Coursepoint Chapter 4 Questions (Health of the Individual...)

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

provide care transition at discharge for speech therapy Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. An example is speech therapy to help restore ability. Blood pressure and mental status exams are examples of secondary prevention associated with the acute stroke. Discussing family history is also secondary prevention in terms of assessing for further risk factors.

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

Physiologic Washing the client's hair meets physiological needs of hygiene.

An adolescent informs the nurse of a desire to learn about birth control. What response by the nurse would gather additional data?

"Would you like to tell me more?" The nurse requires additional information from adolescents prior to arriving at conclusions. The nurse should engage the client's request rather than deferring the matter to the parents. An open ended question such as "Would you like to tell me more?" is more likely to generate discussion than a blunt yes/no question about sexual activity. The nurse would require more information before making a medical referral.

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. Nurses are accountable to act as a client's advocate, even if the client's choices are not in alignment with the nurse's personal choices. The nurse should not assume that a chaplain is desired, nor administer chemotherapy without further dialoguing with the client. Explaining that meditation and prayer are not curative is not helpful in supporting the client's wishes.

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 This couple is likely to have children who are middle-aged adults, in which case the task of maintaining ties with older and younger generations is important. The couple is less likely to be retired or moving from their home and it would be presumptuous to assume the loss of a spouse.

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 Physical Reproductive Affective and coping

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 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% According to Maslow's hierarchy of needs, first-level physiological client needs are most important. These needs are those that are necessary to sustain life, such as breathing and eating. Using Maslow's hierarchy, along with airway, breathing, and circulation (ABCs), assists the nurse to prioritize care when given a client assignment. The client who is experiencing acute respiratory issues with pneumonia who is restless, diaphoretic, and exhibiting an oxygen saturation level of 90% requires priority assessment and intervention. The other clients listed are not currently in acute distress.

An 85-year-old client is being transferred from a house to a nursing home by the client's spouse. What is the first action the nurse should take to help reduce the stress of relocation on the client?

Assess the client's usual lifestyle and daily activities. Assessment of the client's usual lifestyle and daily activities to incorporate them into the client's new life at the nursing home is the first action the nurse should take. Providing opportunities for the client to assist in decision making, careful explanation of procedures and routines before they occur, and frequent reorientation to the new location are important nursing actions to reduce the stress of relocation on the elderly client but should be performed after assessing the client's usual lifestyle and daily activities.

The nurse has developed a strong therapeutic relationship with an electrician who sustained severe burns while working on an industrial site. Which action by the nurse most directly addresses the client's self-actualization needs?

Discussing the client's strengths and dialoguing about body image Aspects of self-actualization include focusing on clients' strengths and fostering a positive body image. Addressing accomplishments and goals is likely to meet clients' self-esteem needs. Facilitating contact and connection between clients and their families is an action that promotes meeting love and belonging needs, as is reorganizing care and facilitating a day pass so that the client can spend Thanksgiving with family.

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 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 the course of illness for those who contract influenza but is not likely to positively impact immunization rates.

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. Thermoregulation is a physiological need. The human body functions within a narrow temperature range with an oral temperature of 97.5 to 99.5°F (36 to 38°C). Homeostatic mechanisms and adaptive responses, such as shivering (to increase body temperature) or sweating (to reduce body temperature), help to maintain body temperature. Offering the client a blanket is appropriate because the external body covering will increase the client's low body temperature. Notifying the physician is not necessary because the temperature is within normal range. A normal or low temperature is not an indicator of dehydration, so increasing the intake of oral fluids is not necessary. A normal or low temperature is not an indication of respiratory distress, so an assessment of the client's respiratory rate is not necessary. Reference:

What is the focus of community-based nursing?

Promoting and maintaining the health of individuals and families This nursing practice focuses on promoting and maintaining the health of individuals and families, preventing and minimizing the progression of disease, and improving quality of life. Its focus is not really community health, maintaining or improving the health of a community, or family health, per se.

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 physical function of the family is to provide a safe environment necessary for growth and development. The child's injuries (a fractured femur with head injury and 1-cm round scabs and blisters on the upper back) suggest physical abuse by slamming the child into a wall while holding on to his leg, along with cigarette burns. All suspected cases of abuse must be reported to the appropriate agency or authority. Failure to report suspected child abuse is considered nursing negligence. Documenting "suspected abuse" in the client's record is inappropriate. Only the objective physical findings and observations should be documented. Referring the family for follow-up care to social services does not satisfy the legal obligation to report the suspected crime of child abuse to the proper authorities. Asking the physician to question the parents about the suspected abuse can jeopardize the child's safety by alienating the parents and creating distrust between the parents and the healthcare providers.

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. Conflict is an example of a psychosocial risk factor. Chemical dependency is considered a lifestyle risk factor, whereas a lack of adequate housing is an environmental risk factor. Lack of electricity is an economic risk factor.

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 Reaction formation involves acting just the opposite of one's true feelings; thus, being extremely nice to the nursing instructor is the opposite of what the student feels. Imitating the speech of the nursing instructor is consistent with identification. Accusing the nursing instructor of being prejudiced is consistent with projection. Developing stomach pains when talking with the nursing instructor reflects somatization.