Foundations Test 4

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse explains to the client that COPD is a chronic disease. Why is COPD considered a chronic disease?

It has a gradual onset and lasts for a long time. Rationale: Chronic illness has a gradual onset and lasts for a long time. It is usually seen in old age. It may or may not be due to acute illness. Chronic diseases are a major cause of morbidity in the population.

A teenaged client reports having diarrhea before every test in school. The nurse recognizes that this client needs to focus on which dimension of health?

Emotional Dimension Rationale: This is an example of the emotional dimension. Long-term stress affects body systems, and anxiety affects health habits. The intellectual dimension encompasses cognitive abilities and past experiences, whereas the physical dimension includes factors such as genetics, gender, and race. The sociocultural dimension relates to a client's economic level, lifestyle, family, and culture.

When caring for a client who has just been diagnosed with a chronic illness, the nurse understands the importance of promoting health by highlighting which concept?

Focus on what is possible. Rationale: When a client has a chronic illness, the nurse needs to make every effort to promote health with a focus of care that emphasizes what is possible rather than what can no longer be. The focus should not be on the altered functioning or what can no longer be as this does not assist the client to move to promoting health in the current state. The basis for the change or why the client has an illness is not easy to determine.

Which nursing intervention is an example of tertiary preventive care?

Assisting with speech therapy a client with a traumatic brain injury Rationale: Tertiary prevention begins after the illness and is used to help rehabilitate clients. Speech therapy is an example of tertiary preventive care. The administration of immunizations and teaching stress reduction classes are examples of primary preventive care. Blood pressure screening is an example of secondary preventive care.

A client has had a total knee replacement and is receiving care that includes learning to walk with a walker. What level of prevention is most applicable to this client?

Tertiary Prevention Rationale: Tertiary prevention in health care deals with rehabilitation of the client. Teaching the client to walk with a walker is tertiary prevention. Primary prevention refers to health promotion or illness prevention. Secondary prevention refers to screening and early detection of disease.

The nurse is educating a client with diabetes on how to better control blood sugar levels and recognize the symptoms associated with both hyperglycemia and hypoglycemia. The client is frequently admitted to the hospital due to elevated blood sugars. This education is an example of which level of health promotion?

Tertiary Rationale: Tertiary health promotion and illness prevention begin after the illness is diagnosed and treated, with the goal of reducing disability and helping to rehabilitate to a maximum level of functioning. Educating a client with diabetes on how to recognize areas of risk for the disease is one such example of tertiary promotion. Primary promotion is focusing on educating the client to potential risks. Secondary promotion is screening. There is not a chronic promotion component.

A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, with a random blood glucose reading of 575 mg/dL (31.91 mmol/L), vomiting, and shortness of breath. This client has experienced which phenomenon?

Exacerbation Rationale: This client has experienced a significant exacerbation of a chronic disease (diabetes mellitus), which has manifested as an acute threat to the client's health. Morbidity is an epidemiological statistic of the frequency of a disease. The client's problem does not have an infectious etiology. A risk factor is any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury.

A community health nurse arranges for a dentist to teach local children in the school district how to properly brush their teeth. Which goal will the nurse set for this event?

Health Promotion Rationale: The education on lifestyle choices is part of health promotion activity, which focuses on protecting the person's health. Brushing one's teeth is a lifestyle choice. The goal of the prevention of illness is to detect and prevent the illness. High-level wellness focuses on maximizing the person's highest potential for functioning. Reversal of self-care deficits would involve therapeutic interventions that are directed at contributing factors.

Which is an example of tertiary health promotion?

Rehabilitation Rationale: Tertiary health promotion and disease prevention begin after an illness is diagnosed and treated to reduce disability and to help rehabilitate clients to a maximum level of functioning. Therefore, rehabilitation is an example of tertiary health promotion. Family counseling and Pap tests are examples of secondary health promotion. Water treatment is an example of primary health promotion.

When providing care to a client, the nurse integrates knowledge that a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. The nurse is demonstrating an understanding of which health model?

Health Belief Model Rationale: According to the health belief model, a client's beliefs and actions are related and influenced by the client's personal expectations in relation to health and illness. According to the clinical model, health is defined narrowly as the absence of signs and symptoms of disease or injury. The holistic model views individuals as ever-changing systems of energy, and the interaction of a person's mind, body, and spirit within the environment. The high-level wellness model is the recognition of health as an ongoing process toward a person's highest potential of functioning.

