Test 1 Review - Ch 1-2
A nurse is teaching an 18-year-old client about circumcision care for her second baby. Which statement made by the nurse would be most appropriate to assess the client's learning ability? "I note you're having problems with reading the information. Will you tell me about this?" "Is it difficult having two babies to care for with you being a teenager?" "Can I help fill out the forms for government financial assistance for your family?" "Since leaving high school, have you been able to find employment?"
Correct response: "I note you're having problems with reading the information. Will you tell me about this?" Explanation: The American Medical Association reports that poor health literacy skills are a stronger predictor of health status than age, income, employment status, education level, or racial or ethnic group. Poor health literacy leads to increased complications and increased mortality. The fact that the client is 18 years old in a low socioeconomic situation are predictors for poor health, but finding out about her literacy level is a priority. The other questions will not get at her literacy ability.
The home care nurse has taught the pregnant home care client how to complete several self-assessment parameters. Which statement by the client indicates that teaching has been successful? "I will measure for fundal height from the top of my pubic bone to the bottom of my umbilicus." "I will sit or lie down for two hours and count how many times the baby kicks, looking for at least 10 per two hours." "I will get all of my house cleaning done and then take my blood pressure using the wrist monitor." "I need to drink a sugary drink, wait 2 hours, and then prick my finger to test my blood glucose on a daily basis."
Correct response: "I will sit or lie down for two hours and count how many times the baby kicks, looking for at least 10 per two hours." Explanation: To assess for fetal movements, the client will need to sit or lie down to be able to feel fetal kicks, movements, or rolls during a 2-hour period. This should be done during the same time every day, in which the fetus is the most active. The nurse should instruct the client to keep a log of fetal movement and track the amount of time to reach 10 movements.
A nurse educator is conducting a class on abuse and violence for a group of new graduate nurses during orientation. Which statement by the educator best reflects current practice regarding these problems in women's health? "Asking every client about abuse and family violence is the best way to elicit accurate information." "The nurse should screen for these problems at every client encounter." "The nurse is not legally responsible for reporting suspected abuse or violence." "Since families are more stable than in the past, nurses are not as concerned about these problems as they used to be."
Correct response: "The nurse should screen for these problems at every client encounter." Explanation: Both child and intimate partner abuse is increasing in incidence. Families are more mobile than previously. Screening for child or intimate partner abuse should be included in all family contacts. Nurses must be aware of the legal responsibilities for reporting abuse.
As part of an education program for pregnant women and their partners, the nurse illustrates the various settings available for birth. The nurse determines that the program was successful when the group correctly chooses which statement about home births? "Women giving birth at home have control over every part of labor." "A home birth is probably the most expensive setting for childbirth." "There are very rigid screening procedures that must be followed." "A wide range of pain medications is readily available to the woman."
Correct response: "Women giving birth at home have control over every part of labor." Explanation: Home births permit the woman to maintain control over every aspect affecting the woman's labor, such as positioning, attire, and support persons present. A home birth involves the least amount of cost. Home births are recommended for pregnant women considered to be at low risk for complications. Some birthing centers may have very rigid screening criteria. The availability for pain medication is limited for home births.
On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? 500 additional calories per day 1,000 additional calories per day 250 additional calories per day 750 additional calories per day
Correct response: 500 additional calories per day Explanation: The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.
A young mother with an ill child tells the visiting nurse that she belongs to the Christian Scientist religious group and will not seek medical attention for the child. Which statement best reflects the mother's religion's beliefs about health? Fasting will establish health back to normal. Healing will come through prayer and spiritual regeneration only. Illness comes from violating dietary restrictions, and no treatment will be sought. Illness is an opportunity to develop the soul with no treatment sought.
Correct response: Healing will come through prayer and spiritual regeneration only. Explanation: Christian Scientists view disease as error of the human mind that can be dispelled by spiritual truth. Health is viewed within a spiritual framework; healing will come through prayer and spiritual regeneration with no medical intervention. There is general opposition to human interventions with drugs or other therapies except for legally required immunizations in the Christian Scientist church, and Christian Scientists usually do not use blood or blood components, seek transplants or act as donors, or seek biopsies or physical examination.
Which intervention would be considered most appropriate when working in the L & D department where there is a large percentage of the population of African descent using Vernacular English? Mimic the words being used in the labor room. Utilize an interpreter if having difficulty communicating with people. Repeat questions or instructions in a loud, slow tone while maintaining eye contact. Learn the dialect's cadence and common words.
Correct response: Learn the dialect's cadence and common words. Explanation: African American Vernacular English may be used by black clients who often have a dialect unique to their area. To care for such clients, the nurse should learn their dialect's cadence and common words, but should not attempt to use them, unless that is the nurse's dialect. Trying to speak in a dialect not one's own could be misinterpreted as mockery. Family should not be used as interpreters if at all possible. Saying words slowly but loudly will come across as mockery.
