Chapter 04: Health of the Individual, Family, and Community

A home health care nurse who works in a low- income community assesses the risk factors for patients being serviced. What is an example of a community risk factor?

Children are kept inside the home on a sunny summer day because of lack of recreational opportunities.

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 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

The nurse enters the client's room in the acute care unit immediately after he 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 in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of his head, and multiple 1-cm round scabs and blisters on his upper back. The parents state that their child sustained the injuries by falling out of his high chair. What is the best action for the nurse to take?

Report the suspected child abuse to Child Protective Services.

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

Sociocultural dimension

A new storefront health outreach centre has been proposed for a community. The community health nurse can demonstrate the standards of community health by performing what action?

Ensuring that community residents have fair and equitable access to the facility

In caring for a patient, the nurse recognizes which of the following as the primary educational and support structure for an individual?

Family members

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 nurse is assessing a family and is establishing baselines for planning subsequent interventions. What question best facilitates this aspect of care?

"When we talk about 'health', what exactly does that mean to you?"

A 44-year-old female client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which of the following values?

Urine output of 1500 ml in 24 hours

The nurse in the pediatric unit is caring for a 10-year-old boy admitted with dehydration and diarrhea after eating chicken contaminated with Salmonella bacteria. What action taken by the nurse would be the most effective in preventing the spread of the infectious microorganism?

Washing hands before and after providing the client care

Which of the following theorists supports the developmental framework of family assessment?

Duvall

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

A community is defined as a social group that may or may not share common geographic boundaries yet interact because of

Common interests

You are the community-based nurse who acts as case-manager for a small town about 60 miles from a major health care centre. What is the most important factor of community-based nursing for you be knowledgeable about?

Community resources available to patients.

The charge nurse is assigning client care for the upcoming shift. Which is the priority evaluation when performing this task?

Determine the level and intensity of client care needed according to physical and psychosocial factors.

A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for patients in this developmental stage?

Setting up parenting classes

The nurse receives a client assignment. Which client should the nurse see first?

client admitted with pneumonia, who is restless and diaphoretic with an oxygen saturation of 90%

You are the nurse caring for a patient newly diagnosed with diabetes and you are developing a holistic plan of care. You know that for this plan of care to be successful it must what?

Address the disease but also incorporate the mind, body, and spirit.

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."

Which client requires priority intervention when providing care on a medical-surgical unit?

a postsurgical client who is feeling dizzy with a heart rate of 45/bpm

Which are stressors that affect the health of the family?

Well-funded school systems and inadequate childcare 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 both physical and emotional components: Physical safety and security means being protected from potential or actual harm. Nurses carry out a wide variety of activities to meet patients' physical safety needs, such as the following: -Using proper hand hygiene and sterile techniques to prevent infection -Using electrical equipment properly -Administering medications knowledgeably -Skillfully moving and ambulating patients -Teaching parents about household chemicals that are dangerous to children

The nurse is assessing the family structure of the client. The family household is comprised of two parents, three children, and one grandparent. The nurse recognizes that this is a(n):

Extended family.

Which of the following statements is true regarding Friedman's theory of family-centered nursing care?

The role of the family is essential in every level of nursing practice.

A nurse is caring for a family consisting of three middle-aged adults. Which examples describe developmental tasks of this type of family structure? (Select all that apply.)

•The family must maintain ties with younger and older generations. •The family must prepare for retirement.

A nursing student has a placement in a clinic where pregnant women and new mothers are able to drop in without an appointment. What activity best reflects the principles of family nursing within this community health program?

Providing health promotion education to women as needed

The nurse is admitting a 38-year-old male client to the oncology unit whose religious background is different from her own. The nurse is assessing how the client's religion may affect his 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?"

An adolescent confides in the school nurse that she is arguing daily with her mother, and she often wonders if 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

A home health nurse is visiting the Goldstein family after the recent death of their matriarch. She 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. She asks Mr. Goldstein's cousin what is happening, and he says, "We are Jewish, and the family is 'Sitting Shiva' for my aunt." This family is fulfilling which family function?

Affective and coping functions

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. Physiologic - for oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. These needs are the most basic in the hierarchy of needs, are the most essential to life and, therefore, have the highest priority. Most healthy children and adults meet their physiologic needs through self-care, but meeting physiologic needs is often a major part of the nursing care plan for young, old, disabled, and ill people who require assistance in meeting them. Safety and security- both physical and emotional components. Physical safety and security means being protected from potential or actual harm. Love and belonging needs include the understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to groups such as families, peers, friends, a neighborhood, and a community. Self-esteem needs, which include the need for a person to feel good about oneself, to feel pride and a sense of accomplishment, and to believe that others also respect and appreciate those accomplishments Self-actualization needs, which include the need for individuals to reach their full potential through development of their unique capabilities.

The nurse is assessing a family parented by a 60-year-old grandmother and her 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

As the nurse caring for a 25-year-old patient who has recently been diagnosed with testicular cancer, you know that this patient's illness will impact every aspect of his life. What developmental tasks might you expect to be affected?

Marrying and starting a family

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.

The nurse is taking care of a female client who is scheduled for a mastectomy. The client tells the nurse that she is apprehensive about the operation and asks the nurse to read a passage from the Koran to help her prepare herself for surgery. Which action by the nurse is the most appropriate?

Read the Koran passage to the client.

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

Sociocultural dimension Sociocultural dimension Love and belonging needs: Relationships with others Communications with others Support systems Being part of a community Feeling loved by others Physical dimension Physiologic needs: Breathing Circulation Temperature Intake of food and fluids Elimination of wastes Movement Environmental dimension Safety and security needs: Housing Community/ neighborhood Climate Emotional dimension Self-esteem needs: Fear Sadness Loneliness Happiness Accepting self Intellectual and spiritual dimensions Self-actualization needs: Thinking Learning Decision making Values Beliefs Fulfillment Helping others

The nurse is assessing the family structure of the client and determines it is an extended family. Which of the following represent an extended family?

The family is comprised of two parents, three children, and one grandparent.

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.

Family assessment of a father, mother, and four children has suggested the presence of several risk factors. Which of the following aspects 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.

A nurse at a local homeless shelter is evaluating a new arrival at 10 o'clock at night, a 57-year-old man wearing disheveled clothes. He states that he is looking for a place to sleep because he is exhausted. The man states that he has been living under a bridge since he lost his job 6 months ago, and that he is hungry. The nurse performs which actions in order to address the client's physiological needs? Select all that apply.

•Offer him a sandwich because the cafeteria is closed. •Show him to his room so he can sleep.