Consultation and diagnostic tests are included in which level of health care?

Secondary Care Rationale: Consultation and diagnostic tests are included in the secondary level of health care. The first contact with a general physician is the primary care, and the referral to a highly specialized facility for desensitization is the tertiary care level. The secondary and tertiary care facilities are equipped to provide highly specialized care. Extended care is care provided to clients who no longer require acute hospital care.

A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital for the second time in 2 months with wheezing, dyspnea, and use of accessory muscles when breathing. Which type of situation does the nurse identify is occurring with this client?

The client is having an exacerbation of the COPD. Rationale: COPD is a chronic illness that has periods when the client goes from a chronic state to an acute state such as an acute onset of symptoms. The client will experience periods of exacerbation according to certain precipitating circumstances. Remission occurs in illnesses such as cancer when the symptoms or clinical manifestations disappear. A secondary illness is caused by complications from a primary illness. Clients with a terminal illness have no hope of recovery.

What are some examples of healthy self-care behaviors everyone should adopt? Select all that apply.

- Sleeping 7 to 8 hours each night - Eating regular healthy meals - Maintaining an ideal body weight Rationale: Some self-care behaviors that everyone should adopt to promote health are: sleeping 7 to 8 hours regularly, eating regular and healthy meals, maintaining an ideal body weight, having a regular schedule of exercise, using alcohol in moderation if at all, not smoking, and maintaining a positive self-concept.

Which are characteristics of chronic conditions? (Select all that apply.)

- Are rarely curable - Require lifelong management - Have a prolonged course Rationale: Chronic conditions typically have a slower onset and prolonged course, do not resolve spontaneously, are rarely curable, and require lifelong management. Acute conditions typically have a rapid onset and short course and resolve spontaneously or are curable.

A group of nurses is participating in a community health fair and is engaged in primary prevention activities. Which activities would these nurses be leading? Select all that apply.

- Family planning services - Accident prevention education - Heart-healthy nutrition services Rationale: Primary health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury. Examples of primary-level activities are immunization clinics, family planning services, providing poison control information, and accident prevention education. Other nursing interventions include teaching about a healthy diet, the importance of regular exercise, safety in industry and farms, using seat belts, and safer sex practices. Screenings are a major activity in secondary health promotion. Rehabilitation is associated with tertiary health promotion.

Chronic illness may be characterized by periods of remission. Remission is best defined as:

the presence of a disease with the absence of symptoms. Rationale: Remission is defined as the presence of a disease, but the person does not experience the symptoms. Exacerbation is the reappearance of symptoms of a disease. Disease is a pathologic change in the structure of function of the body or mind. Illness is the response of a person to a disease.

A pregnant client at 10 weeks' gestation is receiving education by the nurse about the importance of abstaining from alcohol while pregnant. What statement made by the client demonstrates an understanding of the education provided?

"I should abstain from alcohol to prevent the development of a fetal alcohol spectrum disorder." Rationale: Congenital disorders such as fetal alcohol spectrum disorders may be prevented by the client abstaining from alcohol while pregnant. Fetal alcohol spectrum disorders are congenital disorders caused by an undetermined amount of alcohol ingested by the mother which affects the fetus in the developmental stages of growth. Abstaining from alcohol will not prevent all types of congenital disorders, but clients should be educated about a variety of preventative measures in order to prevent interruption of the growth and development of the fetus. An idiopathic illness is one in which the cause is undetermined. A hereditary disorder is genetic and not altered by substance intake during pregnancy.

A nurse provides interventions for clients in a long-term care facility to help them meet their intellectual needs. Which nursing actions promote these needs? Select all that apply.

- A nurse provides education about foot care to a client with diabetes. - A nurse explains to an obese client the benefits of following a healthy diet. - A nurse shows residents a video discussing modified activities for older adults. Rationale: The intellectual dimension encompasses cognitive abilities, educational background, and past experiences. These influence the person's responses to teaching about health and reactions to nursing care during illness. They also play a major role in health behaviors. Examples would include a nurse providing client education about foot care to a diabetic client, explaining the benefits of following a healthy diet to an obese client, and showing residents a video discussing modified activities for older adults. The nurse manager shutting down a cafeteria to investigate cases of food poisoning, or referring a client to a grief counselor, would not address the intellectual needs of a client.

Which are factors that impact how a client defines health? Select all that apply.