Which assessment finding 1 hour after birth should be reported to the health care provider? Fundus of uterus is palpable at the level of the umbilicus. Fundus is displaced to the right, and bladder is hard. Large, bruised hemorrhoids are protruding from the anal opening. Lochia rubra is saturating a pad every 45 to 60 minutes.
Correct response: Lochia rubra is saturating a pad every 45 to 60 minutes. Explanation: The nurse should ask the woman to turn under her buttocks can be inspected to be certain blood is not pooling beneath her. If the nurse observes a constant trickle of vaginal flow or a woman is soaking through a pad every 60 minutes, she is losing more than the average amount of blood. She needs to be examined by her primary care provider to be certain there is no cervical or vaginal tear or that poor uterine contraction is not causing excessive bleeding. Following perineal assessment, the nurse should assess the rectal area for the presence of hemorrhoids. If any are present, the nurse should document their number, appearance, and size in centimeters. Fundus of uterus palpable at the level of the umbilicus is normal finding immediately after birth. When the fundus is displaced to right and bladder is hard to palpation, the bladder is full, and the nurse needs to assist client in emptying the bladder. The provider should be notified if a catheter needs inserted if there are no standing prescriptions for an in-and-out cath following birth.
A nurse is explaining to a young couple the advantages of seeking maternal and child health care in an ambulatory setting versus the emergency department in nonemergent situations. Which goal should the nurse emphasize the most? Minimize the separation of children from their parents. Decrease the number of hospital visits. Increase the number of urgent care clinics. Encourage treatment of illness in a calmer setting.
Correct response: Minimize the separation of children from their parents. Explanation: Separation from parents can be traumatic for young children; ambulatory settings minimize this to some degree. Ambulatory care increases responsibility for parents, has no real bearing on the number of needed hospitals (since they treat different types of clients) and the calm environment does not play a role in change in emphasis. Decreasing the number of hospital visits or increasing the number of urgent care centers could possibly result from more emphasis on ambulatory care; however, the main focus would be reducing the trauma a young child may experience receiving medical care.`
A nursing instructor is teaching a group of nursing students about the various options available to provide nursing care in a community. The instructor determines the session is successsful when the students correctly choose which action as the primary focus of home care nursing? Provide care based on insurance coverage. Teach and supervise caregivers. Provide direct client care. Act as a liaison between health care provider and family.
Correct response: Provide direct client care. Explanation: The primary focus of home care nursing is to provide direct care. Teaching and supervising caregivers and acting as a liaison between the health care provider and family are additional functions of the home care nurse which support the direct care. The nurse should be aware of potential insurance restrictions, so that other options may be explored if insurance will not cover specific treatments or medications that the health care provider has determined essential to the client. In these instances, the nurse can then act as the advocate to help find the necessary resources the client may need.
A nurse is working to develop cultural competence. Which aspect would the nurse need to incorporate as the foundation for this concept? Respect Knowledge Empathy Technical skill
Correct response: Respect Explanation: Cultural competence, or respecting cultural differences, allows the nurse to plan culturally competent care and to integrate cultural elements into care.
Which policy recommendation would be more politically correct and culturally sensitive for health care organizations to adopt in terms of caring for LGBT clients? Include the term LGBT whenever the strategic plan discusses the population served. Rewrite policies incorporating the LGBT population as new language into existing policies. Incorporate LGBT partners into visitation rights if the couple has legally been married. List the LGBT partner on official birth certificates if the couple has legally been wed
Correct response: Rewrite policies incorporating the LGBT population as new language into existing policies. Explanation: Changes can be made across health care organizations to increase effective communication with LGBT clients. Rewriting policy to include LGBT populations or incorporating new language into existing policy is an important step. Visiting policies should reflect changing families, and a client should be able to name support people, independent of the support person's legal status as a spouse or adoptive parent.
The camp nurse is reviewing the health information of the participants at a school-age diabetic summer camp. What topic would be most appropriate for this group of campers? Weight control measures Self-administration of insulin Long-term effects of diabetes Latest trends in medication delivery
Correct response: Self-administration of insulin Explanation: School-age children need to learn self-administration of insulin, along with how to check their blood sugar. Although weight control and diet are important, as is peer relationships and being current in available resources, they are not as important for the child's health as learning how to be independent in their insulin administration
To decrease childhood mortality, pediatric nurses need to consistently engage in what activity throughout all age groups? Teach injury prevention and proper safety practices. Provide guidance regarding proper nutrition. Help integrate exercise practices and programs into the lifestyles of individuals and communities. Advocate for more research into control of environmental toxins.
