NUR 100
A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, with a random blood glucose reading of 575 mg/dL (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomenon?
Exacerbation
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
Consultation and diagnostic tests are included in which level of health care?
Secondary care
A mammogram represents which level of prevention?
Secondary prevention
A nurse is caring for an adolescent who has just lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address?
Self-esteem needs
Which lifestyle factor is associated with an increased risk for chronic diseases?
Smoking
Which are factors that impact how a client defines health? Select all that apply.
Society Family Culture Community
When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which concept?
Focus on what is possible.
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 nursing activity reflects secondary prevention?
Making a referral for a mammogram
A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital for the second time in 2 months with wheezing, dyspnea, and use of accessory muscles when breathing. Which type of situation does the nurse identify is occurring with this client?
The client is having an exacerbation of the COPD.
The mother of three young children makes the following statements to the nurse working in community health. Drag and drop each statement in the order of priority from Maslow's basic priorities to Maslow's more complex priorities. Use all options.
"Sometimes we run out of food the day before I get paid." "There have been two murders in our neighborhood in the last year." "My teenage son is so quiet. He works and goes to school all the time and doesn't have time for friends." "I keep my kids' clothes clean, but we don't have money for the latest styles." "I try to get along with our neighbors, but they are from a strange culture with weird ideas."
A community health nurse is following Division of Community Health (DCH) guidelines to develop programs for the next year. On which program option will the nurse chose to focus?
A research-based article that offers evidence that nutrition is improved when community gardens are developed.
Which nursing intervention is an example of tertiary preventive care?
Assisting with speech therapy a client with a traumatic brain injury
The body's attempt to restore balance through self-regulatory mechanisms is termed:
Homeostasis
Which behaviors are necessary for a person to successfully adapt to a chronic illness? Select all that apply.
Learn to live as normally as possible Maintain a positive self-concept Maintain a sense of hope
A client has been admitted to the hospital for treatment of pancreatitis secondary to alcoholism. The client states that it is nearly impossible to quit drinking because of the deep entrenchment of alcohol use in the client's circle of friends and line of work. As well, the client claims to have thought that drinking only beer and foregoing hard alcohol would prevent health problems. This client is exhibiting health consequences rooted in which human dimensions?
Sociocultural and intellectual
A community health nurse arranges for a dentist to teach local children in the school district how to properly brush their teeth. Which goal will the nurse set for this event?
health promotion
When chronic illnesses and disabilities are present, individuals benefit most from activities that:
help them maintain independence.
A community health nurse in a rural area is concerned that the community needs better health care promotion after reading the statistics published by the state health department. Which factor should the nurse find alarming in the report?
increased use of emergency departments for nonemergency issues
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
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
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
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
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
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 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
What is the definition of wellness?
An active state of being healthy
Which are characteristics of chronic conditions? (Select all that apply.)
Are rarely curable Require lifelong management Have a prolonged course
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 is assessing the communication style of the client. Communication is an example of which dimension of the individual?
Sociocultural dimension
The nurse recognizes that the client who makes the decision to accept a new diagnosis and follow the prescribed treatment plan is in which stage of an illness?
Stage 3-Assuming a dependent role
The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary level prevention?
Teaching about adhering to a low-sodium diet
A nurse is immunizing children against measles. This is an example of what level of preventive care?
Primary
What level of prevention is represented by educating a group of clients on car seat safety?
Primary prevention
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 community is defined as a social group that may or may not share common geographic boundaries yet interact because of
common interests
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.
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 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 taking care of a client who has a new, permanent colostomy. The nurse is talking with the client about the new appliance and asking how the client feels about managing it. Which client response indicates understanding of the relationship between self-concept and health?
"I am developing a set of realistic expectations to help me manage my overall health and quality of life."
A pregnant client at 10 weeks' gestation is receiving education by the nurse about the importance of abstaining from alcohol while pregnant. What statement made by the client demonstrates an understanding of the education provided?
"I should abstain from alcohol to prevent the development of a fetal alcohol spectrum disorder."
The nurse manager of the acute care unit has decided to implement a team nursing approach for client care. One of the staff members asks, "Will we each take care of our own clients?" What is the appropriate response by the manager?
"The care will be divided and the registered nurse (RN) will have a licensed practical/vocational nurse (LPN/LVN) and unlicensed assistive personnel (UAP) to provide care together."
Which scenario accurately depicts the influence of one's religious beliefs?
