Chapter 4 POINT QUESTIONS

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 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 Although all of the needs listed need to be addressed, the nurse would identify mobility issues as the priority need based on Maslow's hierarchy. In addition to it being a physiologic need, it also appears to be the underlying issue related to the client's other needs. Addressing mobility may have a positive impact on the client's other needs.

A nurse is applying for a position as a community-based nurse. Which type of assignments should this nurse choose to accept in this role? Select all that apply.

Visiting a client recently discharged from the hospital Conducting an assessment on a family with a terminally ill child A community-based nurse provides care to individuals or families within a community. Examples are visiting clients recently discharged from the hospital and conducting family assessments. A community health nurse focuses on whole populations. Examples are disaster preparation, organizing clinics, and developing education materials for the public.

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."

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 Conflicts between family members are considered psychosocial risk factors. Lifestyle risk factors are habits or behaviors people choose to engage in such as smoking and exercise. Developmental risk factors are characterized by vulnerability to negative social and environmental influences, such as peers and underage drinking. Biological risk factors are related to genetics, the brain, health habits, and medical issues.

What is an example of a community risk factor?

Children are kept inside on a sunny day due to a lack of recreational opportunities. A key component of the question is the term community. The most basic definition of a community is a specific population or group of people living in the same geographic area under similar regulations and having common values, interests, and needs. The only option above that addresses community is the one in which children are kept inside the home on a sunny summer day because of a lack of recreational opportunities. The other options are focused on individuals, which is not the direction of the question.

A nurse is planning a seminar for the local community. Which topics are examples of health promotion discussions? (Select all that apply.)

Examples of heart-healthy diet Information on increasing activity and exercise Providing examples of heart-healthy diets and information on increasing activity and exercise are health promotion topics. Smoking cessation and blood pressure control are examples of illness prevention. Offering the names and numbers of healthcare providers is resource sharing.

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 five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. When assessing the family of a depressed client for affect and coping function, it is helpful for the nurse to be aware of the family's communication style. This information can help identify family difficulties and teaching points that could benefit the client and the family.

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 Rest is a basic physiologic need, because it allows time for the body to rejuvenate and be free of stress. Lack of sleep and rest may become a safety issue if not addressed. Love and belonging is related to acceptance in a group. Self-esteem is related to how one sees one's self.

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 Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as moving and ambulating patients. Assisting the patient to ambulate ensures that the patient will not experience a fall. From the bottom of the hierarchy upwards, the needs are: physiological, safety, love and belonging, esteem and self-actualization. The third stage in Maslow's hierarchy of needs is the social stage (also known as the love and belonging stage), which includes interpersonal relationships. Human behavior is driven by needs, one of which is the need for a sense of personal importance, value or self-esteem. Self-actualization represents growth of an individual toward fulfillment of the highest needs; those for meaning in life, in particular.

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 Duvall (1977) identified critical family developmental tasks and stages in a family life cycle. Duvall's theory, based on Erikson's theory of psychosocial development, states that all families have certain basic tasks for survival and continuity as well as specific tasks related to developmental stages throughout the life of the family. The question asks about a community clinic that serves mostly families with young children and the priority intervention for clients in this developmental stage. Setting up parenting classes is the only answer that addresses the stated developmental stage. Families with adolescents and young adults would be at the appropriate developmental stage for providing sex education and alcohol/drug information. The community clinic would not focus on screening for congenital defects.

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 Through socialization, the family teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides feedback; and guides problem solving. Incorporating religious beliefs, values, and attitudes is an example of socialization. Physical functions of the family include providing a safe, comfortable environment necessary for growth and development, rest, and recuperation. The reproductive function of the family is raising children. The affective and coping function of the family involves providing emotional comfort to family members.

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." Effective and healthy families exhibit open communication among its members. Protecting the spouse from worry by not discussing money matters stifles communication and jeopardizes the family's affective and coping functions. It is appropriate for a father to provide emotional comfort to his son by allowing him to sit on his lap during the interview. Paying cash is an appropriate way to manage family finances. The mother is stating her personal belief about housework in a clear and open manner.

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. Friedman and associates identified the importance of family-centered nursing care, based on four rationales. First, the family is composed of interdependent members who affect one another. If some form of illness occurs in one member, all other members become part of the illness. Second, a strong relationship exists between the family and the health status of its members; therefore, the role of the family is essential in every level of nursing care. The third rationale is that the level of health of the family and, in turn, each member can be significantly improved through health-promotion activities. Finally, illness of one family member may suggest the possibility of the same problem in other members; through assessment and intervention, the nurse can assist in improving the health status of all members.

