Community Health Exam 3 Practice Questions

26. Which would most likely to be provided by a local health department in a rural community? a. Collaborating with local health clinics to provide outreach services b. Funding a local research project c. Establishing the poverty guidelines for the area d. Building a free-standing migrant health clinic

ANS: A Uniquely positioned within rural communities, LHDs are a potential catalyst for addressing the long-standing challenges associated with urban-rural health disparities. While focused on improving the health of populations, LHDs provide a wide array of services focused on assessing health status, mobilizing action to address health-related issues, and ensuring the delivery of important health services in the community. The ability of rural health departments to develop and cultivate partnerships is important for the integration of public health within the larger health care delivery system. The local health department would be more likely to collaborate with existing resources before building its own free-standing clinic. Poverty guidelines are established by the federal government. It is unlikely that a local health department in a rural area has funding available for research projects. DIF: Cognitive Level: Understand (Comprehension)

1. Which factors result in rural residents having less access to health care than urban dwellers? (Select all that apply.) a. Employment opportunities may be low paying and seasonal. b. There are greater distances to travel and limited choice of health care providers. c. Health care providers prefer to work in higher-paying urban settings. d. Rural residents are less likely to have health insurance. e. Rural persons' economic resources are tied up in land, not easily accessible cash. f. Rural persons believe in self-sufficiency and self-care, not asking others for help.

ANS: A, B, C, D A recent Institute of Medicine study reported rural medical access problems in these areas, with some hospital and pharmacy closures; greater distances to travel for physician services; and limited, if any, choice of providers. Rural residents were more likely than urban residents to lack insurance. In 2015, about 18% of the persons living in rural counties were at the poverty level. Having economic resources invested in land and believing in self-sufficiency and self-care are not reasons why rural residents have less access to health care than urban dwellers. DIF: Cognitive Level: Remember (Knowledge)

6. Which do expert rural nurses report as benefits of their work? (Select all that apply.) a. Ability to develop close relationships and give holistic care b. Being able to practice in the community where one lives c. Constant challenges d. Continual growth as an expert generalist e. Higher salary than in urban areas f. Intensity of purpose

ANS: A, B, C, D, F Positive aspects of rural nursing include the ability to give holistic care, to know everyone well, and to develop close relationships with the community and with coworkers. Autonomy, professional status, and being valued by the agency and community have been reported components of positive job satisfaction. The rural nurse is a generalist, and generalist is not synonymous with boring. Interviews with rural nurses show that they feel an "intensity of purpose" that makes rural nursing distinctive. Nurses living and practicing in the same place have a strong sense of integration and continuity between practice and community. DIF: Cognitive Level: Understand (Comprehension

3. Which best describes why for-profit managed care organizations (MCOs) have not begun to move into rural areas to increase the number of persons served? (Select all that apply.) a. High startup and administrative costs are needed. b. A large number of elderly are on Medicare or Medicaid, which results in low reimbursement. c. Managed care has not yet had time to go beyond major population centers. d. MCOs are waiting until federal reimbursements for underserved rural health areas become higher. e. The population is too small and too spread out. f. Rural health areas are too geographically unattractive and lack any recreational possibilities for managers to want to work there.

ANS: A, B, C, E MCOs recognize the risks to expanding into rural areas. Risks are probable high startup and administrative costs. Managed care has yet to move into much of rural America because of small dispersed populations, few visits per individual, and large numbers of elderly on Medicare with low-level reimbursements that do not make the aggregate financially attractive to MCOs. It is not likely that federal reimbursements for underserved rural health areas will become higher. The lack of attractive living for managers has not been a reason why MCOs have not moved into rural areas. DIF: Cognitive Level: Understand (Comprehension)

5. Which best describes why there are more long-term consequences (such as death) to a driver injured in a truck accident in a rural area than a driver injured in a truck accident in an urban area? (Select all that apply.) a. Rural drivers are more likely to speed over long distances than urban drivers. b. Rural drivers are not as skilled with vehicles as urban drivers, so they are more severely injured in a crash. c. The urban driver is taken immediately for care, whereas the rural driver might be injured on an isolated field and not found by anyone for hours. d. Urban drivers are more likely to use their seat belts than rural drivers. e. Urban drivers are probably rushed to an emergency department, whereas the rural driver lives far away from emergency services, often over bad roads and possibly through severe weather. f. Urban drivers trade their vehicles in rather frequently, whereas rural drivers keep their vehicles for as long as they can make them run, so the vehicles are much less roadworthy.

ANS: A, C, D, E Getting patients from the place of injury to the trauma center within the "golden hour" is frequently not possible in rural areas because distance, terrain, climatic conditions, and communication methods produce barriers. Some rural facilities are more than 1 hour away by air from the nearest trauma center or tertiary care hospital. Driving at high speeds, driving long distances, driving in winter conditions, not using seat belts, and consuming alcohol have been cited as contributing to greater levels of injury deaths and disability by rural residents in the West. There is no evidence to suggest that rural drivers are not as skilled as urban drivers or that their vehicles are less roadworthy. DIF: Cognitive Level: Understand (Comprehension)

2. In comparison with mental health care in urban areas, which best describes how mental health care in rural areas differs? (Select all that apply.) a. Access to care is more limited or not available at all locally. b. Cost for treatment is typically reimbursed at a lower rate. c. Depression is frequently not recognized or is not treated. d. Ethnic and racial disparities exist. e. Primary health care professionals accept responsibility for mental health treatment. f. The suicide rate is notably higher.

