prep u ch 4
Which nursing diagnosis is the priority according to Maslow's hierarchy of basic needs?
Constipation related to decreased mobility
The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs?
Safety and security
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.
A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for clients in this developmental stage?
Setting up parenting classes
Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family?
Socialization
A 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?
"Family members are equally involved in planning and implementation of care."
A community is defined as a social group that may or may not share common geographic boundaries yet interact because of
Common interests
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?
Community indicates people who share similar characteristics.
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."
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?
Address the disease but also incorporate the mind, body, and spirit.
The nurse in the adolescent in-patient psychiatric unit is interviewing the family of a 16-year-old client admitted for depression and threatened suicide. What assessment information is most essential for the nurse in determining the affective and coping function of the family?
Family patterns of communication
A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate?
limit the family visits to once daily
Which statement is true regarding Friedman's theory of family-centered nursing care?
The role of the family is essential in every level of nursing practice.
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?
Love and belonging
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
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
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?
Increased financial concerns
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
The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?
Sociocultural dimension
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."
A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?
sit with the client and ask them about their feelings
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?
Physiologic
A nurse in a wellness center is presenting a class on integrating holistic therapies with traditional health care. The nurse talks about the trend in health care to treat each client in a manner that reconnects the total being. Which would best be considered a holistic approach to health?
Physical, emotional, and spiritual well-being
The nurse on the elective surgery floor receives a report that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action?
Wash the nurse's hands before and after the dressing change.
In the implementation of effective client care, the nurse should
assess the client's family dynamics and community.
