk of Interrupted Family Process.

The nurse assists a postoperative patient with ambulation. The nurse recognizes that assisting the patient when performing this skill meets which of Maslow's basic human needs? a) Self-actualization. b) Self-esteem. c) Safety and security. d) Love and belonging

c) Safety and Security: 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.

John and Mary, each parents of one child, are both divorced. When they marry, the family structure that is formed will be described as which of the following? a) Nuclear family b) Extended family c) Blended family d) Cohabiting family

c) blended family A blended family is formed when parents bring unrelated children from previous relationships together to form a new family.

What is the best broad definition of a family? a) A father, a mother, and children. b) A group whose members are biologically related. c) A unit that includes aunts, uncles, and cousins. d) A group of people who live together.

d) A group of people who live together. Although all the responses may be true, the best definition is a group of people who live together.

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) A biologic risk factor. b) A lifestyle risk factor. c) A developmental risk factor. d) A psychosocial risk factor

d) A psychosocial risk factor: Conflicts between family members are considered psychosocial risk factors.

Which of the following is one of the developmental tasks of the older adult family? a) Maintain a supportive home base b) Prepare for retirement c) Cope with loss of energy and privacy d) Adjust to loss of spouse

d) Adjust to loss of spouse A developmental task of the older adult family is adjusting to the loss of a spouse.

The nurse recognizes the importance of including patients' families in assessment, care, decision-making, education, and discharge planning. When determining who constitutes a patient's family, which of the following criteria should the nurse prioritize? a) Interdependence b) Time commitment c) Genetic relationship d) Emotional bonding

d) Emotional bonding Family can be defined simply as any group of people who live together and are emotionally bonded. This consideration supersedes the significance of genetics, time commitment, or interdependence.

During the course of assessing the family structure and behaviors of a pediatric patient's family, the nurse has identified a number of highly significant risk factors. Which of the following actions should the nurse prioritize when addressing these risk factors? a) Validate the family's unique way of being. b) Introduce the family to a family that possesses fewer risk factors. c) Enlist the help of community and social support. d) Engage in appropriate health promotion activities.

d) Engage in appropriate health promotion activities. The role of the nurse in reducing risk factors involves activities that promote health for all family members at any level of development. This consideration supersedes the importance of validating the family's present way of being or enlisting the help of others. Introducing the family to a "model" family is ethically and logistically questionable.

A home healthcare nurse is performing a home visit to a 58-year-old man and his 56-year-old wife who receives home chemotherapy as part of her treatment regimen for breast cancer. The nurse will recognize that this family is likely to be engaged in which of the following development tasks? a) Adjusting to retirement b) Moving from the family home c) Adjusting to the loss of a spouse d) Maintaining ties with older and younger generations

d) Maintaining ties with older and younger generations This couple is likely to have children who are middle-aged adults, in which case the task of maintaining ties with older and younger generations is important. The couple is less likely to be retired or moving from their home and it would be presumptuous to assume the loss of a spouse.

Which of the following family structures is presently most common in the United States? a) Households with two parents, each of whom works outside the home b) Single-parent households headed by a woman c) Traditional nuclear families with one wage earner d) Blended families in which one or both partners bring children to the relationship

a) Households with two parents, each of whom works outside the home The family is an institution that has undergone significant change in recent decades. Currently, two-career families, in which both parents work outside the home, are the norm.

The nurse who is caring for a child admitted after an automobile accident recognizes the importance of including the child's family in the plan of care. Inclusion of the family meets which of Maslow's basic human needs? a) Love and belonging. b) Physiologic. c) Self-actualization. d) Self-esteem

a) Love and Belonging: Love and belonging needs include the understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to families, peers, friends, a neighborhood, and a community. The inclusion of family and friends in the care of a patient is a nursing intervention to meet this need.

A nurse working with patients in the community is aware that which of the following is a true statement related to environmental factors in a community? a) Barriers to accessing healthcare within a community may include lack of transportation. b) Lack of health insurance is a negative environmental factor affecting one's access to healthcare. c) The quality of air and water are relatively consistent when comparing urban and rural environments. d) Environmental factors focus on the harmful effects on an individual's health.

a) Barriers to accessing healthcare within a community may include lack of transportation: Environmental barriers to accessing healthcare within a community include lack of transportation, distance to services, and location of services.

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? a) Discussing the patient's strengths and dialoguing with him about his body image. b) Encouraging the patient to talk about his previous accomplishments and his goals for the future. c) Reorganization of his care and facilitating a day pass so the patient can spend Thanksgiving with his family. d) Encouraging the patient's friends and family to take an active role in his care at the hospital.

a) Discussing the patient's strengths and dialoguing with him about his body image. Aspects of self-actualization include focusing on patient's strengths and fostering a positive body image. Addressing accomplishments and goals is likely to meet patients' self-esteem needs. Facilitating contact and connection between patients and their families is an action that promotes love and belonging needs.

