Chapter 5 Frameworks for Health Promotion, Disease Prevention, and Risk Reduction
10. The nurse decided to use a learning model based on Skinner with a client with diabetes to improve compliance with dietary and blood glucose assessment requirements. Which would be the best way to implement this program? A) Give rewards for a lower blood sugar level and a food diary that reflects moderate dietary compliance. B) Eliminate the reward and punish the client when she fails to comply with dietary guidelines. C) Demonstrate positive reinforcement by decreasing dietary guidelines and blood sugar parameters. D) Institute a strict timeline to accomplish goals.
Ans: A Feedback: According to Skinner (1953), health behaviors are seen as incremental steps toward a final goal. In the learning model, the nurse establishes and reinforces a goal and rewards the client for partial accomplishment, if necessary. Incremental increases are then made as the pattern of behavior is shaped toward a specific goal. Reinforcement is used to motivate the client to either continue or discontinue a behavior. Giving rewards for a lower blood sugar level and a food diary that reflects moderate dietary compliance is the best example of implementing a learning model of behavior change. Punishment and enforcing a strict timeline do not provide positive reinforcement and thus are not good examples of the learning model. Lowering the requirements of the goal is also not a good example of this model, as the goal should not change.
3. Absenteeism due to illness has increased recently in the local middle school. The increase is noted to be related to exacerbation of asthma symptoms in the student population. Which would be the most effective approach in decreasing absenteeism among this population? A) Develop an asthma education and surveillance program that addresses students, families, and faculty members. B) Develop a policy to exclude students with a diagnosis of asthma from admission to the school. C) Create an asthma prevention plan within the school environment, based in the school nurse's office. D) Create an education program for faculty related to the prevention of exacerbation of asthma systems.
Ans: A Feedback: Community health nurses are focused specifically on modifiable risks of acquiring disease. This requires nurses to analyze trends in risk surveillance data and consider the physical, emotional, and psychosocial challenges people face when confronting disease, physical stressors, and the possibility of premature death. Public health science uses in-depth processes of data collection across the natural history of disease to define trends, and in this way assists nurses and other public health officials in prioritizing the steps needed to minimize risk and improve the quality of care in populations. Only the development of a program that addresses students, families, and faculty members and that takes into account surveillance data is in-depth enough to be effective. The other options do not reflect public health science or approach the problem in a holistic manner.
13. A 34-year-old client is recovering from a below-the-knee amputation secondary to a motor vehicle accident. The nurse meets with the client to update his care plan, and client states that he knows that he will walk again. He asks for physical therapy schedules and timelines for prosthetics on the basis of his healing process. On the basis of knowledge of the theory of reasoned action, the client's behavior reflects: A) An enhanced ability to meet his goals on the basis of his intention and behaviors B) Goal setting that is unrealistic and irrational based on the client's diagnosis and behaviors C) A depression that will complicate the healing process D) Denial of the injury and part of the healing process
Ans: A Feedback: The theory of reasoned action states that a person's given behavior is primarily determined by his or her intention to perform that behavior (Fishbein & Ajzen, 1975). This intention is determined by the person's attitude toward the behavior (beliefs about the outcomes of the behavior and the value of these outcomes) and the influence of the person's societal environment or subjective norm (beliefs about what others think the person should do). The ability to perform the behavior (a belief that it can be done) is the critical aspect of the change process. The other answers do not reflect the theory of reasoned action.
5. The local clinic is dedicated to the well adult and child. It has evening hours and offers varied programs for the community. The programs include immunizations and classes on fire safety, health education, and car safety, to name a few. How would the nurse explain the level of prevention used in this setting to your colleagues? A) Primary B) Secondary C) Tertiary D) Quaternary
Ans: A Feedback: When an individual person or a group is considered in good health and shows no signs or symptoms of disease or physical challenges, nurses in interdisciplinary teams and community partnerships are involved in primary prevention. Secondary prevention is a planned effort to minimize the impact of disease and injury once it is realized. Tertiary prevention is the long-term management and treatment of clients with chronic conditions. Quaternary prevention is fabricated.
