NURS 204 Chapter 4

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 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

During the patient assessment, the client shares that the family attends church nearly every Sunday. Which function of the family does this represent?

Socialization

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 is reviewing the health care records of a family who have experienced varying life crises. The nurse should identify which as health risk factors? Select all that apply.

The grandmother dies at the age of 98. The daughter is pregnant at the age of 15. The father is exposed to asbestos at work.

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.

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 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

In the implementation of effective client care, the nurse should

assess the client's family dynamics and community.

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

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.

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.

Which are stressors that affect the health of the family?

Inadequate childcare services

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

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

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.

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 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.

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

Been socialized in healthcare

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 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 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

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

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.

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."

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 implementing interventions that focus on protecting a client from physical and emotional harm. Which category of needs is the nurse addressing?

Safety and security

Which theorist supports the developmental framework of family assessment?

Duvall

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."

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."

The nurse is providing discharge information to the mother of a 4-year-old who was just diagnosed with influenza A. Which comments, made by the mother, indicate a potential problem in this child's future care? Select all that apply.

"How much does this antibiotic cost?" "I have already missed two day's work because I was sick."

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 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.

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

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.

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 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 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.

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 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 community offers physician offices, a county health department, a community hospital, an assisted living facility, two nursing homes, and hospice. The nurse recognizes that these agencies represent which type of community factor?

Community healthcare structure

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 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 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

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

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 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 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

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-year-old spouse. The nurse should recognize that this family is likely to be engaged in which development task?

Maintaining ties with older and younger generations

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

A nurse is conducting a community health assessment for high risk families. What risk factors should the nurse identify? Select all that apply.

New sibling was introduced two months ago. Family does not have health insurance. Home is located in an area with gang violence. Nearest acute care facility is 45 minutes away.

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

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

Physiologic

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

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.

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.

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

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

Sociocultural dimension

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