Ch. 4 (Health of the Individual, Family, and Community)
The nurse enters the client's room in the acute care unit immediately after he 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.
The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which of the following is an individual need?
Safety
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 admitting a 38-year-old male client to the oncology unit whose religious background is different from her own. The nurse is assessing how the client's religion may affect his 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?"
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?
Coping with loss of energy and privacy
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 psychosocial risk factor
The nurse is assessing a client diagnosed with early-onset Alzheimer's disease. The spouse states that it is making them uncomfortable to be the sole care provider due to the degree of lifestyle changes that will be required. Which factors will be a priority issue when assessing for a risk of caregiver role strain?
-Past history of poor relationship between caregiver and care receiver -Inexperience with giving care to others -Caregiver as the spouse
A nurse is caring for a family consisting of three middle-aged adults. Which examples describe developmental tasks of this type of family structure?
-The family must prepare for retirement. -The family must maintain ties with younger and older generations.
The nursing instructor is discussing holistic health care with her nursing students. The instructor talks about the different factors the nurse must consider when creating a holistic plan of care. What are these factors?
-The patient's developmental life stage -The patient's emotional context -The patient's physiologic health condition
A nurse has the Petty Family as a client, who consists of a wife, husband, and their 4-year-old daughter. The husband has been unemployed for 8 months, and they lost their apartment. The family has been staying in neighborhood shelters and, on occasion, with the husband's father for a night or two. When evaluating this family, the nurse identifies this family as which type?
A homeless family
A community has a lead smelting factory that is contaminating the air. According to Higgs and Gustafson, the community health nurse must
Assist in the protection of members
The nurse is assessing the family structure of the client. The family household is comprised of two parents, three children, and one grandparent. The nurse recognizes that this is a(n):
Extended family.
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
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 of the following statements is true regarding Friedman's theory of family-centered nursing care?
The role of the family is essential in every level of nursing practice.
Which nursing diagnosis is the priority according to Maslow's hierarchy of basic needs?
Constipation related to decreased mobility
Which of the following theorists supports the developmental framework of family assessment?
Duvall
The charge nurse is assigning client care for the upcoming shift. Which is the priority evaluation when performing this task?
Determine the level and intensity of client care needed according to physical and psychosocial factors.
The nursing student asks the instructor to explain what a community is. Which statement by the instructor would be inappropriate?
"Communities have few effects on the health of the individuals that live there."
A nurse is planning education on self-administration of insulin to the client and his 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."
The home health nurse is making an initial visit to a client's home. During the visit she observes the mother cooking dinner, the father watching television with a child on his lap, and the grandmother in a rocking chair reading the Bible. The nurse recognizes this family structure as which of the following?
Extended family
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
The wife of a comatose client wishes to wash the client's hair. Washing the client's hair meets which basic human need?
Physiologic
The nurse is assessing the family structure of the client and determines it is an extended family. Which of the following represent an extended family?
The family is comprised of two parents, three children, and one grandparent.
A 44-year-old female client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which of the following values?
Urine output of 1500 ml in 24 hours
The nurse in the pediatric unit is caring for a 10-year-old boy admitted with dehydration and diarrhea after eating chicken contaminated with Salmonella bacteria. What action taken by the nurse would be the most effective in preventing the spread of the infectious microorganism?
Washing hands before and after providing the client care
Which are stressors that affect the health of the family?
Well-funded school systems and inadequate childcare services
Place the following nursing interventions in order of priority according to Maslow's hierarchy of basic needs.
-The nurse teaches the client about foods high in fiber. -The nurse teaches the daughter how to administer the client's insulin. -The nurse assists the client in making a phone call to the client's daughter. -The nurse positions the bed of the Muslim client who is bedfast toward Mecca.
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 who is using DuVall's conceptual framework to assess a family with two parents and three children must first determine the
Age of the oldest child
A community is defined as a social group that may or may not share common geographic boundaries yet interact because of
Common interests
The nurse is assessing a family parented by a 60-year-old grandmother and her 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
The nurse is taking care of a female client who is scheduled for a mastectomy. The client tells the nurse that she is apprehensive about the operation and asks the nurse to read a passage from the Koran to help her prepare herself for surgery. Which action by the nurse is the most appropriate?
Read the Koran passage to the client.
The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?
Sociocultural dimension
A couple with adolescent children is most likely to focus on which of the following developmental tasks?
Strengthening marital relationships
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 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.
Once physiologic needs are met, nurses can concentrate on meeting self-actualization needs of patients. What are examples of self- actualization needs according to Maslow's hierarchy of needs? (Select all that apply.)
