ECPI 2020 NUR164 CHAPTER 4 HEALTH OF THE INDIVIDUAL, FAMILY AND COMMUNITY

1)A nurse provides nutrition for a client through a feeding tube. 2)A nurse places a No Smoking sign on the door of a client who is receiving oxygen. 3)A nurse includes family members in the care of a client. 4)A nurse helps a client focus on the client's strengths following a diagnosis of breast cancer. 5)A nurse prepares a room for a clerical visit requested by a client.

Place the following examples of interventions to meet human needs in order from the most basic, highe- priority needs to the lower-priority needs based on Maslow's hierarchy.

Safety and security

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?

Position the client in a side-lying position.

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 ?

Family patterns of communication

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?

"What can we do to help you meet any religious needs you may have?"

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 clients health care needs. Which question by the nurse is the best way to consider the clients religious practices in the plan of care?

Read the Koran passage to the client.

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?

Confront personal biases about this type of family structure.

The nurse makes a home visit to evaluate a 3-week-old baby. On arrival at the family's home, the nurse discovers that the parents of the baby are a lesbian couple. When planning appropriate nursing interventions for this family, which must the nurse do first?

"Communities have few effects on the health of the individuals that live there."

The nursing student asks the instructor to explain what a community is. Which statement by the instructor would be inappropriate?

Community health care structure

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?

Children are kept inside on a sunny day due to a lack of recreational opportunities.

What is an example of a community risk factor?

Promoting and maintaining the health of individuals and families

What is the focus of community-based nursing?

-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.

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

Urine output of 1500 mL in 24 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?

limit the family visits to once daily

A client is experiencing a stress response each time the family visits the room. What nursing intervention is most appropriate?

Community indicates people who share similar characteristics.

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?

Have the client assume responsibility for the cleanliness of the dayroom.

A client who was admitted to a drug treatment center 3 days ago is boasting to the other residents about using drugs for 2 years, and that the former employer never suspected the drug use. Which action, if taken by the nurse, would be most appropriate for this client?

The parents have a tumultuous relationship, with frequent separations in the past.

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?

Nuclear

A family that consists of two homosexual parents and three children living in the same house is an example of which type of family?

affective and coping functions

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?

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

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?

social support

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

Erikson's theory of psychosocial development

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?

"Our 16-year-old just seems to butt heads with us at every turn."

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?

Emphasizing the client's strengths

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?

"Family members are equally involved in planning and implementation of care."

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?

provide care transition at discharge for speech therapy

A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention?

Limited time in learning to be a marital partner

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?

A psychosocial risk factor

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?

Physiologic

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?

-Knowledge about the value of the MyPlate diagram -Understanding food preferences of clients from the Jewish community -Information on the client's financial status related to meal provisions -Ability the client to prepare food at home

Patient care dealing with nutrition and metabolism should include which factors? Select all that apply.

Adjustment to retirement

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?

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

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 role of the family is essential in every level of nursing practice.

Which statement is true regarding Friedman's theory of family-centered nursing care?

Common interests

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

Address the disease but also incorporate the mind, body, and spirit.

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?

Been socialized in healthcare

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

Offer the client an extra blanket.

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 aiso reports being "chilly." Which nursing action is most appropriate?

Socialization

question 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?

extended family.

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):

-The family must maintain ties with younger and older generations. -The family must prepare for retirement.

A nurse is caring for a family consisting of three middle-aged adults. Which examples describe developmental tasks of this type of family structure? Select all that apply.

Self-esteem needs

A nurse is caring for an adolescent who lost a leg in a motor vehicle accident. Which human need would the address?

Love and belonging

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?

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

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.

Report the suspected child abuse to Child Protective Services.

Anurse 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?

Medicate the client for pain.

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?

Sociocultural dimension

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

Grab bars are installed in a client bathroom to facilitate safe showering.

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?

Advocate for the client's choice.

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?

Wash the nurse's hands before and after the dressing change.

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?

Safety

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?

-Education programs -Communication facilities -Transportation services -Recreation programs

Which community characteristics affect the health of individuals? Select all that apply.

Family structures may change over time.

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?

Community resources available to clients

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?

Maintaining ties with older and younger generations

A home healthcare nurse is performing a home visit to a 56-year-old client who receives home chemotherapy as part of a treatment regimen for breast cancer, as well as to the client's 58-vear- old spouse. The nurse should recognize that this family is likely to be engaged in which development task?

heightens arousal and increases energy

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?

Physiologic

The wife of a comatose client wishes to wash the client's hair, Washing the client's hair meets which basic human need?

Mobility

Question 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?

Providing the mother the phone number for the poison control center

Which in tervention performed by the nurse is most appropriate for assisting a client in meeting safety and security needs based on Maslow's hierarchy of needs?

Duvall

Which theorist supports the developmental framework of family assessment?

Immunization has become the community norm

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?

Extended family

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?

Measuring the client's intake and output during recovery

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?

sit with the client and ask them about their feelings

A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?

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

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?

Increased financial concerns

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?

The father is an engineer and the mother is an elementary school teacher.

describes the socioeconomic status of the family? The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?