11. The nurse decides to use the health belief model for a wellness walking program for older adults. The walk is to begin each day at 8 PM. Each day a different participant is to start a chain of phone calls to other participants to remind all to attend. The nurse informs the clients in the clinic that walking will improve their overall health and well-being. Two older adults show up the first night and none the second. Which information should the nurse gather to explain the failure of the program? (Select all that apply.) A) The severity of the physical challenge related to the client population B) What stands in the way of taking action toward the goal of health promotion C) The presence or absence of cues needed for the program to achieve success D) The presence or absence of a strong team leader among the participants E) The need to increase persuasion when implementing the program
Ans: A, B, C Feedback: The health belief model, developed by Hochbaum (1956) and Rosenstock (1974), specifies that individual, family, or community health-related behavior depends on (1) the severity of the potential illness or physical challenge, (2) the level of conceivable susceptibility, (3) the benefits of taking preventive action, and (4) what stands in the way of taking action toward the goal of health promotion. This model uses cues as an important way to remind people of healthy behaviors and to promote these actions. A strong team leader and persuasion are not integral parts of the health belief model.
7. The nurse works in a facility that provides hospice care for clients with cancer diagnoses. The nurse recognizes that the care provided in this facility is tertiary in nature. The nurse develops a plan for the clients that would include the tenets of tertiary prevention. The plan would include: (Select all that apply.) A) Palliative care B) Pain control C) Isolation D) Supportive spiritual development E) Diminished involvement of significant others
Ans: A, B, D Feedback: Tertiary prevention includes rehabilitation and palliative care. Nurses providing this level of care assess disease progression, watch for opportunistic infections, and control pain or other side effects of treatment. Care also includes supporting life choices that bring emotional comfort to clients such as family involvement, decreased isolation, supportive spiritual development, and organized help from communities. Isolation and diminished involvement of significant others do not enhance the client's health and well-being and are not examples of tertiary prevention.
16. A 19-year-old client is diagnosed as HIV positive. Which behaviors might be indicators of noncompliance with her drug regimen and require further assessment? (Select all that apply.) A) Depression B) Indifference to self-advocacy in sexual relationships C) Goal-oriented attitude toward treatment plan D) Client's expression of concern for the health and well-being of her children E) Client's expression of concern regarding the ability to pay for her medications
Ans: A, B, E Feedback: In women, there is a relationship between poor self-image, depression, and lack of self-advocacy in sexual relationships (DeMarco, Johnsen, Fukuda, & Deffenbaugh, 2001). From a treatment perspective, depressive symptoms are underdiagnosed and are associated with lower medication adherence, risky behaviors, and poor health outcomes (Sanzero et al., 2005). Goal orientation toward the treatment plan and expressions of concern for her children would tend to indicate compliance, not noncompliance, with her drug regimen.
19. Secondary HIV prevention or positive prevention is used when caring for African-American women living with HIV by addressing which behavioral risks? (Select all that apply.) A) Interpersonal mistrust B) Alcoholism C) Poor adherence to treatment D) Smoking E) Compromised self-advocacy in sexual relationships
Ans: A, C, E Feedback: Advancing the scientific understanding of secondary HIV prevention (what is called positive prevention) in African-American women by exploring ways to address behavioral risk reduction prevents further transmission of HIV and the serious negative psychological consequences of living with HIV disease. African-American women experience disproportionate levels of (1) interpersonal mistrust and fear of disclosure related to perceived stigma, (2) poor adherence to treatment and other health promotion and disease prevention efforts, (3) delay in seeking care related to mental health comorbidities and addiction recovery issues, and (4) compromised self-advocacy in sexual relationships. Alcoholism and smoking are not behavioral risks associated with African-American women living with HIV.