ANS: A, C, E, F Nationally, suicide is the 11th leading cause of death, but in rural America it is the second leading cause of death. Decreased access to mental health services for treatment of depression may contribute to these higher rates. Because of the lack of qualified mental health care providers, rural residents often receive services from primary care providers. Ethnic and racial disparities exist whether in urban or rural health care. DIF: Cognitive Level: Understand (Comprehension)

4. A nurse has written a research proposal studying how technology can be used in innovative ways in rural areas to improve patient outcomes. Which should the nurse contact about funding opportunities? (Select all that apply.) a. Research Centers Program b. Health and Human Services Department (HHS) c. Health Resources and Services Administration (HRSA) d. Federal Office of Rural Health Policy e. Rural Health Research Gateway f. The Center for Rural Health at a local university

ANS: A, D, F The HRSA provides access to and support for research through the Research Centers Program. The Research Centers Program is the only federal research program entirely dedicated to producing policy-relevant research on health care and population health in rural areas. Each research center has its own identity (although it may be part of a larger organization), website, and core staff that include a disciplinary mix of health services research, epidemiology, public health, geography, medicine, and mental health. Over the 4-year award cycle, each research center develops a portfolio of several research projects per year in conjunction with input from the Federal Office of Rural Health Policy and other experts. Universities across the country have created centers for rural health research. To strengthen the dissemination of research results, the Rural Health Research Gateway is a "one-stop shop" for the research centers, providing easy access to projects funded by ORHP and summaries of research in progress. The Health and Human Services Department does not provide funding for rural area research. DIF: Cognitive Level: Apply (Application)

8. Which best explains why having parity in insurance coverage does not always help persons with depression? a. Many persons find that the medications do not relieve symptoms. b. Most depressed persons do not seek treatment. c. Most depression is situational, and having insurance does not change the situation. d. Psychotherapists will not accept the low reimbursement offered by insurance plans.

ANS: B Although effective treatments and medications exist, most people (almost two thirds) with depressive illness do not seek help. Parity in insurance coverage helps for depressed persons who are encountering situational depression to receive services and promotes care being provided by a variety of providers. DIF: Cognitive Level: Understand (Comprehension)

10. A patient with severe panic attacks refuses to come to the mental health clinic to get help even after being assured there is no charge for the initial assessment. Which provides the best explanation for this behavior? a. People know that the treatment is to confront your fears in small doses, and the very idea is overwhelming and frightening. b. Such persons have anticipatory anxiety, so they try to avoid situations that may lead to a panic attack, such as leaving their house. c. The recurring symptoms such as tachycardia, chest pain, nausea, and sweating are seen as symptoms of a physical illness, not a mental illness. d. They are too depressed to take action.

ANS: B As the avoidance behavior intensifies, the client begins to withdraw further to avoid being in places or situations from which escape may be difficult. Individuals with agoraphobia frequently progress to the point where they cannot leave their homes without experiencing anxiety. DIF: Cognitive Level: Apply (Application)

3. Which best describes how brain imaging scans are being used? a. To deliver electroconvulsive therapy to high-risk individuals b. To help detect and diagnose medical disorders and illnesses c. To help determine treatment options for mental disorders d. To help determine the effects of psychotherapy

ANS: B Brain imaging scans, also called neuroimaging scans, are being used more and more to help detect and diagnose a number of medical disorders and illnesses. Currently, the main use of brain scans for mental disorders is in research studies to learn more about the disorders. These researchers study healthy brain development, effects of mental illnesses, or effects of mental health treatments on the brain. Brain neuroimaging helps researchers study healthy brain development, effects of mental illnesses, or effects of mental health treatments on the brain. DIF: Cognitive Level: Remember (Knowledge)

18. A patient had a distorted thought pattern, which led to very uncomfortable feelings and inappropriate behaviors. Which type of therapy would most likely be successful? a. Behavioral therapy b. Cognitive-behavioral therapy c. Family therapy d. Group therapy

ANS: B Cognitive-behavioral therapy may be used in individual, family, couples, or group therapy. The goal is to identify and correct distorted thought patterns that can lead to troublesome feelings and behaviors. In comparison, behavioral therapy uses learning principles to change thought patterns and behaviors systematically; it is used to encourage the individual to learn specific skills to obtain satisfaction. Family therapy involves problem-solving sessions with members of the family. Group therapy involves a small group of people with similar problems who, with the guidance of a therapist, discuss individual issues and help each other with problems. DIF: Cognitive Level: Apply (Application)

2. Which event occurred in 1965? a. State mental hospitals were created. b. The mentally ill were deinstitutionalized. c. Electroconvulsive therapy was discovered to help depression. d. Community mental health centers for outpatient care were established.

ANS: B Deinstitutionalization is the release of institutionalized people, especially mental health patients, from an institution for placement and care in the community and was initiated in 1965. From 1955 to the mid-1980s, the number of patients in state facilities fell from 560,000 to 155,000 because patients moved back out into the communities. The Community Mental Health Centers Act of 1964 provided federal support for mental health services. The act supported measures to implement facilities to care for those who were mentally retarded and to construct community mental health centers. The creation of state mental hospitals and the discovery of electroconvulsive therapy occurred before 1965. DIF: Cognitive Level: Remember (Knowledge)

17. A family was very pleased with how well their child was doing now that he was on medication. They congratulated the nurse on getting their child help and said they were so impressed that the nurse was able to cure him. Which would be the most appropriate response by the nurse? a. Congratulate them on being so supportive to their child through this ordeal. b. Stress that the medication is controlling the symptoms and their child will continue to need their support. c. Thank them for their recognition of the role you—and all nurses—play in promoting health. d. Verbalize your observations of how well their child is doing.

