Nursing 222 chapter 4

A nurse is conducting a community health assessment for high risk families. What risk factors should the nurse identify? Select all that apply. Home is located in an area with gang violence. Family does not have health insurance. Nearest acute care facility is 45 minutes away. Family adheres to a strict vegetarian diet. New sibling was introduced two months ago.

a, b, c

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. Limited number of institutions providing health care Small number of recreational opportunities for adults and children Low incidence of violent crimes in the community Overlapping of industrial zones with residential zones Absence of air pollution

a, b, d

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? a. Community indicates people who share similar characteristics. b. Neighborhoods meet basic human needs, where communities do not. c. Neighborhoods are, by definition, smaller units within a community. d. Communities are defined by geography.

a. Community indicates people who share similar characteristics.

The home health nurse is making an initial visit to a client's home. During the visit the nurse observes the mother cooking dinner, the father watching television with a child on the lap, and the grandmother in a rocking chair reading the Bible. The nurse recognizes this family structure as which of the following? Extended family Nuclear family Single-parent family Blended family

a. Extended family

The community environment affects the well-being of the individual and the family. Which is the health responsibility of the family? Maintain a healthy lifestyle Provide recreational services Provide educational facilities Facilitate health care services

a. Maintain a healthy lifestyle

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? Report the suspected child abuse to Child Protective Services. Refer the child and the family to social services for follow-up. Document the suspected child abuse in the child's health care record. Ask the physician to question the parents about the suspected child abuse.

a. Report the suspected child abuse to Child Protective Services.

The nurse receives an 8-year-old client in the pediatric unit following a tonsillectomy. Which assessment finding requires immediate intervention by the nurse? a. The client makes a rattling noise when breathing through the mouth. b. The client tells the nurse that the client's throat hurts. c. The client cries to the nurse that the client wants to go home. d. The client is sleepy from the anesthesia, but arouses when addressed by name.

a. The client makes a rattling noise when breathing through the mouth.

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." The father asks the nurse, "Do you mind if my little boy sits on my lap during the interview?" The mother states, "This house would be a mess if I didn't clean it every day." The mother states, "We like to pay cash for the things we need."

a. The father states, "I don't discuss money matters with my wife because I don't want her to worry."

The nurse recognizes that the community affects the ability of individuals to meet basic human needs. Which example is not a characteristic of a healthy community? The number of assaults increased 2% over the last year. A new youth center provides after school programs for teens. The quality of drinking water exceeds the state requirements. Volunteer opportunities for older adults increased the past two years.

a. The number of assaults increased 2 % over the last year

A community is defined as a social group that may or may not share common geographic boundaries yet interact because of Common interests Political beliefs Similar school districts Economic interests

a. common interests

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? Measuring the client's intake and output during recovery Finding a safe environment for the client on discharge Ensuring that the client has family and friends visit Helping the client to fill out an advanced directive form

a. measuring the clients intake and output during recovery

The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual? Sociocultural dimension Physical dimension Emotional dimension Environmental dimension

a. sociocultural dimension

An 85-year-old client is being transferred from a house to a nursing home by the client's spouse. What is the first action the nurse should take to help reduce the stress of relocation on the client? Provide opportunities for the client to assist in decision making. Assess the client's usual lifestyle and daily activities. Reorient the client frequently to the new location. Carefully explain all procedures and routines to the client before they occur.

b. Assess the client's usual lifestyle and daily activities.

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family? The family members vacation together every year at a beach resort. The father is an engineer and the mother is an elementary school teacher. The family consults their rabbi and synagogue members during times of stress. The family celebrates Hanukkah and Passover with special meals.

b. The father is an engineer and the mother is an elementary school teacher.

A nurse is working with a single-parent family. When planning the care for this family, which need should the nurse anticipate as being a priority concern? Health promotion Financial concerns Child health issues Excessive support systems

b. financial concerns

Which are stressors that affect the health of the family? Family members who live in the same geographic location Many job opportunities with adequate income Inadequate childcare services Public transportation present throughout the community

c. Inadequate childcare services

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. Single-parent b. Blended c. Extended d. Nuclear

d. Nuclear

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? Providing alcohol and drug information Providing sex education Screening for congenital defects Setting up parenting classes

d. Setting up parenting classes

The nurse is admitting a 38-year-old client to the oncology unit whose religious background is different from the nurse's own. The nurse is assessing how the client's religion may affect the client's health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care? "What can we do to help you meet any religious needs you may have?" "Will your religion allow us to give you blood if you need it?" "Do you have any dietary restrictions that we should know about?" "I am a Christian and believe in Jesus. What does your religion believe?"

a. "What can we do to help you meet any religious needs you may have?"

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? Affective and coping Socialization Reproductive Physical

b. socialization

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? Conflict between family members Lack of knowledge about child safety Increased financial concerns Child abuse and neglect

c. Increased financial concerns

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? A psychosocial risk factor A lifestyle risk factor A developmental risk factor A biologic risk factor

a. A psychosocial risk factor

The nurse is aware that basic client needs must be met before a client can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a client after physiologic needs have been met? A nurse arranges for a teenage client to have visits from school friends. A client enrolls in art class after recovering from major surgery. 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.

d. Grab bars are installed in a client bathroom to facilitate safe showering.