- Family - Culture - Community - Society Rationale: Each client defines health in terms of the client's own values and beliefs. The person's family, culture, community, and society also influence this personal perception of health. Music does not affect how a person defines health.

Which client would most benefit from the nurse including in the plan of care interventions addressing the client's social health?

A spouse and parent who is angry about no longer being able to work due to a spinal cord injury Rationale: A spouse and parent who is angry about no longer being able to work due to a spinal cord injury has had a drastic role change, which can cause a feeling of powerlessness and feelings that the client is no longer useful to the family. This is an alteration in the client's social health. Social health is an outcome of feeling accepted and useful. Nursing interventions that allow the client to feel useful or express feelings about the role change can enhance social health. A client with a sexually transmitted infection has a physical health problem. A stressed client who is learning to using guided imagery for relaxation is adapting to an alteration in their emotional health. A new mother cradling her infant is displaying appropriate bonding.

What level of prevention is represented by educating a group of clients on carseat safety?

Primary prevention Rationale: Primary prevention focuses on the health of a person with the goal of preventing disease or illness. Carseat safety education is primary prevention. Secondary prevention refers to screening and early detection of disease. Tertiary prevention refers to rehabilitation and prevention of complications after diagnosis with a disease. Educational is not a level of prevention.

Why are health promotion and illness prevention a key responsibility of nurses?

Chronic illnesses are the leading health problem in the world. Rationale: Because chronic illnesses are the leading health problems in the world, health promotion and illness prevention activities are vital to nursing care. By endorsing health promotion and illness prevention, the nurse can assist the client to achieve optimal health even with a chronic illness. It is true that treating chronic illnesses can be expensive, they do cause pain and suffering, and people do not like to be sick, but these are not the most important reasons for promoting health and preventing illnesses.

To be an effective change agent for wellness, the nurse must:

Consume a healthy diet Rationale: Nurses focused on wellness advocate the use of lifestyle modification skills that alleviate stress and promote a state less susceptible to disease, such as eating a healthy diet. Skipping breakfast, drinking caffeinated beverages, and being sedentary are not associated with improved health or wellness.

A nurse is planning a health fair in the community to highlight promotion and prevention of the leading cause of death in the United States. Which disease process should the nurse address?

Coronary Artery Disease Rationale: Heart disease is the leading cause of death in the United States. Lung cancer, emphysema, and cerebrovascular accidents are not the leading causes of death in the United States.

Risk factors for illness are divided into six categories. Working with carcinogenic chemicals is an example of which type of risk factor?

Environmental Risk Factor Rationale: Working and living environments may contribute to disease. Working with cancer-causing chemicals is an example of an environmental risk factor for illness. Physiologic risk factors are those relating to an individual's body or biology. Lifestyle risk factors are habits or behaviors people choose to engage in. A health habit risk factor is any attribute, characteristic, or exposure of an individual that increases the likelihood of developing a disease or injury.

A client comes to the health center for a routine visit. During the visit, the client tells the nurse, "I'm motivated to do things now to make sure I'm the healthiest I can be." When planning this client's care, the nurse should focus on which area?

Health Promotion Rationale: Health promotion is the behavior of a person who is motivated by a personal desire to increase well-being and health potential. In contrast, illness/disease prevention, also called health protection, is behavior motivated by a desire to avoid or detect disease or to maintain functioning within the constraints of an illness or disability. Self-concept incorporates both how people feel about themselves (self-esteem) and the way they perceive their physical self (body image). Diagnosis of disease involves a medical aspect such that a disease is traditionally diagnosed—and treatment is prescribed—by a physician or advanced practice nurse, whereas nurses focus on the person with an illness.

When chronic illnesses and disabilities are present, individuals benefit most from activities that:

Help them maintain independence Rationale: Although their chronic illnesses and disabilities cannot be eliminated, adults can benefit most from activities that help them maintain independence and achieve an optimal level of health. The other answers, while beneficial, are not as helpful.

The body's attempt to restore balance through self-regulatory mechanisms is termed:

Homeostasis Rationale: Homeostasis is the organism's attempt to restore balance. Equilibration is a distractor for this question. Self-conception is related to the individual's feelings and attitudes about oneself. Biofeedback is a relaxation technique.

The nurse is caring for a client admitted to the hospital with pneumonia and associated pleuritic chest pain. Which would be a priority when creating the nursing care plan?

