Chapter 4

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

Report the suspected child abuse to Child Protective Services.

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? Political Safety Education Socialization

Safety

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

Safety and security

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? Volunteer opportunities for older adults increased the past two years. A new youth centre provides after school programs for teens. The quality of drinking water exceeds the state requirements. The number of assaults increased 2% over the last year.

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

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 her hands before and after the dressing change. Change the abdominal dressing more frequently. Apply extra gauze dressings to the wound to absorb the drainage. Use sterile gloves to change the abdominal dressing.

Wash her hands before and after the dressing change.

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 A developmental risk factor A lifestyle risk factor A biologic risk factor

A psychosocial risk factor

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? 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.

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

The community offers physician offices, a county health department, a community hospital, an assisted living facility, two nursing homes, and hospice. The nurse recognizes that these agencies represent which type of community factor? Environmental factors Social support systems Community healthcare structure Protection and safety agencies

Community healthcare structure

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? Transportation costs to the health care centre. Community resources available to patients. Eligibility requirements for services. Possible charges for any services provided.

Community resources available to patients.

The charge nurse is assigning client care for the upcoming shift. Which is the priority evaluation when performing this task? Examine the departmental budget to determine the financial consequences of staffing patterns. Consider the educational level and experience of the nursing staff. Calculate the number of staff scheduled to work the oncoming shift. Determine the level and intensity of client care needed according to physical and psychosocial factors.

Determine the level and intensity of client care needed according to physical and psychosocial factors.

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? Employment history of the parents Responsibilities of the adolescent Environmental hazards in the home Family patterns of communication

Family patterns of communication

The nursing student asks the instructor to explain what a community is. Which statement by the instructor would be inappropriate? "The members of a community share some characteristic in common, such as cultural values." "A community provides resources and services that help to keep its members healthy." "Communities have few effects on the health of the individuals that live there." "A community is a group of individuals who live in the same geographic area."

"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." "Family members are at risk of developing diabetes mellitus in future." "Family members are a point of contact and are able to check on your progress." "Family members can take you to the hospital if any emergency occurs."

"Family members are equally involved in planning and implementation of care."

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 multigenerational family A blended family A homeless family An extended family

A homeless family

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 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 open communication Strengthen the marital relationship Maintain a supportive home environment

Adjustment to retirement

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? Physical function Economical function Socialization function Affective and coping functions

Affective and coping functions

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 Economic interests Similar school districts

Common interests

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): Blended family. Traditional family Cohabiting family. Extended family.

Extended family.

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? Assisting the client to validate their feelings regarding treatment options. Cutting up food and opening drink containers for the client. Seeking input from the client regarding their preferences for a snack. Providing the mother the phone number for the Poison Control Center

Providing the mother the phone number for the Poison Control Center

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. Gently inform the client that nurses cannot practice religion with clients. Ask the client if she would like to call a minister to pray with her. Ask if someone else on staff is the same religion as the client.

Read the Koran passage to the client.

The nurse provides the mother of a toddler with the phone number for the Poison Control Centre. Which level of Maslow's hierarchy of needs is the nurse addressing? Physiologic needs Loving and belonging needs Safety and security needs Self-actualization needs

Safety and security needs

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

Self-esteem needs

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

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

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

Been socialized in healthcare

A 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? 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. The mother has a history of heavy alcohol use. The family lives in a small apartment in a poor neighborhood with high crime rates.

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

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

Family members

A community health nurse is providing care to several farming families in a rural community. Which of the following would be most important for the nurse to integrate into the plans of care for these families? All family types have similar problems regardless of their structure. The extended family structure has fewer issues that impact family functions. Family structures may change over time. The traditional nuclear family structure is the current norm.

Family structures may change over time.

A nurse is caring for a 78-year-old male client who has been hospitalized following a stroke. Which nursing action has the highest priority for this client? Helping the client to fill out an advanced directives form Measuring the client's I&O during recovery Finding a safe environment for the client upon discharge Ensuring that the client has family and friends visit him

Measuring the client's I&O during recovery

The nurse assesses a client who is postoperative day 1 following a total abdominal hysterectomy. Assessment data includes BP 150/88 mm Hg, HR 100/bpm, RR 22/min with a pain scale of 8 out of 1-10. The abdominal dressing in clean, dry, and intact. The client's orders indicate ambulation today. Which is the priority nursing action? Notify the healthcare provider of the client's condition. Medicate the client for pain. Remove the abdominal dressing and assess the incision. Assist the client out of bed to walk in the hall.

Medicate the client for pain.

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 Provide housing for the community Determine ways to change the industry Educate the community

Assist in the protection of members

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

Increased financial concerns

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 Involvement from significant others Stress of education, job, and parenting Economic difficulties associated with parenting

Limited time in learning to be a marital partner

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

Nuclear

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? Document the type of seizure in the client's health record Position the client in a side-lying position. Notify the physician. Reorient the client to person, place, and time.

Position the client in a side-lying position.

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

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? Reproductive Affective and coping Socialization Physical

Socialization

Which are stressors that affect the health of the family? Public transportation present throughout the community. Well-funded school systems and inadequate childcare services. Many job opportunities with adequate income. Family members who live in the same geographic location.

Well-funded school systems and inadequate childcare services.

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

a postsurgical client who is feeling dizzy with a heart rate of 45/bpm

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?" "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?"

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

Which of the following theorists supports the developmental framework of family assessment? Minuchin Bowen Duvall Satir

Duvall

According to Archer, what are the three general types of communities? Connected, casual, and formal Financial, protective, and valued Healthy, cultural , and independent Emotional, structural, and functional

Emotional, structural, and functional

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? Single-parent family Blended family Extended family Nuclear family

Extended family

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 identifies strengths in a client who is scheduled for a mastectomy. A nurse arranges for a teenage client to have visits from school friends. A client enrolls in art class after recovering from major surgery. Grab bars are installed in a client bathroom to facilitate safe showering.

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

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

Sociocultural dimension

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

The client makes a rattling noise when she breathes through her mouth.

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? An elevated urine specific gravity Oral intake of 1500 ml in 24 hours An elevated hematocrit level Urine output of 1500 ml in 24 hours

Urine output of 1500 ml in 24 hours

In conjunction with the client, the nurse has set the following client outcomes. Which client outcome reflects Maslow's level of self-esteem needs? The client will ambulate 20 feet using a walker by May 2. The client will identify two people that can be called to assist with transportation to the physician's office by March 9. The client will identify the signs and symptoms of hypoglycemia by January 22. The client will verbalize feelings of increased confidence in performing a finger-stick blood sugar.

The client will verbalize feelings of increased confidence in performing a finger-stick blood sugar.

A nurse is caring for a family consisting of three middle-aged adults. Which examples describe developmental tasks of this type of family structure? Select all that apply. The family must prepare for retirement. The family must cope with loss of energy and privacy. The family must maintain ties with younger and older generations. The family must support moral and ethical family values. The family must adjust to the cost of family life. The family must adjust to loss of spouse.

The family must maintain ties with younger and older generations. The family must prepare for retirement.

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

The role of the family is essential in every level of nursing practice.