ANS: B Psychotherapeutic medications do not cure mental illness; they act by controlling symptoms. Thus, it is important for the nurse to stress to the family that the medication is controlling the symptoms and the child needs their continued support. Both of these factors are important for the long-term success and treatment of the child. DIF: Cognitive Level: Apply (Application)

1. Which provides the best description of severe mental illness (SMI)? a. Having been clearly diagnosed with at least two mental health disorders within the past year b. Having a diagnosable mental disorder with moderate functional behavior in a specific area of lifestyle at any time during the past year c. Being unable to function in society because of a mental illness d. Being convicted of several impulsive crimes during the past year

ANS: B SMI occurs in adults who currently or at any time during the past year have a diagnosable mental, behavioral, or emotional disorder with moderate, severe, or extreme functional behavior in specific areas of lifestyle. These mental health disorders afflicting persons who are 18 years of age or older present emotional or behavioral functioning that is so impaired as to interfere substantially with their capacity to remain in the community without supportive treatment or services of a long-term or indefinite duration. DIF: Cognitive Level: Remember (Knowledge)

3. A nurse suspects that a client is depressed. Which symptoms are most likely being exhibited by the client? (Select all that apply.) a. Paranoia b. Fatigue c. Irritability d. Difficulty concentrating e. Hallucinations f. Impulsivity

ANS: B, C, D Symptoms of depression include the following: persistent sad, anxious, or "empty" feelings; feelings of hopelessness or pessimism; feelings of guilt, worthlessness, or helplessness; irritability, restlessness; loss of interest in activities or hobbies once pleasurable, including sex; fatigue and decreased energy; difficulty concentrating, remembering details, and making decisions; insomnia, early-morning wakefulness, or excessive sleeping; overeating or appetite loss; thoughts of suicide, suicide attempts; aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment. DIF: Cognitive Level: Apply (Application)

2. Which are the causes of mental illness? (Select all that apply.) a. Excessive amounts of brain serotonin, dopamine, and -aminobutyric acid b. Genetic inheritance combined with neurochemical and metabolic changes c. Living through a severe disaster, whether manmade or natural d. Physiological abnormalities in the brain structure e. Posttraumatic stress syndrome (PTSD) f. Social isolation, rejection, and/or stress

ANS: B, C, D, E, F Genetic expressions, combined with neurochemical and metabolic changes and environmental insults, may result in the display of mental disorder characteristics. Evidence indicates that structural brain abnormalities can be related to some mental illnesses, such as schizophrenia, depression, and Alzheimer disease. Natural and manmade disasters, such as hurricanes, floods, violence, terrorism, war, and the global economic crisis are profound stress-inducing events that can lead to mental illness. Researchers reported high levels of PTSD among survivors. DIF: Cognitive Level: Remember (Knowledge)

9. Which best summarizes the symptoms of a person with bipolar disorder? a. Chronic, unrealistic, and exaggerated worry about life b. Ongoing hallucinations and delusions c. Changes in mood from depression to mania d. A persistent abnormally elevated or irritable mood

ANS: C Bipolar disorder refers to a group of mood disorders that present with changes in mood from depression to mania. The depressed phase is manifested by symptoms seen in major depressive disorder. The manic phase is characterized by a persistent abnormally elevated or irritable mood, impaired judgment, flight of ideas, pressured speech, grandiosity, distractibility, excessive involvement in goal-directed activities, few hours sleeping, and impulsivity. These symptoms may co-occur with psychotic features, such as hallucinations and delusions. Generalized anxiety disorder is characterized by chronic, unrealistic, and exaggerated worry and tension about one or more life circumstances lasting 6 months or longer. DIF: Cognitive Level: Understand (Comprehension)

12. Which female would be at greatest risk for developing bulimia nervosa? a. A 13-year-old who is constantly snacking on food from her backpack all day b. A 14-year-old student who is known as a nerd c. A 15-year-old cheerleader who wants to be a professional ballerina d. An 11-year-old student with the highest Grade Point Average (GPA) in the school

ANS: C Bulimia nervosa typically begins in adolescence or during the early 20s, usually in conjunction with a diet. High school and college students, as well as members of certain professions that emphasize weight and/or appearance (e.g., dancers, flight attendants, cheerleaders, athletes, actors, models), are at a high risk. Based on these descriptors and the typical characteristics of a person who has bulimia, the 15-year-old cheerleader demonstrates the greatest risk. DIF: Cognitive Level: Apply (Application)

7. Which mental illness is most frequently diagnosed among adults in the United States? a. Acute stress disorder b. Bipolar disorder c. Depression d. Schizophrenia

ANS: C Depression is the most frequently diagnosed and one of the most disabling mental illnesses in the United States. Depression affected approximately 16.1 million American adults, or about 6.7%, of the U.S. population age 18 and older, in the past year. Acute stress disorder, bipolar disorder, and schizophrenia are not diagnosed as frequently as depression. DIF: Cognitive Level: Remember (Knowledge)

6. Which was required by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008? a. That alcoholism be recognized as a disease and treatment be given in residential facilities b. That drug addiction be accepted as a mental health diagnosis and addicts be treated rather than jailed when caught c. That health insurance must cover treatment for mental illness on the same terms and conditions as physical illness d. That community clinics must treat clients for mental illness just as they treat prisoners who have a physical illness

ANS: C In 2008, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act was enacted. The law requires health insurance to cover treatment for mental illness on the same terms and conditions as physical illness. This law does not require that alcoholism be recognized as a disease, that drug addiction be accepted as a mental health diagnosis, or that community clinics must treat clients for mental illness. DIF: Cognitive Level: Understand (Comprehension)

5. Which would be most upsetting for American families when their loved one, after serving in Iraq or some other battlefield, returns home? a. Many families, especially those with children, do not want guns in the house. b. Reabsorbing them into the family structure is challenging and difficult. c. The suicide rate is twice as high as among nonveteran adults. d. They must use the Veterans Affairs medical system for medical care.