1. Health People 2020 (HP 2020) is a guidepost for nurses and interdisciplinary teams in community and public health. New focal areas for HP 2020 include: (Select all that apply.) A) Adolescent health B) Diabetes C) Genomics D) Nutrition and weight status E) Social determinants of health
Ans: A, C, E Feedback: Ten new focal areas were added to HP 2020, beyond those included in HP 2010. These include the following: adolescent health; blood disorders and blood safety; dementias, including Alzheimer disease; early and middle childhood; genomics; global health; healthcare-associated infections; health-related quality of life and well-being; lesbian, gay, bisexual, and transgender health; older adults; preparedness; sleep health; and social determinants of health. Diabetes and nutrition and weight status were focal areas that were already included in HP 2010.
18. A woman arrives at the clinic for a routine appointment. She has been HIV positive for 3 years and states she is doing well. She currently is involved in a relationship with a man who is HIV positive. She states that she is not consistent with safe sex practices due to her significant other's preferences and feels uncomfortable asking him to wear a condom. Which is the nurse's best response to promote the client's health? A) "You won't become pregnant as long as you are taking your drug cocktail." B) "You will not be protected against other strains of HIV or sexually transmitted infections (STIs)." C) "You will both be safe because you both already have HIV." D) "Let's have you both tested for STIs."
Ans: B Feedback: Although both the woman and her partner are already HIV positive, they can still transmit different strains of HIV to each other, as well as other STIs and can then go on to infect others. Thus, they are not "safe" and the woman should be encouraged to advocate for herself by insisting that her partner wear a condom. The client's drug cocktail will not prevent her from becoming pregnant from unprotected sex. Testing for STIs for the woman and her partner may be appropriate, but not until the client is made to understand the importance of protected sex.
6. Using the tenets of secondary prevention, the committee seeks to establish an HIV/AIDS clinic. The nurse states that it is important for the location of the clinic to be associated with the local hospital. The committee states that the cost of the clinic associated with the hospital is higher than one that is free standing. Which presents the best rationale for the nurse's suggestion? A) Third-party insurance will reimburse the clinic visits only if the clinic is attached to the hospital. B) The hospital can more easily implement programs of care for the clients. C) The hospital will cover the clients only if the clinic is approved by the hospital governance board. D) The hospital will have a vested interest in the success of the clinic.
Ans: B Feedback: Clients diagnosed with HIV/AIDS need secondary prevention services. To screen effectively for the presence of this condition, a test should be backed by a healthcare infrastructure that can implement programs of care for people who have a verified risk of the disease or physical challenge. The other rationales for placement of the clinic are not based on the tenets of secondary prevention.
2. The nurse identifies the specific indicators and focal areas needed to establish immunization and well-child clinics in a low-income neighborhood. What actions are needed to meet the health outcomes of the project? A) Identify the need in the community for the clinic on the basis of subjective data. B) Develop a plan to meet the costs and promote the benefits of the project. C) Consider the identified neighborhood's need for healthcare compared with that of other low-income neighborhoods by interviewing the members of the neighborhood. D) Assume that the neighborhood will welcome the institution of a well-child and immunization clinic.
Ans: B Feedback: Knowing how to address the need for change and the actual change at a personal, family, and community level must be based on science—evidence based on rigorous understanding of a problem. Specific actions that can best achieve positive health outcomes can then be determined. Consideration must be given to realistic viability of solutions, costs and benefits, and the degree to which individual people will accept these approaches. Developing a plan to meet the costs and promote the benefits of the project meets these criteria. The other answers are not evidence based.
21. The nurse works at community clinic that provides various types of health screenings for members of the community. One day, the nurse provides tuberculin tests for a group of new hospital employees. Which type of screening procedure is this? A) Mass screening B) Selective screening C) Multiphasic screening D) Case finding
Ans: B Feedback: Selective screening is performed for specific high-risk populations, such as tuberculin tests for hospital employees. Mass screening is performed on an entire population, such as blood lead level screening, Papanicolaou (Pap) smears, and phenylketonuria of newborns. Multiphasic screening involves a variety of screening tests applied to the same population on the same occasion, such as a series of tests performed on a single blood sample, periodic surveillance of drug therapy, and monitoring the stage of an illness. Case finding is a type of screening ordered by a clinician when searching for illness as part of a client's periodic health examination.
