Ch 4
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?
Position the client in a side-lying position.
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?
Self-esteem needs
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
The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?
The father is an engineer and the mother is an elementary school teacher.
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.
Community
a specific population or group of people living in the same geographic area under similar regulations and having common values, interests, and needs
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):
extended family.
A nurse working in an "Aging in Place" facility interviews a married couple in their late seventies. Based on Duvall's Developmental Tasks of Families, which developmental task would the nurse assess for this couple?
Adjustment to retirement years
A nursing student's parents are both physicians. The nursing instructor may feel the student has
Been socialized in healthcare
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 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?
Family structures may change over time.
Which are stressors that affect the health of the family?
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?
Limited time in learning to be a marital partner
A nurse is developing a plan of care for a client to meet the client's safety and security needs. Which intervention would the nurse include? Select all that apply.
Using aseptic technique when providing wound care Teaching the client about what to expect with upcoming surgery Administering prescribed medication at the required time
nuclear family
the traditional family, is composed of two parents and their children
physiological needs (Physical dimension)
for oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. These needs are the most basic in the hierarchy of needs and the most essential to life, and therefore have the highest priority
A nurse is practicing community-based nursing in a mobile health clinic. What typically is the central focus of this type of nursing care?
Individual and family health care needs
safety and security needs (Environmental dimension)
Physical safety and security means being protected from potential or actual harm. Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as the following: Using proper hand hygiene and sterile techniques to prevent infection Using electrical equipment properly Administering medications knowledgeably Skillfully moving and ambulating patients Teaching parents about household chemicals that are dangerous to children
A nurse caring for patients in a long-term care facility uses available resources to help patients achieve Maslow's highest level of needs: self-actualization needs. Which statements accurately describe these needs? Select all that apply.
The self-actualization process continues throughout life. A person achieves self-actualization by focusing on problems outside self. Self-actualization needs may be met by creatively solving problems.
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?
Urine output of 1500 mL in 24 hours
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
A nurse uses Maslow's hierarchy of basic human needs to direct care for patients on an intensive care unit. For which nursing activities is this approach most useful?
Establishing priorities of care
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 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
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.
self-esteem needs (Emotional dimension)
include the need for a person to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments. Positive self-esteem facilitates the person's confidence and independence. having patient set goals
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?
Read the Koran passage to the client.
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.
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
love and belonging needs (Sociocultural dimension)
include the understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to groups such as families, peers, friends, a neighborhood, and a community. Including family and friends in the care of the patient Establishing a nurse-patient relationship based on mutual understanding and trust (by demonstrating care, encouraging communication, and respecting privacy) Referring patients to specific support groups (such as a cancer support group or Alcoholics Anonymous)
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?"
Maslow's Hierarchy of Needs
(level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization
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?
Community health care 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?
Community indicates people who share similar characteristics.
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
The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow's basic human needs is being met by this nurse?
Safety and security
A family that consists of two homosexual parents and three children living in the same house is an example of which type of family?
Nuclear
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?
Offer the client an extra blanket.
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 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 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?
"Our 16-year-old just seems to butt heads with us at every turn."
A nurse works with families in crisis at a community mental health care facility. What is the BEST broad definition of a family?
A group of people who live together and depend on each other for support
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 client will be hospitalized for at least three weeks following a serious automobile accident. How can the nurse best support this client's love and belonging needs during this hospitalization? Select all that apply.
Allow a family member to stay at the bedside as much as possible. Be caring in the provision and planning of care.
The nurse caring for families in a free health care clinic identifies psychosocial risk factors for altered family health. Which example describes one of these risk factors?
Both parents work and leave a 12-year-old child to care for his younger brother.
The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of nursing interventions help meet physiologic needs? Select all that apply.
Changing a patient's oxygen tank Helping a patient eat his dinner
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?
Emphasizing the client's strengths
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?
Erikson's theory of psychosocial development
A visiting nurse working in a new community performs a community assessment. What assessment finding is indicative of a healthy community?
It offers access to health care services
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?
Providing the mother the phone number for the poison control center
A nurse is implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing?
Safety and security
A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two children. Which interview questions directed to the single mother could the nurse use to assess the affective and coping family function? Select all that apply.
Who is the person you depend on for emotional support? Who keeps your family together in times of stress?
self-actualization needs (Intellectual and spiritual dimensions)
the need for people to reach their full potential through development of their unique capabilities. Acceptance of self and others as they are Focus of interest on problems outside oneself Ability to be objective Feelings of happiness and affection for others Respect for all people Ability to discriminate between good and evil Creativity as a guideline for solving problems and pursuing interests