ANS: C Male veterans in communities are twice as likely to die by suicide as their civilian counterparts. There is nothing to support that these veterans will have guns in their homes. The veterans will be able to use the Veteran Affairs system for medical care and there may be challenges with their return home, but that should not be as upsetting as the risk for suicide for their loved one. DIF: Cognitive Level: Understand (Comprehension)

13. Which female would be at greatest risk for developing anorexia nervosa? a. A young woman who had been badly hurt in a car accident and is now living with her grandparents but managing to retain her high school Grade Point Average (GPA) b. A young woman who is a fantastic athlete but acts out and does what she feels is best, regardless of what others think c. A "good girl," obedient to her parents' wishes, who always agrees with peers in her clique and strives to do everything perfectly d. A student under a lot of stress from family events at home but who has good coping skills and recognizes that she is coping with major life changes

ANS: C Risk factors for eating disorders are perfectionism, low self-esteem, stress, poor coping skills, sexual/physical abuse, poor self-image, dependency on others' opinions and deference to others' wishes, and being emotionally reserved. Based on these descriptors and the typical characteristics of a person who has anorexia, the "good girl" demonstrates the greatest risk. DIF: Cognitive Level: Apply (Application)

27. Which best describes how the federal government tries to both encourage and support rural health clinics under the Community Health Centers (CHC) program? a. Allowing tax deductions for charitable contributions to rural health clinics (RHCs) b. Donating equipment and supplies to establish such clinics c. Reimbursing both Medicare and Medicaid at a higher rate than otherwise d. Requiring recipients to serve in a rural health clinic for 3 years in exchange for financial assistance while in school

ANS: C The CHC program, administered by the U.S. Public Health Service, benefits underserved areas and populations. RHCs are designed to improve access to primary care. As an incentive to rural communities to apply for RHCs, Medicare and Medicaid are reimbursed at a higher rate than usual. DIF: Cognitive Level: Understand (Comprehension)

28. Which best describes how Migrant Health Clinics (MHCs) under the Migrant Health Program are often different from other clinics? a. Care is restricted to those who can document that they are employed in agriculture. b. They are much better funded than typical rural clinics. c. Staff are typically bilingual and bicultural. d. They welcome illegal immigrants to receive care.

ANS: C The MHCs and the Migrant Health Program provide comprehensive nursing and medical care and support services to migrant and seasonal farm workers and their families from many countries in Latin America and the Caribbean. Bilingual, bicultural health personnel, including lay outreach workers, use culturally appropriate protocols for providing primary care, preventive health care, transportation, dental care, pharmaceuticals, and environmental health. The funding at the MHC may not be any different than other rural clinics. Their primary purpose is not to provide care to illegal immigrants, rather to migrant and seasonal workers. DIF: Cognitive Level: Understand (Comprehension)

20. A nurse is working in a community setting caring for persons with mental health problems and their families. Which accurately describes how the nurse would fulfill the nursing role of coordinator? a. Being an advocate by writing letters to legislators demanding more resources for care for the mentally ill b. Encouraging all those involved to fight the community's tendency to stigmatize the mentally ill and their families c. Assisting the mental health client in navigating community agencies d. Establishing supportive interpersonal relationships with all those involved

ANS: C The nurse as coordinator helps the consumer "navigate" the segmented web of agencies and other service providers. Being an advocate and encouraging the community to overcome the stigma of mental illness are both activities the nurse would fulfill through the role of activist. Establishing supportive interpersonal relationships is fulfilled through the role of practitioner. DIF: Cognitive Level: Apply (Application)

11. A person with obsessive-compulsive disorder (OCD) knows the ritual is senseless but is unable to stop. Which best explains why he does not quit doing the ritual? a. As rituals become habit, others will worry about the person if he or she suddenly stops engaging in the ritual behavior. b. Engaging in rituals allows the individual to feel in control. c. If the compulsion is resisted, anxiety increases. d. Rituals, even if nonsensical, are comforting and reassuring.