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? A biologic risk factor A lifestyle risk factor A psychosocial risk factor A developmental risk factor

c. psychosocial risk factor

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? Love and belonging Self-actualization Safety and security Self-esteem

c. safety and security

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea? contact the primary care provider explain that the physical symptoms are all in their head sit with the client and ask them about their feelings Immediately administer an antiemetic.

c. sit with the client and ask them about their feelings

A nursing student's parents are both physicians. The nursing instructor may feel the student has a. Defined her future b. Difficulty in changing her attitudes c. Been educated in healthcare d. Been socialized in healthcare

d. Been socialized in healthcare

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? a. Kohlberg's theory of moral development b. Freud's psychoanalytic theory c. Piaget's theory of cognitive development d. Erikson's theory of psychosocial development

d. Erikson's theory of psychosocial development

A nurse is implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing? Love and belonging Self-esteem Physiologic Safety and security

d. safety and security

A new graduate nurse asks a nurse manager working at the community health center, "I've heard people talk about community health nursing and community-based nursing. Is there a difference?" Which response by the nurse manager would be appropriate? "Community health nursing involves care for entire populations whereas community-based nursing focuses on individuals and families in that population." "There really isn't any difference between the two at all. Both terms are used to denote health care for all groups of people." "Community health nursing focuses primarily on providing care to people in their homes and living in a specific community." "Community health nursing emphasizes the need to address the cultural differences among the individuals and families in the community while community-based nursing does not."

a. "Community health nursing involves care for entire populations whereas community-based nursing focuses on individuals and families in that population."

The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include? Adjustment to retirement Maintain a supportive home environment Maintain open communication Strengthen the marital relationship

a. Adjustment to retirement

What factors must the nurse consider when creating a holistic plan of care? (Select all that apply.) a. The client's physical environment b. The client's developmental life stage c. The client's conceptual integration of life d. The client's emotional context e. The client's physiologic health condition

b, d, e

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate? do not intervene and allow the client to work out the family issue limit the family visits to once daily tell the family they are causing too much stress explain that family visits and support are important

b. limit the family visits to once daily

Which client requires priority intervention by a nurse providing care on a medical-surgical unit? A client with a blood pressure of 98/40 mm Hg who needs to ambulate to the bathroom A newly admitted client who is upset due to a new cancer diagnosis An older adult client who is yelling and angry with family members A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min

d. A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min

A nurse is caring for a client newly diagnosed with diabetes mellitus and developing a holistic plan of care. For this plan of care to be successful, it must what? Take into account the cost of care. Connect families, friends, and the environment. Provide a connection between medicine and nursing. Address the disease but also incorporate the mind, body, and spirit.

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

The nurse is assessing the family structure of the client. The family household comprises two parents, three children, and one grandparent. The nurse recognizes that this is a(n): cohabiting family. traditional family blended family. extended family.

d. extended family

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? Self-esteem Safety and security Physiologic Love and belonging

d. love and belonging

The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action? Change the abdominal dressing more frequently. Use sterile gloves to change the abdominal dressing. Apply extra gauze dressings to the wound to absorb the drainage. Wash the nurse's hands before and after the dressing change.

d. wash the nurse's hands before and after the dressing change

What is an example of a community risk factor? Children are kept inside on a sunny day due to a lack of recreational opportunities. A child is born with a severe intellectual disability. An 80-year-old client is at risk for falls at home due to clutter in the hallways and stairways. A client is genetically inclined to develop crippling arthritis.

a. Children are kept inside on a sunny day due to a lack of recreational opportunities.

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? a. Mobility b. Feelings of isolation c. Anxiety about the future d. Role change

a. mobility

A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention? provide care transition at discharge for speech therapy discuss family history of hypertension conduct mental status assessment every 2 hours assess blood pressure every 4 hours

a. provide care transition at discharge for speech therapy

Which theorist supports the developmental framework of family assessment? a. Minuchin b. Duvall c. Bowen d. Satir

b. Duvall

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 type of factor is the primary influence on this aspect of the family's health? a. Family risk factors b. Community health care structure c. Economic factors d. Lifestyle influences

b. community health care structure

During the nurse's admission interview the client says, "I don't get too much rest because I am in nursing school and work full time to support myself and my kids." The nurse classifies this statement as an issue at which level of Maslow's basic needs? Safety and security Physiologic Self-esteem Love and belonging

b. physiologic

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? a Involvement from significant others b. Stress of education, job, and parenting c. Limited time in learning to be a marital partner d. Economic difficulties associated with parenting

c. Limited time in learning to be a marital partner

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? Possible charges for any services provided Transportation costs to the healthcare center Community resources available to clients Eligibility requirements for services

c. community resources available to clients

he nurse is implementing care for several clients. Which client is the nurse helping to reach the highest level of Maslow's hierarchy of basic human needs? The nurse teaches the son how to perform passive range of motion with the father. The nurse allows the family to sit quietly at the client's bedside after visiting hours. The nurse provides privacy for the client and family during times of prayer. The nurse teaches the daughter how to do a finger-stick blood glucose level check for the mother.

c. The nurse provides privacy for the client and family during times of prayer.

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

c. The parents have a tumultuous relationship, with frequent separations in the past.