A client who practices Orthodox Judaism will not eat pork.
What are examples of meeting physiologic needs according to Maslow's hierarchy of needs? (Select all that apply.)
A nurse administers pain medication to a postoperative client. A home care practitioner requests quiet so that a client can sleep.
Which scenario is an example of a characteristic of Stage 2 of illness?
A person tells his family that he is sick and allows family members to take care of him.
Why are health promotion and illness prevention a key responsibility of nurses?
Chronic illnesses are the leading health problem in the world.
An exacerbation refers to the reactivation of a disease. Which condition is associated with exacerbation?
Chronic Illness
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.
A community-based nurse acts as a case manager for a small town about 60 miles from a major healthcare center. What is the most important factor of community-based nursing for this nurse to be knowledgeable about?
Community resources available to clients
A nurse is planning a health fair in the community to highlight promotion and prevention of the leading cause of death in the United States. Which disease process should the nurse address?
Coronary artery disease
A teenaged client reports having diarrhea before every test in school. The nurse recognizes that this client needs to focus on which dimension of health?
Emotional dimension
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
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
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.
When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model?
Health Belief Model
Which is the most accurate definition of health?
Health is a state of complete physical, mental, and social well-being.
Which definition of health is the best?
Health is a state of complete well-being.
A client comes to the health center for a routine visit. During the visit, the client tells the nurse, "I'm motivated to do things now to make sure I'm the healthiest I can be." When planning this client's care, the nurse should focus on which area?
Health promotion
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
Which items represent lifestyle risk factors for altered family health? Select all that apply.
Ingestion of high-fat foods Smoking by the parents Inadequate dental hygiene
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?
It has a gradual onset and lasts for a long time.
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 community environment affects the well-being of the individual and the family. Which is the health responsibility of the family?
Maintain a healthy lifestyle
An older adult client reports having stopped taking the prescribed medications for Addison disease for financial reasons. Upon questioning, the client shares that Medicare Part D is not helping. Which option should the nurse point out may be a solution for this client?
Medigap insurance
The nurse is caring for a client admitted to the hospital with pneumonia and associated pleuritic chest pain. Which would be a priority when creating the nursing care plan?
Monitoring airway clearance
The nurse is preparing to talk to a local community group regarding chronic illness. The nurse informs the group that both external and internal factors influence a person's health. When discussing the fact that the male client has a higher chance of developing lung cancer due to his gender, which dimension is the nurse referring to?
Physical dimension
The nurse's community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. Which level of health promotion is this an example of?
Primary
Which is an example of tertiary health promotion?
Rehabilitation
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 caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness?
Symptoms are not experienced
A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventive care?
Tertiary
A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?
Tertiary prevention
Which model is most useful in examining the cause of disease in an individual, based upon external factors?
The Agent-Host-Environment Model
The nurse receives an 8-year-old client in the pediatric unit following a tonsillectomy. Which assessment finding requires immediate intervention by the nurse?
The client makes a rattling noise when breathing through the mouth.
A client comes to a scheduled appointment with a new flyer from the insurance company (above) and asks the nurse how all these things can be included. How should the nurse respond?
This is referred to as an integrated delivery system. Everyone is working together to provide their clients the best possible care.
What have the models of health promotion and illness prevention been used for?
To help health care providers understand health-related behaviors
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.
The nurse in a free clinic caring for clients uses the Health Belief Model, which is based on three components. What is the main focus for this model?
What people believe to be true about their health
A home health nurse is visiting a family after the recent death of their matriarch. The nurse 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. The nurse asks what is happening, and is told, "We are Jewish, and the family is 'Sitting Shiva'." This family is fulfilling which family function?
affective and coping functions
A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
agent
To be an effective change agent for wellness, the nurse must:
consume a healthy diet
Which theorist supports the developmental framework of family assessment?
duvall
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
A nurse is working with a single-parent family. When planning the care for this family, which need should the nurse anticipate as being a priority concern?
financial concerns
An older adult client who has been hospitalized due to a stroke is about to be discharged from a rehabilitation center where the client had to relearn how to perform activities of daily living, including feeding and dressing. The client has often voiced a desire to be as active as possible. The client now expresses a strong desire to go home. The nurse recognizes that these statements made by the client indicate that the client is:
giving up the dependent role
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 assists the client in the development of a healthy lifestyle. The adoption of these lifestyle changes in the client's life is considered:
self-care.
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