ANS: C The person with OCD feels compelled to engage in some ritual to avoid a persistent frightening thought, idea, image, or event. Obsessions are recurrent thoughts, emotions, or impulses that cannot be dismissed. Compulsions are the rituals or behaviors that are repeatedly performed to prevent, neutralize, or dispel the dreaded obsession. When the individual tries to resist the compulsion, anxiety increases. DIF: Cognitive Level: Apply (Application)

4. Which best describes how people with mental illness are viewed by the general public? a. Individuals in need of assistance b. Criminals who need to be institutionalized c. Lazy, weak, and immoral d. Contributing members of society

ANS: C Throughout history, the symptoms of mental illness have been perceived as permanent, dangerous, frightening, and shameful. People with a diagnosis of mental illness have been described as lazy, idle, weak, immoral, irrational, and, too often, criminal. DIF: Cognitive Level: Understand (Comprehension)

1. Which behaviors best represent the definition of mental health? (Select all that apply.) a. Currently enjoys receiving unemployment benefits b. Frequent dates, although most relationships are short term c. Happily married and successful parent of three children d. Just promoted with more responsibilities and increased salary e. Lives alone in a small apartment f. Set up a memorial fund for research after death of a family member

ANS: C, D, F In 1999, the Surgeon General's Report on Mental Health defined mental health as a state of successful performance of mental function that results in productive activities, fulfilling relationships with others, and an ability to adapt to change and cope with adversity. The correct behaviors represent the ability to maintain employment and relationships, and to adapt to change, including adversity. The incorrect responses demonstrate behaviors that do not support mental health—enjoyment in receiving unemployment benefits, short-term relationships, and living alone. DIF: Cognitive Level: Understand (Comprehension)

24. Which difference is found in parish nursing in a rural area as opposed to parish nursing in an urban area? a. Rural parish nurses are less likely to be involved in case management or care coordination than their urban counterparts. b. Rural residents are more grateful for the nurse's assistance because there are so few health resources in rural areas. c. Rural residents are typically less committed to traditional values or a strong religious faith. d. Rural residents may discuss health concerns with the nurse wherever they meet, whether in church or the local market.

ANS: D In urban settings, contact with parishioners was primarily at the church, whereas contacts in rural settings were most often in the home, on the phone, or in other community-based settings. DIF: Cognitive Level: Understand (Comprehension)

25. A nurse saw there was a need for a hospice facility in a rural area, because so many of the residents were quite elderly and death was common. Which best explains why the community would not immediately see the wisdom of the nurse's suggestion? a. Change is always difficult; the nurse just needs to keep reinforcing the need for such a facility. b. The nurse did not tell residents how much their taxes would need to go up to support such a facility. c. Residents were fearful of confronting death in such an open way. d. Rural residents prefer to use their informal social support networks when help is needed.

ANS: D Limited availability and accessibility of formal health care resources in rural areas combined with self-reliance and self-help traits of rural residents have resulted in the development of strong rural community informal care and social support networks. Rural residents are more apt to entrust care to established informal networks than to new formal care systems. It is unlikely that creation of such a facility would impact their taxes. The nurse needs to partner with the community to implement the change process while building upon the community's strengths, beliefs, and values systems. DIF: Cognitive Level: Understand (Comprehension)

15. A student said she wanted to discuss an issue with the nurse but that it was confidential. Therefore, she asks the nurse to promise as a professional to keep this a secret. She then shares that her roommate is very depressed; her older sister committed suicide, and she is planning on killing herself if she does not pass her final examinations. Which action should be taken by the nurse? a. As a professional who made a promise, the nurse teaches the student how to recognize if her roommate is getting ready to actually do it and the phone number of the suicide hot line. b. As secrecy was promised, the nurse can only encourage the student to encourage her roommate to seek help. c. The nurse should give the student brochures and information plus the suicide hotline phone number to share with her roommate. d. The nurse should stress that one cannot keep a secret when someone's life is at stake and immediately go to assess the roommate.

ANS: D Suicide is preventable. Most people want to live but sometimes cannot see any other alternative. Now that the nurse knows the roommate is talking about suicide, the nurse cannot agree to keep the secret but must intervene and seek immediate help. DIF: Cognitive Level: Apply (Application)

19. Which best describes the change that was made to mental health care through the implementation of the ACA? a. Psychotherapy began to be considered part of mental health services. b. Mental health services expanded to additional providers. c. Spending limits were placed on mental health services. d. Parity now exists for mental health services.

ANS: D The Affordable Care Act (ACA) built on the 2008 Mental Health Parity and Addiction Equity Act (Substance Abuse and Mental Health Services Administration [SAHMSA], 2017) to extend federal parity protections to 62 million Americans with mental illnesses (USDHHS, Office of the Assistant Secretary for Planning and Evaluation, 2013). This parity law aimed to ensure that when coverage for mental health and substance use conditions is provided, it is generally comparable to coverage for medical and surgical care. The ACA built on the parity law by requiring coverage of mental health and substance use disorder benefits for millions of Americans who currently lack these benefits. Mental and behavioral health services are recognized as essential health benefits. Consequently, the ACA stipulated that all plans must cover behavioral health treatment, such as psychotherapy and counseling; mental and behavioral health inpatient services; and substance abuse treatment (HealthCare.gov, 2017). Similarly, preexisting mental and behavioral health conditions are covered, and spending limits aren't allowed. Parity protections now exist for mental health services. DIF: Cognitive Level: Understand (Comprehension)

14. A nurse is picking up her child from nursery school when the daycare teacher says to her, "One of the boys we care for does not seem able to sit still and listen, but is always running around and getting into things. His parents are not worried. His mother said her brother was the same way when he was a kid. Since you are a nurse, do you have any ideas on how I can calm him down?" Which would be the most appropriate response by the nurse? a. "I'm not a pediatric nurse; I really don't know what to tell you." b. "I'm sorry you're concerned, but being impulsive and very physically active is quite normal for 3- to 4-year-old children." c. "Tell the parents he has to see the doctor as he's not doing well in nursery school." d. "Why not suggest that it's time for him to have a complete assessment and suggest the physician call you for an update on how he is doing in nursery school?"