12. The committee has established the need for a sick child clinic in an impoverished neighborhood. The demographic data have been collected, and the committee is ready to meet with a group of local businesspeople who are willing to support the project financially. The plan is for the committee and group to combine to facilitate the establishment of the clinic. Using a transtheoretical model, which level of readiness has the committee achieved? A) Contemplation B) Preparation C) Action D) Relapse
Ans: B Feedback: The stages in a transtheoretical model are as follows: precontemplation (no screening programs scheduled and no intention to schedule screening); contemplation (no screening programs scheduled but intent to start a program soon); preparation (no definite screening program but have taken steps to develop a program); action (developed a screening program and intent to sustain the program); maintenance (have had the program for some time and intend to continue); relapse (had a program, do not have a program currently, but intend to have one soon). The committees in this case are in the preparation stage, as they have taken steps to start the clinic but have not actually started it yet.
15. A 27-year-old client comes from a background of physical and sexual abuse. Violence victimization continued with her partners until recently. She is currently in a support group for victims of abuse. The client's social background places her at risk for: (Select all that apply.) A) Increased safe sex behaviors B) Decreased safe sex behaviors C) Decreased risk for HIV/AIDS D) Increased risk for HIV/AIDS E) Increased risk of depression
Ans: B, D, E Feedback: Trauma such as child sexual abuse, intimate partner violence, adult sexual abuse, and victimization from exposure to violent environments contribute to behaviors associated with increased HIV risk and disease sequelae. Violence victimization increases depressive symptoms, decreases safe sex behaviors, increases the chance of becoming HIV seropositive, and increases the chances of acquiring and being treated for a sexually transmitted infection (STI) within a year's time (Laughon et al., 2007).
4. Multiple family units in an underserved neighborhood have children who have not been vaccinated per health guidelines. The nurse researches the problem and establishes a well-child clinic within walking distance to the neighborhood. The clinic is poorly attended. Which would be the nurse's best action to revise the program and improve attendance to the clinic? A) Determine whether the location of the clinic is not conducive to attendance. B) Discuss the problem of attendance at the next community council meeting. C) Interview members of the neighborhood to determine why they do not use the clinic. D) Discuss the problem with the local minister and request him to discuss the clinic at the next prayer service.
Ans: C Feedback: Although the morbidity and mortality data reports are quantitative, it is important to understand that in most cases, perceptions of health or well-being on the part of individuals, families, and communities are subjective. The science of diagnosis and healthcare follow-up may be present, but it is the subjective perceptions of others that often determine a person's willingness to participate in health promotion initiatives. Interviewing members of the neighborhood to determine why they do not use the clinic is the only option that recognizes the need to perceive the subjective perceptions of the neighborhood.
9. The nurse conducts a class on the basics of nutrition to a group of obese adults. The nurse counsels the audience, telling them that they need to change their behaviors. By the end of the class, the nurse has lost the audience. To enhance audience participation and learning in the next class, the nurse should: A) Use consistent methods of persuasion B) Offer advice while the participants are passive C) Encourage the group to participate in the decision making D) Encourage the group to continue ambivalent behaviors
Ans: C Feedback: Motivational interviewing, which was developed by Rollnick and Miller (1995), is defined as a "directive, client-centered communication style for eliciting behavior change by helping clients/[groups] to explore and resolve ambivalence." To address behavior change using this method, the motivation comes from the client and is not imposed by a clinician. The client needs to resolve ambivalence to change a behavior with autonomy. Persuasion on the part of the clinician only intensifies resistance. The communication style is therefore one of directing the client to examine and resolve ambivalence. This method does not (1) argue with a group or community by insisting it has a problem that needs to change, (2) offer advice without actively encouraging group-identified choices, (3) give advice while the group is put in a passive role, (4) impose diagnostic labels, or (5) use coercive tactics.
