Nurs. Fund: Ch 4.

A client asks the nurse how cortisol works. What is the appropriate nursing response?

"It suppresses the immune response."

Nursing, as a profession, has long held the belief that providing nursing care to an individual patient means providing nursing care to the entire family. What does this mean when put into a holistic framework of patient care?

Active participation by individuals and families in health promotion is integral to this framework of patient care.

The nurse is caring for a client diagnosed with terminal cancer who wishes to use meditation and prayer to be cured. What is the appropriate nursing action?

Advocate for the client's choice.

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

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

The nurse has developed a strong therapeutic relationship with an electrician who sustained severe burns while working on an industrial site. Which action by the nurse most directly addresses the client's self-actualization needs?

Discussing the client's strengths and dialoguing about body image

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

The epidemiology nurse finds a lower occurrence of influenza cases in a section of a large metropolitan city. Further research reveals higher influenza immunization rates in that section of the city. The nurse determines which probable cause for this occurrence?

Immunization has become a community norm.

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?

Medicate the client for pain.

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 client comes to the health center for a follow-up visit. Assessment reveals that the client is experiencing problems ambulating and moving about due to degenerative joint disease; in addition, the client is feeling isolated due to the limitations in mobility. The client also reports feeling anxious about the future related to the mobility issues and being unable to fulfill the role as the major provider. Which need would the nurse identify as the priority?

Mobility This is both important to the patients health and mental well being.

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.

The community environment affects the well-being of the individual and the family. Which is the health responsibility of the family?

Maintain healthy lifestyle

A nurse is working as part of a group to address factors within the community affecting the health of the families in that community. Which area would the nurse identify as playing a role in contributing to altered health status? Select all that apply.

- Limited number of institutions providing health care - Small number of recreational opportunities for adults and children - Overlapping of industrial zones with residential zones

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 client is admitted to the emergency department following a tornado in which multiple people were killed or injured. The nurse applies direct pressure to an open wound on the client's thigh while assuring the client that the weather has cleared. Which of Maslow's basic human needs is the nurse addressing with the actions? Select all that apply.

- Physiologic - Safety and security

A nursing student's parents are both physicians. The nursing instructor may feel the student has:

Been socialized in healthcare

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

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.

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 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 patients safety is first in any case. This is a life threatening scenario.

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 Self actualization Esteem Love/belonging Safety Physiological

A family assessment of a father, mother, and four children has suggested the presence of several risk factors. Which aspect 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.

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.

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 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

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 nurse is assessing a client with stress-related problems. Which factor influences responses to stressors?

Social support

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.

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 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.

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 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 caring for a client diagnosed with pancreatitis. Which is a priority need for nursing management of this client?

Acute pain in the abdomen

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."

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.

Which are examples of meeting self-actualization needs according to Maslow's hierarchy of needs? (Select all that apply.)

- A nurse takes a course in communication to better relate to clients. - A nurse subscribes to several nursing journals. - A nurse attains a master's degree in nursing.

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 marital partners

A nurse is caring for a 78-year-old client who has been hospitalized following a stroke. Which nursing action has the highest priority for this client?

Measuring the client's intake and output during recovery