ANS: D The three major characteristics of attention-deficit hyperactivity disorder/attention-deficit disorder (ADHD/ADD) are inattention, hyperactivity, and impulsivity. Although parents may notice symptoms and signs, it is often teachers who recognize the behaviors consistent with ADHD/ADD and suggest referral for assessment and treatment. Suggesting a referral is the most appropriate response for the nurse because of the symptoms that have been reported. DIF: Cognitive Level: Apply (Application)

19. A woman stumbled into the rural health clinic and explained that she had an incredible headache. She was sweating and began vomiting into the wastebasket by the intake nurse's desk. Which diagnosis should be anticipated by the nurse? a. Acute adult panic disorder b. Acute alcohol intoxication c. Acute appendicitis d. Acute meningitis e. Acute pesticide poisoning

ANS: E Signs and symptoms of acute pesticide poisoning are fairly clear, and most health providers in rural communities would recognize them. Common symptoms include headache, dizziness, diaphoresis, nausea, and vomiting. If left untreated, those affected may experience a progression of symptoms including dyspnea, bronchospasm, and muscle twitching. Deaths are relatively uncommon, but they do occur. The nurse is reminded that not all farm laborers are men. The symptoms that are being displayed are not typical of acute panic disorder, acute alcohol intoxication, acute appendicitis, or acute meningitis. DIF: Cognitive Level: Apply (Application)

16. A college student visits the student health center and tells the nurse that his roommate is talking about killing himself, has given some of his possessions away, and he believes the roommate has a gun. Which action should be taken by the nurse? a. Ask the student why he is telling this story; what does he expect the nurse to do? b. Call the police immediately, and have the student tell them the story. c. Call the roommate, and set up an appointment for him to come to the student health center to discuss how things are going in his life right now. d. Call the roommate, ask if he is thinking of killing himself, and, if so, how is he thinking of doing that? e. Immediately locate the roommate, talk to him, and, if the story is confirmed, stay with him until emergency services arrive.

ANS: E Whenever an individual exhibits suicide warning signs, nurses should refer the person to a mental health clinic or provider as soon as possible. This may involve taking emergency action by calling the local emergency services number in the community and staying with the person until help arrives. DIF: Cognitive Level: Apply (Application)

21. A nurse eagerly explained to a long-term disabled male client the most recent relevant research related to his care. The client, rather than express appreciation, said, "I prefer to have my care given this way." The nurse explained that research suggested an alternative approach was more clinically effective, but the client said, "I am more comfortable during the day if my care is given this way." Which action should be taken by the nurse? a. Accept that the client knows what works best b. Ask the nursing supervisor to review the research with the client c. Give evidence-based care according to current research findings d. Negotiate a compromise between patient preferences and research-based approach to care

ANS: A A person who lives with a disability commonly becomes an expert at knowing what works best for his or her body. The nurse must ask the client what works best for him or her and what goals the client is pursuing. Research is based on probabilities of effectiveness with large groups, but individuals may have a different unique reaction to any intervention. DIF: Cognitive Level: Apply (Application)

12. Which is the most prevalent type of substance use problem among male and female veterans? a. Binge drinking b. Overuse of prescription drugs c. Marijuana use d. Use of smokeless tobacco

ANS: A Binge drinking and cigarette smoking are the most prevalent types of substance use problems among male and female veterans, affecting about 11% of the veteran population, with disorders more common among males younger than 25 years of age. Substance use disorders (SUDs) involve a pattern of use of alcohol, tobacco, and illegal and prescription drugs that results in marked distress and/or impairment (American Psychiatric Association [APA], 2013). DIF: Cognitive Level: Remember (Knowledge)

13. Which best explains why companies do not build work places in rural areas where people are anxious to find full-time employment? a. Employers need highly educated and skilled employees. b. Managers do not want to be transferred into a rural area where they will not fit in and will not be comfortable. c. Rural persons do not work as hard as urban dwellers. d. Smells emanating from farms are unacceptable to persons working inside.

ANS: A Counties that have a low-wage economy have difficulty providing the infrastructure needed to provide education for low-wage families. They therefore have difficulty attracting new employers who might contribute to the economic development of a rural area but need a more highly educated workforce. Rural workers are known for their strong work ethic, but they may not have the educational skills that are necessary. Smells from farms is not a typical reason as to why companies do not build in rural areas. DIF: Cognitive Level: Understand (Comprehension)

3. Which statement regarding developmental disabilities is accurate? a. Those with developmental disabilities exhibit limitations before 18 years of age. b. Those with developmental disabilities see improvement in their functional ability as they age. c. Developmental disabilities are diagnosed before 1 year of age. d. Developmental disabilities result in a physical handicap.

ANS: A Developmental disabilities encompass those conditions that are manifested by limitation before the legal age of adulthood, which is 18. This includes issues that limit or present challenges to the performance of activities of daily living (ADLs). Developmental disabilities encompass those lifelong conditions that are chronic in nature and may incorporate either or both intellectual and physical disabilities. Developmental disabilities can be diagnosed at any point in time during childhood. A handicap is not a characteristic of a person, but rather a description of the relationship between the person and the environment; a handicap results when a person with an impairment cannot fulfill a normal life role in society on a macro level of analysis. DIF: Cognitive Level: Understand (Comprehension)

5. A nurse is interviewing a client to determine if she is eligible for VA benefits. Which question would assist the nurse in determining the requirement of service? a. "Did you serve active duty for 24 consecutive months?" b. "Which branch of the military service did you serve?" c. "Were you dishonorably discharged?" d. "How long has it been since you left the military?"