17. A 32-year-old African-American client is diagnosed with HIV. She is at her 6-month appointment following diagnosis and treatment. The client states that she has not revealed her diagnosis to her boyfriend because she is afraid that he will leave. She expresses feelings of anger because she must put her feelings and illness aside or be abandoned. The client's behaviors reflect: A) Denial of her disease process B) Noncompliance with her drug regimen C) Inability to advocate for herself D) Fear of financial insolvency
Ans: C Feedback: The concept of "silencing the self" has been used to explain how gender roles negatively influence self-advocacy behaviors in women. Women tend to silence their voice in relationships to maintain connections with others, even if that means they will subsequently suffer physically, psychologically, or socially. According to Jack (1991), women are reinforced culturally to (1) care for others' needs before their own, (2) abide by designated societal rules of behavior, (3) refrain from directly expressing their feelings and needs, and (4) outwardly maintain compliance, while feeling hostility inwardly, because of their silencing behaviors. Silencing the self is relevant to the proposed study because it is a concept that is identified and understood in the context of relationships with others, that is, a relational concept. There is no evidence that Carlene is denying her disease process, not complying with her drug regimen, or is fearful of financial insolvency.
20. A 43-year-old African-American client is HIV positive. She has a personal history of abuse, which ended when her husband died 2 years ago. When counseling the client about adherence to her treatment plan, the nurse finds her intelligent and goal oriented. In addition to her need for education and follow-up regarding her HIV diagnosis and treatment, which associated condition should the nurse most consider when caring for this client? A) Cardiac tamponade B) Chronic obstructive pulmonary disease C) Posttraumatic stress disorder D) Cirrhosis of the liver
Ans: C Feedback: When providing physical care to clients with HIV and working to decrease communicability using the ecological model, consider the client's mental health symptoms, severity/frequency of the effects from significant trauma, such as posttraumatic stress disorder, substance use and abuse, and addiction. Cardiac tamponade, chronic obstructive pulmonary disease, and cirrhosis of the liver are not typically associated with either HIV or a history of abuse.
14. A 47-year-old client and three members of his neighborhood have had their homes robbed and belongings scattered. The client contacts the police and, with their assistance, develops a neighborhood watch. The watch is organized and 24 families have been recruited to participate. The watch will be active throughout vacation months and as needed. This organization is representative of: A) Transtheoretical model B) Theory of reasoned action C) Social learning D) Relapse prevention model
Ans: D Feedback: The relapse prevention model has been used specifically with issues that relate to adherence. For example, communities interested in crime prevention may be aware that in certain months of the year there is an increase in violent crime. They would then create a community campaign to promote nonviolence by increasing law enforcement presence and improving faith-based support. Social learning/social cognitive theory is a behavior change approach affected by environmental influences, personal factors, and attributes of the behavior itself. The theory of reasoned action states that a person's given behavior is primarily determined by his or her intention to perform that behavior (Fishbein & Ajzen, 1975). The transtheoretical model, developed by Prochaska and DiClemente (1983), is a sequential approach to behavior change that involves timely readiness of the learner.
8. An immigrant from Guatemala, age 47, is admitted to the coronary care unit with congestive heart failure. This is the fourth admission for this client, and the physician believes that the client's inability to adhere to his diet and medication regimen is the reason for his frequent admissions. The physician refers the client to the local community health nurse, on discharge from the hospital. Which would be most appropriate for the nurse to include in this client's plan of care? A) Insisting that the client adhere to his diet B) Developing culturally relevant and gender-sensitive interventions C) Teaching the family to adapt their cultural dietary plans to the client's diagnosis D) Assessing the client's financial needs and obtaining financial assistance as needed
Ans:B Feedback:The development of culturally relevant and gender-sensitive interventions that demonstrate positive outcomes in health and well-being is the focus of prevention efforts. Approaching individuals and groups about behavior change must incorporate knowledge of diverse client perspectives and include the use of counseling skills and motivational interviewing. To address behavior change using motivational interviewing, the motivation comes from the client and is not imposed by a clinician. The client needs to resolve ambivalence to change a behavior with autonomy. Persuasion on the part of the clinician only intensifies resistance. Thus, the nurse should not insist that the client adhere to his diet, which does not reflect the client's cultural needs as a Hispanic male. Teaching the family to adapt their cultural dietary plans to the client's diagnosis addresses only one of the client's needs. Assessing the client's financial needs and obtaining financial assistance is the role of the social worker, not the nurse.