Monitoring airway clearance Rationale: Priority management, according to Maslow's hierarchy, starts at physiological needs, such as the need for oxygen, food, water, rest, and elimination. Therefore, difficulty breathing is the priority issue that the nurse must manage because it affects the ability of the client to get adequate oxygen. Symptoms such as pain, thirst, and needing to urinate, although important, are not a priority over difficulty breathing. Likewise, infection control is important but is not priority.

he nurse's community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. Which level of health promotion is this an example of?

Primary Rationale: Primary health promotion and illness prevention is directed toward promoting good health and preventing the development of disease process or injury. Primary-level activities include immunization clinics, providing poison-control information, and education about seat belt and child-safety seat use. Secondary-level activities include screening programs and early identification of disease. Tertiary-level prevention is concerned with returning the client to the optimal function after diagnosis. Medical is not a level of health promotion or illness prevention.

A nurse is immunizing children against measles. This is an example of what level of preventive care?

Primary Rationale: Primary health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury. Immunizations are an example of primary health promotion. Secondary health promotion and illness prevention focus on screening for early detection of disease, with prompt diagnosis and treatment of any found. Tertiary health promotion and illness prevention begin after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate clients to a maximum level of functioning. The term chronic is not related to health promotion.

The nurse's community outreach class is giving a presentation on seat belts and child safety seats at the local firehouse every weekend in October. Which level of health promotion is this an example of?

Primary Rationale: Primary health promotion and illness prevention is directed toward promoting good health and preventing the development of disease process or injury. Primary-level activities include immunization clinics, providing poison-control information, and education about seat belt and child-safety seat use. Secondary-level activities include screening programs and early identification of disease. Tertiary-level prevention is concerned with returning the client to the optimal function after diagnosis. Medical is not a level of health promotion or illness prevention.

Which needs are being met when a nurse recommends a senior citizen community center for an older client who is living alone?

Sociocultural needs Rationale: Increased social interaction, as would be provided by visiting a senior citizen community center, would primarily address a client's sociocultural needs. Emotional needs address how the mind affects body functions and responds to body conditions. Long-term stress affects body systems, and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change the body's responses to illness. The intellectual dimension encompasses cognitive abilities, educational background, and past experiences. Spiritual beliefs and values are assessed when addressing spiritual needs.

A nurse is caring for a client who has COPD, a chronic illness of the lungs. The client is in remission. Which statement best describes a period of remission in a client with a chronic illness?

Symptoms are not experienced Rationale: Chronic illnesses usually have a slow onset and many have periods of remission (the disease is present but the client does not experience symptoms). Exacerbation is when the symptoms of the disease reappear. Chronic illnesses do not go away; the disease continues to be present.

The nurse is caring for a client with a diagnosis of heart failure. This admission is the client's third admission within 90 days. The nurse educates the client with the goal of preventing readmission. Which nursing activity for this client would represent tertiary level prevention?

Teaching about adhering to a low-sodium diet Rationale: Tertiary health promotion and illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate the client to a maximum level of functioning. Nursing activities on a tertiary level include teaching a client with heart failure the importance of adhering to a low-sodium diet. Primary prevention is directed toward promoting health and preventing the development of disease processes or injury. This client has a diagnosis. Secondary health promotion and illness prevention focus on screening for early detection of disease with prompt diagnosis and treatment of diseases found.

Which model is most useful in examining the cause of disease in an individual, based upon external factors?

The Agent-Host-Environment Model Rationale: The Agent-Host-Environment Model is useful for examining the cause of disease in an individual. The agent, host, and environment interact in ways that create risk factors. The Health-Illness Continuum is a way to measure a person's level of health. The High-Level Wellness Model is characterized by functioning to one's maximum potential while maintaining balance and purposeful direction in the environment. The Health Belief Model is used to describe health behaviors.

What have the models of health promotion and illness prevention been used for?

To help health care providers understand health-related behaviors. Rationale: Several models of health promotion and illness prevention have been used to help health care providers understand health-related behaviors and adapt care to people from diverse economic and cultural backgrounds. The models include the health belief model, the health promotion model, the health-illness continuum model, and the agent-host-environment model. These models do not define a medical framework in the care of the disabled; these models do not create a forum for improving rehabilitative care; and these models do not formulate care plans for use with the disabled.

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

provide care transition at discharge for speech therapy Rationale: 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.