Chapter 4 pt.3

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. explaination Nurses must remember that there are no absolutes, such as "rights" or "wrongs," about what makes a family. The structure of an individual's family may change several times over a lifetime, and the nurse must learn to address clients' needs throughout these changes. The traditional nuclear family is not the norm. Each type of family structure creates different issues and problems that, in turn, influence a family's ability to perform basic functions.

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. explanation The most probable cause for this occurrence is that immunization has become a community norm. People tend to do what others in their community do. Free or low-cost immunizations are given in many areas without increasing the immunization rate. Education has little to do with immunization or vaccination rates. Tobacco use may complicate course of illness for those who contract influenza but is not likely to positively impact immunization rates.

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 explaination Norepinephrine (noradrenaline) heightens arousal and increases energy. Acetylcholine and dopamine promote coordinated movement. Serotonin stabilizes mood, induces sleep, and regulates the temperature of a person. Substance P transmits the sensation of pain, whereas endorphins and enkephalins interrupt the transmission of substance P and promote a sense of well-being.

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.

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. explaination Active participation by individuals and families in health promotion supports the self-care model historically embraced by the nursing profession. This model is congruent with the philosophy that seeks to balance and integrate the use of traditional medicine and advanced technology with the influence of the mind and spirit on healing.

Which theorist supports the developmental framework of family assessment?

Duvall

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. explaination The nurse is likely to use Maslow's hierarchy of needs as a tool for setting priorities for client care. Using this tool, the nurse considers the client's physical needs, such as managing pain, as a priority in this situation. The nurse addresses other needs, such as assisting the client with ambulation, after the client's health condition stabilizes. There is no need to contact the healthcare provider about condition unless vital signs do not improve following the management of the client's pain. Removing the abdominal dressing is not indicated.

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 explaination According to Maslow's hierarchy of basic human needs, physiologic (Level 1) needs, such as maintaining fluid balance, are of the highest priority, so measuring the client's intake and output during recovery is the nursing priority in this case.

The nurse recognizes that the community affects the ability of individuals to meet basic human needs. Which example is not a characteristic of a healthy community?

The number of assaults increased 2% over the last year. explaination Violent crimes negatively impact the health of a community. A healthy community provides a safe and healthy environment for its residents (quality drinking water), offers services to meet the needs of the residents (youth center, volunteer opportunities), and offers access to healthcare services.

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. explaination Physical safety and security mean being protected from potential or actual harm. The abdominal dressing with a foul smell indicates the presence of bacteria. It is most important for the nurse to prevent the spread of infection to the nurse and others and to protect the client. Proper hand washing before and after the dressing change to prevent the spread of infection is a nursing activity that will meet these physical safety needs.

A nursing student is engaging in a conversation with a nursing instructor whom the student intensely dislikes. Which nursing student behavior is consistent with reaction formation?

being extremely nice to the nursing instructor