ANS: A Veterans—and sometimes their survivors and dependents—are eligible for VA benefits when they fulfill two requirements related to service and separation. (1) Service: they must have served in active duty for 24 consecutive months or for a full period of call (Reserves and Guard). There are some exceptions to the length of service minimum, the most important being when a person is discharged for disability incurred or aggravated in the line of duty. (2) Separation: they must have been separated under any condition other than dishonorable. DIF: Cognitive Level: Apply (Application)

21. A nurse was becoming very frustrated at the ongoing stream of farmworkers with respiratory problems each spring. Which action should be taken by the nurse? a. Provide community education on herbicides and other chemicals spread each spring with information on self-protective measures, such as respirators. b. Fight to get farmers to quit spreading chemicals on their fields each spring. c. Suggest that farmers spray water on the fields immediately after the chemicals are spread to reduce dust in the air. d. Tell farm workers to obtain different employment. e. Try to get farmers to reduce the amount of chemicals used on their fields.

ANS: A Environmental health issues in rural communities, such as pesticide exposure or health hazards from point-source factory emissions, are more effectively assessed and remedied on a community level than on a case-by-case basis. Nurses' involvement in helping people understands health problems in a larger context can be the genesis of change. It is not realistic to have farmers quit or reduce the spreading of chemicals, spray water on their fields after chemical application, or ask them to obtain different employment. Nurses must work with farmers so that they are able to use safe measures when applying the chemicals to their fields. DIF: Cognitive Level: Apply (Application)

5. Which best describes the purpose of the core-based statistical areas (CBSA) system? a. To reflect trends in population distribution across the county b. To differentiate between urban and metropolitan areas c. To emphasize the importance of noncare areas d. To report the demographic characteristics of those living in the area

ANS: A In June 2003, the Office of Management and Budget (OMB) released a new classification scheme to better reflect trends in population distribution across the nation (OMB, 2016). The MSA designation has been replaced by county-level core-based statistical areas (CBSAs) to simplify the multilevel designations. Within CBSAs, metropolitan areas are those counties that contain at least one urbanized area of 50,000 or more people. A micropolitan area contains a cluster of 10,000 to 50,000 persons. Counties that are neither metropolitan nor micropolitan are called "outside CBSAs," also known as noncare areas (U.S. Census, 2013). DIF: Cognitive Level: Understand (Comprehension)

16. As a concerned citizen and professional, a nurse encourages the local senators and representatives to support expansion of health clinics for the poverty stricken. Which location is in most desperate need? a. Rural areas where migrant and seasonal farmworkers (MSFW) labor b. Inner city poverty-stricken neighborhoods c. Near elderly low-income housing units d. Inside high schools in poverty-stricken neighborhoods

ANS: A In general, MSFW may have the poorest health of any aggregate in the United States and the least access to affordable health care. Thus, a location that serves this population would be most important. DIF: Cognitive Level: Apply (Application)

7. Which describes what has been identified by public health experts as the number one priority in rural areas? a. Access to health care b. Access to education c. Access to telecommunications d. Access to better-paying employment opportunities

ANS: A In the Rural Healthy People 2020 survey, 80% of respondents listed access to health care as a top rural priority. Although access to education, telecommunications, and well-paying employment are important, they have not been identified as the number one priority in rural areas. DIF: Cognitive Level: Understand (Comprehension)

18. Which best describes the prevalence of autism in the United States? a. The prevalence of autism has increased in the past decade. b. The prevalence of autism has decreased in the past decade. c. The prevalence of autism has remained stable in the past decade. d. Because the etiology is unknown, it is difficult to determine the prevalence of autism.

ANS: A It has been estimated that about 1 in 88 children (or slightly more than 1.1%) have autism. Alarmingly, between 2000 and 2010, autism's prevalence increased 119%, with estimates at 1 in 68 births. Autism has no known etiology, but more frequently occurs among older parents. DIF: Cognitive Level: Understand (Comprehension)

4. Which insight is being stressed by advocacy groups regarding persons with disabilities today? a. Disability results when physical and social barriers in the environment prevent a person from taking equal part in community life. b. Handicapped persons have as much right to social support as nonhandicapped persons. c. It is recognized that an individual may be limited by an environmental barrier in society. d. Impairment is a result of society's reaction more than mental or physical condition.

ANS: A Nearly all definitions identify an individual as disabled on the basis of a physical or mental impairment that limits the person's ability to perform an important activity. The complementary possibility—that the individual is limited by a barrier in society or the environment—is never considered. Advocacy groups, such as the Committee on a National Agenda for the Prevention of Disabilities, stress that environment and the reactions of others are as crucial as the actual physical or mental limitation. DIF: Cognitive Level: Understand (Comprehension)

3. A client is describing the time period that he served in the National Guard. Which statement would he be most likely to make? a. "I completed monthly drills and 2-week annual trainings." b. "I achieved the rank of officer and was promoted to the U.S. Army." c. "I served overseas based on decisions made by the federal government." d. "I selected Japan as my destination for my overseas tour of duty."