Correct response: Teach injury prevention and proper safety practices. Explanation: The leading cause of death throughout childhood is unintentional injury.
The client is a 1-year-old girl from a low-income family presenting with a vitamin D deficiency and anemia. What assistance program would you recommend to the child's young mother? WIC SCHIP ECI CHIP
Correct response: WIC Explanation: The special supplemental nutrition program for women, infants, and children (WIC) provides services to supply nutritional food to low-income women and their children. SCHIP or CHIP provides health insurance to newborns and children in low-income families who do not otherwise qualify for Medicaid and are uninsured. The Early Childhood Intervention (ECI) program, sponsored by Easter Seals, is available for the child with disabilities or developmental delays.
A postpartal woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? Avoid using soap for any perineal care. Wash her perineum with her daily shower. Use an alcohol wipe to wash her episiotomy line. Refrain from washing lochia from the suture line.
Correct response: Wash her perineum with her daily shower. Explanation: A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.
The nurse is educating the family of a 2-day old Chinese American boy with myelomeningocele about the disorder and its treatment. Which action involving an interpreter could jeopardize the family's trust in the health care providers? allowing too little time for the translation of health care terms using a person who is not a professional interpreter asking the interpreter questions not meant for the family using a relative to communicate with the parents
Correct response: asking the interpreter questions not meant for the family Explanation: Asking questions or having private conversations with the interpreter may make the family uncomfortable and destroy the nurse/client relationship. Translation takes longer than a same-language explanation, and the family may need additional to clarify terms; this must be considered so that the family is not rushed. Use of a nonprofessional may result in some inaccuracy in translating medical terminology but should not impact the trust of the family. Using a relative can upset the family relationships or cause legal problems but also does not affect trust with the healthcare providers.
While interviewing a client, a nurse assesses the client's reaction to health care and determines that the reaction reflects the client's preferred ways of acting based on traditions. Which term would the nurse use to document this information? culture cultural values ethnicity race
Correct response: cultural values Explanation: Culture is a view of the world and a set of traditions that a specific social group uses and transmits to the next generation. Cultural values are preferred ways of acting based on those traditions. Ethnicity refers to the cultural group into which a person was born, although the term is sometimes used in a narrower context to mean only race. Race refers to a category of people who share a socially recognized physical characteristic. The term is rarely used today as the research on the human genome shows no basic differences in structure among people.
A pregnant client is being discharged. The nurse is educating the client about the advantages of continuing her treatment at home. Which advantages would the nurse include? Select all that apply. increased individual teaching lifestyle assessments increased health care costs increased self-care value influence from nurse
Correct response: increased individual teaching lifestyle assessments increased self-care Explanation: The home care setting allows the nurse to spend time with the individual and the family in a private environment in which teaching can occur. This also allows for a lifestyle assessment to better understand ways in which to promote healthy behaviors, not simply those related to pregnancy. Home care also increases that ability of the client to perform self-care that may have otherwise been done by others (for the client) in the acute care setting. The home care setting decreases health care costs and allows the nurse to better asses the values and priority of the client and family.
A 33-week gestation infant dies after 1 week of life in the neonatal intensive care unit. This infant's death rate would be classified under which statistical category? infant death under one month neonatal death preterm gestational death postneontal death
Correct response: neonatal death Explanation: The neonatal death rate is the number of deaths of an infant in the first 28 days of life. Gestational age is not a consideration when reporting deaths of infants. The other categories are not classifications for reporting infant deaths.
The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply. previous oral contraceptive use first pregnancy age 30 years severe varicose veins preeclampsia
Correct response: previous oral contraceptive use severe varicose veins preeclampsia Explanation: Risk factors associated with thromboembolism include oral contraceptive use, multiparity, age over 35 years, severe varicose veins, and preeclampsia.
What makes the area of family nursing a difficult arena to provide care at times? The presence of family in the hospital rooms Family members who might not agree on treatments and a plan of care Family-centered care plans and use of community areas in acute care settings Nurses having different values from families
The family may not agree of the plan of care or treatment plans with each other or for their children. This is a difficult situation as the children do not have their rights to make their own decisions and the family needs to agree.
What are the differences between health promotion, health maintenance, health restoration, and health rehabilitation?
This action is an example of health promotion, which may be defined as educating parents and children to follow sound health practices through teaching and role modeling. Health maintenance is intervening to maintain health when risk of illness is present. Health restoration is using conscientious assessment to be certain symptoms of illness are identified and interventions are begun to return the client to wellness most rapidly. Health rehabilitation is helping prevent complications from illness, helping a client with residual effects achieve an optimal state of wellness and independence, and helping a client to accept inevitable death.