Ch. 4 PrepU

Which client requires priority intervention by a nurse providing care on a medical-surgical unit?

A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min

An adolescent confides in the school nurse that the adolescent is arguing daily with her mother and often wonders whether 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 nurse is assessing a family for possible risk factors that may be contributing to the family's altered health status. When assessing for environmental risk factors, which questions would the nurse ask? Select all that apply.

"Is there anything going on at work that is causing you stress?" "Are you financially able to keep your home safe for your children?"

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 receives a client assignment. Which client should the nurse see first?

A client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90%

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 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.

A nurse working with patients in a community is aware that which 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 nursing student's parents are both physicians. The nursing instructor may feel the student has

Been socialized in healthcare

Which is the basic unit of human society?

Family

In caring for a client, the nurse recognizes which as the primary educational and support structure for an individual?

Family members

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 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 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 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 assisting a neurologist, who is assessing the norepinephrine (noradrenaline) level of a client who is reporting stress. Which function does norepinephrine (noradrenaline) perform?

heightens arousal and increases energy

What factors must the nurse consider when creating a holistic plan of care? (Select all that apply.)

The client's developmental life stage The client's emotional context The client's physiologic health condition

The nurse is implementing care for several clients. Which client is the nurse helping to reach the highest level of Maslow's hierarchy of basic human needs?

The nurse provides privacy for the client and family during times of prayer.

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.

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 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

Which theorist supports the developmental framework of family assessment?

Duvall

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

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

social support

The nurse is assessing the family structure of the client. The family household comprises two parents, three children, and one grandparent. The nurse recognizes that this is a(n):

Extended family.

A nurse caring for a 25-year-old client who has recently been diagnosed with testicular cancer knows that this client's illness will impact every aspect of life. What developmental task is likely to be affected?

Marrying and starting a family

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

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 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.

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.

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

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 for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention?

provide care transition at discharge for speech therapy

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 as prescribed by the healthcare provider.

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

A new graduate nurse asks a nurse manager working at the community health center, "I've heard people talk about community health nursing and community-based nursing. Is there a difference?" Which response by the nurse manager would be appropriate?

"Community health nursing involves care for entire populations whereas community-based nursing focuses on individuals and families in that population."

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

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 community is defined as a social group that may or may not share common geographic boundaries yet interact because of

Common interests

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 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 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 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 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

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.

The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which is an individual need?

Safety

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

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

Sociocultural dimension

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 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 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

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 developing a plan of care for a client to meet the client's safety and security needs. Which intervention would the nurse include? Select all that apply.

Using aseptic technique when providing wound care Teaching the client about what to expect with upcoming surgery Administering prescribed medication at the required time

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 nurse is admitting a 38-year-old client to the oncology unit whose religious background is different from the nurse's own. The nurse is assessing how the client's religion may affect the client's 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?"

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

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

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

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 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.