The nurse has arranged for a stroke patient to participate in a daily group rehabilitation program that aims to improve the mobility, independence, and activities of daily living (ADLs) of participants. This program is likely to address which of the following needs? Select all that apply. a) Physiologic needs b) Safety and security needs c) Love and belonging needs d) Self- esteem needs e) Self-actualization needs

a) Physiologic needs b) Safety and security needs c) Love and belonging needs d) Self-esteem needs e) Self-actualization needs A rehabilitation program is likely to be multidimensional, addressing the physiology of the patient's movement while prioritizing and ensuring safety. Improving independence and ADLs is likely to benefit the patient's self-esteem and self-actualization after the effects of stroke. The group format of the program is likely to provide some measure of belonging with those who have had similar experiences, thus preventing isolation.

A couple with adolescent children is most likely to focus on which of the following developmental tasks? a) Strengthening marital relationships. b) Establishing a mutually satisfying marriage. c) Coping with loss of energy and privacy. d) Adjusting to retirement

a) 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.

Where do individuals learn their health belief's and values? a) in the family b) in school c) from school nurses d) from peers

a) in the family Healthcare activities, health beliefs, and health values are learned within one's family.

Which of the following levels of basic human needs is most basic? a) physiologic b) safety and security c) love and belonging d) self-actualization

a) physiologic Physiologic needs are the most basic and must be met at least minimally to sustain life.

The 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? a) Reproductive. b) Socialization. c) Affective and coping. d) Physical

b) Socialization: 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.

Which of the following statements is true regarding Friedman's theory of family-centered nursing care? a) Illness of one family member strengthens the roles of the sick member in the family structure. b) The role of the family is essential in every level of nursing care. c) The family is composed of independent members who live and function individually. d) The focus on health should be directed at improving the health of the sickest member of the family.

b) The role of the family is essential in every level of nursing care: 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.

Practicing careful hand hygiene and using sterile techniques are ways in which nurses meet which basic human need? a) physiologic b) safety and security c) self-esteem d) love and belonging

b) safety and security By carrying out careful hand hygiene and using sterile technique, nurses provide safety from infection.

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? a) The family's electricity has been cut off at various times due to nonpayment. b) The mother has a history of heavy alcohol use. c) The parents have a tumultuous relationship with frequent separations in the past. d) The family lives in a small apartment in a poor neighborhood with high crime rates.

c) The parents have a tumultuous relationship with frequent separations in the past. Conflict is an example of a psychosocial risk factor. Chemical dependency is considered a lifestyle risk factor while a lack of adequate housing is an environmental risk factor.

Of the following statements, which one is true of self-actualization? a) Humans are born with fully developed self-actualization. b) Self-actualization needs are met by having confidence and independence. c) The self-actualization process continues throughout life. d) Loneliness and isolation occur when self-actualization needs are unmet.

c) The self-actualization process continues throughout life. Self-actualization, or reaching one's full potential, is a process that continues through life.

Of all the physiologic needs, which one is the most essential? a) food b) water c) elimination d) oxygen

d) oxygen Oxygen is the most essential of all needs because all body cells require oxygen for survival.

In caring for a patient, the nurse recognizes which of the following as the primary educational and support structure for an individual? a) Teachers and coaches. b) Family members. c) Clergy. d) Peers

b) Family members: The family is the primary educational and support structure for an individual. The family, as a social unit, provides the environment and relationships necessary for members to meet their basic human needs.

A family that consists of two homosexual parents and three children living in the same house is an example of which type of family? a) Blended. b) Nuclear. c) Single-parent. d) Extended

b) 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, and all members of the family live in the same house until the children leave home as young adults.

Which of the following is one element of a healthy community? a) Meets all the needs of its inhabitants b) Offers access to healthcare services c) Has mixed residential and industrial areas d) Is little concerned with air and water quality

b) Offers access to healthcare services A healthy community offers access to healthcare services to treat illness and to promote health.

The nurse is creating a nursing care plan for a patient who has numerous needs in the various dimensions of his life. As a result, the nurse is faced with the challenge of prioritizing certain needs over others. Place the following levels of needs in the correct ascending order. a) Self-esteem needs b) Physiologic needs c) Self-actualization needs d) Love and belonging e) Safety and security needs

b) Physiologic needs e) Safety and security needs d) Love and belonging needs a) Self-esteem needs c) Self-actualization needs