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 This family exhibits the function of affective and coping by observing the ritual of "Sitting Shiva." By observing this Jewish, seven-day period of mourning for first-degree relatives (husband, wife, parent, or child) the family provides emotional comfort to family members, helps to establish their identity, and maintains it in times of stress. Economical function provides financial aid to family members. Physical function provides a safe, comfortable environment necessary for growth and development. Through socialization the family teaches values, attitudes, and provides feedback, and with the function of reproduction the family produces and raises children.

A Spanish-speaking client is admitted to the emergency department with a urinary tract infection and is experiencing a stress response from hospitalization. What is the priority nursing intervention?

contact a translator

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. An extended family is composed of family members, including aunts, uncles, and grandparents, who live in close geographic proximity to one another. A traditional family consists of two parents and their children. A blended family is formed when parents bring unrelated children from previous relationships together to form a new family. Unmarried individuals who choose to live together for a variety of reasons form a cohabiting family

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 Somatization is manifesting an emotional stress through a physical disorder. Treating the nausea with an antiemetic will not get at the root cause of the emotional issue. Contacting the primary care provider is not appropriate, as the diagnosis of somatization is present. Explaining that the physical symptoms are all in the client's head is not therapeutic. Sitting with the client to explore what is really going on is most appropriate nursing response.

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

Sociocultural dimension Communication is essential for interaction with others and is an example of the sociocultural dimension. The physical dimension incudes physiological health and nutrition. Housing and community are examples of the environmental dimension. The emotional dimension includes fear, sadness, loneliness, and acceptance of self.

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."

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 According to Maslow, the first-level physiologic needs are the most important. They are the activities necessary to sustain life, such as breathing, circulation, and eating. Using Maslow's theory and the ABCs (airway, breathing, circulation) to help prioritize care of clients, the nurse needs to see the client experiencing acute problems with circulation and a heart rate of 45 beats/min. All other client problems are not the priority at this time.

Which are stressors that affect the health of the family?

Inadequate childcare services

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

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?"

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 holistic plan of care seeks to balance and integrate the use of crisis medicine, advanced technology, and the mind, body, and spirit, which are incorporated though the use of the nursing process. Taking into account the cost of care is only one facet of a holistic picture. Connecting families, friends, and the environment is important, but mind, body, and spirit define holism. A holistic plan of care may provide a connection between medicine and nursing, but it does not define it.

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

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. Communities are thought to contain persons who share similar characteristics, whether it be social interaction, cultural or ethnic ties, or geographic area. Communities may be larger or smaller that a geographic neighborhood and are not defined by geography. Communities exist because they meet basic human needs.

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 community-based nurse must be knowledgeable about community resources available to clients as well as services provided by local agencies, eligibility requirements, and any possible charges for the services. The other answers are incorrect because they are not the most important factor for a community-based nurse to be knowledgeable about.

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 Many single-parent families are headed by women. Single parents often have special problems and needs, including financial concerns and role shifts (i.e., having the roles of both parents). Single-parent families are not less knowledgeable about child safety than other family types, nor is there a higher incidence of child abuse, neglect, or conflict among family members.

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 It is within families that people grow, are nurtured, acquire a sense of self, develop beliefs and values about life, and progress through life's developmental stages. Developmental tasks associated with young adulthood include marrying and starting a family. The other options are incorrect because achieving self-actualization, reviewing life's accomplishments, and establishing financial security are not developmental tasks for this stage of the client's life.

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 When a person is experiencing a stressor, it is important for the nurse to reduce or eliminate the stress. In this case, it is appropriate to limit the family visiting time to allow the client to recover without experiencing a stress response. Telling the family they are causing the stress is not therapeutic. Telling the client that the family should be there invalidates the client's feelings. Doing nothing is not an appropriate response to decrease or remove the stressor.

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 People who believe that their love and belonging needs are unmet often feel lonely and isolated. The nurse addresses this by establishing a nurse-client relationship based on mutual understanding and trust (by demonstrating caring, encouraging communication, and respecting privacy). Physiologic needs are the most basic in the hierarchy of needs and the most essential to life. Safety and security needs have both physical and emotional components: physical safety and security means being protected from potential or actual harm; emotional safety and security involves trusting others and being free of fear, anxiety, and apprehension. Self-esteem needs include the need for a person to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments.

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 Safety and security needs have both physical and emotional components. Physical safety and security means being protected from potential or actual harm. Emotional safety and security involves trusting others and being free of fear, anxiety, and apprehension. Physiologic needs are the most basic in the hierarchy and the most essential to life. They must be met at least minimally to maintain life. Love and belonging needs include the understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to groups such as families, peers, friends, a neighborhood, and a community. Self-esteem needs include the need for a person to feel good about himself or herself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments.

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 occupations of the parents provide financial support for the family and contribute to the socioeconomic status of the family. Affiliation with a religious organization can be a source of social support during stressful times, which can promote adaptive coping for the family. Cultural and religious activities of the family define values and beliefs important to family members. Recreational activities, such as vacationing together, promote interaction of family members.