A nurse subscribes to several nursing journals to stay abreast of developments in the profession. A student nurse takes a course in communication to improve her ability to relate to patients. A nurse attains a master's degree in nursing by going to school in the evening. Correct response: A nurse attains a master's degree in nursing by going to school in the evening. A student nurse takes a course in communication to improve her ability to relate to patients. A nurse subscribes to several nursing journals to stay abreast of developments in the profession.
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
Which action by the nurse demonstrates the nurse's efforts to meet the client's self-actualization needs?
The nurse arranges for the client's clergy to visit after visiting hours.
You are the nurse caring for a patient newly diagnosed with diabetes and you are developing a holistic plan of care. You know that for this plan of care to be successful it must what?
Address the disease but also incorporate the mind, body, and spirit.
A home health nurse is visiting the Goldstein family after the recent death of their matriarch. She 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. She asks Mr. Goldstein's cousin what is happening, and he says, "We are Jewish, and the family is 'Sitting Shiva' for my aunt." This family is fulfilling which family function?
Affective and coping functions
A nurse working with patients in a community is aware that which of the following is a true statement related to environmental factors in that community?
Barriers to accessing health care within a community may include lack of transportation.
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
Based on the patient assessment, the nurse formulates the following nursing diagnoses for the client. Which nursing diagnosis reflects Maslow's level of self-esteem needs?
Disturbed Body Image related to inability to cope with left leg amputation
According to Archer, what are the three general types of communities?
Emotional, structural, and functional
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?
Grab bars are installed in a client bathroom to facilitate safe showering.
Which basic needs area of Maslow's hierarchy of human needs is met when the nurse arranges for the client's clergy to visit after visiting hours?
Self-actualization needs
A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for patients in this developmental stage?
Setting up parenting classes
A nurse is prioritizing care for patients in a hospital setting. Place the following examples of interventions to meet human needs in order from highest-level needs to lower-level needs based on Maslow's hierarchy.
-A nurse provides nutrition for a patient through a feeding tube. -A nurse places a No Smoking sign on the door of a patient who is receiving oxygen. -A nurse includes family members in the care of a patient. -A nurse prepares a room for a clerical visit requested by a patient. -A nurse helps a patient focus on her strengths following a diagnosis of breast cancer.
The nurse is teaching a group of nursing students about how health of community members is affected. Which community characteristics affect the health of individuals?
-Communication facilities -Recreation programs -Education programs -Transportation services
The nurse is reviewing the health care records of the Clifford Family who has experienced varying life crises. The nurse identifies which of the following as health risk factors?
-Grandma Opal Clifford dies at the age of 98. -Mr. Clifford is exposed to asbestos at work. -Shirley Clifford is pregnant at the age of 15.
The nurse recognizes that many factors place the family at increased risk for altered health. Which items represent lifestyle risk factors for altered family health?
-Inadequate dental hygiene -Ingestion of high fat foods -Smoking by parents
A nurse at a local homeless shelter is evaluating a new arrival at 10 o'clock at night, a 57-year-old man wearing disheveled clothes. He states that he is looking for a place to sleep because he is exhausted. The man states that he has been living under a bridge since he lost his job 6 months ago, and that he is hungry. The nurse performs which actions in order to address the client's physiological needs?
-Offer him a sandwich because the cafeteria is closed. -Show him to his room so he can sleep.
A home health care nurse who works in a low- income community assesses the risk factors for patients being serviced. What is an example of a community risk factor?
Children are kept inside the home on a sunny summer day because of lack of recreational opportunities.
You are the community-based nurse who acts as case-manager for a small town about 60 miles from a major health care centre. What is the most important factor of community-based nursing for you be knowledgeable about?
Community resources available to patients.
The nurse is caring for an 85-year-old, female client hospitalized for dehydration. The nurse notices that the patient is shivering and takes the client's temperature. She notes an oral temperature of 97.8°:F (36.6°:C). The client also says that she is "chilly." What action, if taken by the nurse, is most appropriate?
Offer the client an extra blanket.
An 83-year-old client has had a stroke and has right hemiparesis. He has an inability to garden and is being cared for by his family. The family states he seems depressed and has no current interests. Based on the family's information, it would be appropriate for the family to allow the client to assist in planning an herb garden in the home. This is an example of
Output
What is the focus of community based nursing?
Promoting and maintaining the health of individuals and families.
A nurse in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of his head, and multiple 1-cm round scabs and blisters on his upper back. The parents state that their child sustained the injuries by falling out of his high chair. What is the best action for the nurse to take?
Report the suspected child abuse to Child Protective Services.