ANS: A Personnel serving in the National Guard or Reserves are considered part-time employees. The key difference among them is that the Reserves report to the federal government, whereas the National Guard is administered by each state (e.g., the Pennsylvania National Guard is called into action by the governor of Pennsylvania). These individuals serve no more than 39 days a year, unless called into action. Usually, their service consists of monthly drills and 2-week annual trainings. Reservists may be called very suddenly to active duty (full-time) for deployments, requiring that they leave their family, regular job, and community for a time. The National Guard and Army are two separate entities—promotion does not change the military that is being served. DIF: Cognitive Level: Apply (Application)

22. Which describes a dimension of the social determinants of health (SDH) defined within Healthy People 2020? a. Employment b. Education c. Gender d. Income

ANS: B Five broad dimensions of SDH are defined within Healthy People 2020 as: (a) Economic Stability, (b) Education, (c) Social and Community Context, (d) Health and Health Care, and (e) Neighborhood and Built Environment. Each of these dimensions includes key issues that identify more specific factors (U.S. Department Health and Human Services Healthy People 2020, 2013). Employment, gender, and income are not addressed as dimensions of the social determinants of health within Healthy People 2020. DIF: Cognitive Level: Remember (Knowledge)

15. A man came for follow-up care to the free clinic, explaining that he had applied for a job based on his education and years of previous work experience, but, being in a wheelchair, he was turned down. Which response would be most appropriate for the nurse? a. "If you know you can do the job, go to the free legal aid clinic for assistance. The employer may not know the law." b. "No one would want to hire a handicapped person, so you can continue to come here for free care." c. "Because it can be expensive to obtain the necessary equipment to help you do that job, the employer has every right to refuse to hire you." d. "The law says, if a handicapped person applies, he or she has to get hired even if an able-bodied person also applies."

ANS: A The Americans with Disabilities Act (ADA) became law in 1990. This landmark civil rights-styled legislation prohibits discrimination toward people with disabilities in everyday activities by guaranteeing equal opportunities for people with disabilities related to employment, transportation, public accommodations, public services, and telecommunications. A qualified individual with a disability must meet legitimate skill, experience, education, or other requirements of an employment position. The person must be able to perform the essential functions of the job, such as those contained within a job description, with or without reasonable accommodations. DIF: Cognitive Level: Apply (Application)

5. Which concern can a nurse as a citizen help address? a. Advocating for removal of environmental and social barriers to needed services b. Continuing to engage in political action to increase funding for care for the handicapped c. Recognizing that it is better to offer to help than to wait for a person with handicaps to have to ask for assistance d. Needing to not stare or ask personal questions of a person with a disability

ANS: A The Committee on a National Agenda for the Prevention of Disabilities model states disability occurs when a person's physical or mental limitations, in interaction with physical and social barriers in the environment, prevent the person from taking equal part in the normal life of the community. Confronting environmental and social barriers to needed services can frustrate and exhaust many people with disabilities and their families. The nurse—as a citizen and a concerned professional—can advocate for removal of such barriers. This issue is the most important for the nurse to address, allowing the nurse to partner with clients and families affected by disabilities to remedy barriers that negatively affect quality of life for this population. DIF: Cognitive Level: Apply (Application)

18. Which person would be called chronically homeless? a. A person has been homeless for more than a year b. A person who lives with a roommate when between jobs c. A person who has been staying with friends or family for an extended period of time d. A person has been residing each night in a homeless shelter for almost 3 months

ANS: A The chronically homeless individual is defined as an unaccompanied adult who has been homeless for an extended or numerous periods and has one or more disabling conditions. DIF: Cognitive Level: Understand (Comprehension)

11. Which underlying factor most likely contributes to homelessness? a. Substance abuse b. Unemployment c. Posttraumatic stress syndrome (PTSD) d. Depression

ANS: A The text states that persons as active agents do make decisions that result in homelessness. These choices result in a shortage of affordable housing, insufficient income, and scarcity of supportive services as societal conditions that contribute to homelessness rather than cause homelessness. However, these decisions are made in highly contextualized conditions, frequently in the midst of mental illness or addiction to alcohol and/or other substances. Substance abuse may in turn lead to unemployment which causes insufficient income. Additionally, PTSD and severe mental illness can cause substance abuse to occur. DIF: Cognitive Level: Understand (Comprehension)

6. Which compositional factor influences rural health needs? a. Demographics of the people living in an area b. Local environment c. The geography of the area d. The political and social institutions in the community

ANS: A There is a growing emphasis on the distinction between context, which is defined by the characteristics of places of residence, and composition, which is the collective health effects that result from a concentration of persons with certain characteristics. Problems in rural areas are compositional when they derive from individual characteristics of groups of people residing in rural settings. Examples of compositional sources of health disparities include such characteristics as age, education, income, ethnicity, and health behaviors. The environment, geography, and political and social institutions are considered to be characteristics of place. DIF: Cognitive Level: Remember (Knowledge)

22. A nurse was trying to decrease the amount of respiratory illness in the community. Which approach should be used by the nurse? a. Attend each farmworkers' meeting and listen to how they perceive and discuss their problems b. Offer to teach the farmers' spouses how to protect their families, such as having the farmer shower and change clothes before coming into the house c. Suggest the community work together to obtain a community college so farmworkers could be educated for other employment opportunities d. Teach children in the school system the importance of seeking employment in cities rather than staying on the farm

ANS: A Using informal networks in the community is essential. The involvement of informal networks and local leaders in planning health interventions is crucial. To be able to do that, the nurse must first listen to how the community perceives its problems. DIF: Cognitive Level: Apply (Application)

20. A clinic nurse is completing a patient intake interview with a noncommissioned veteran who has recently transitioned to civilian life. Which would be the most appropriate for the nurse to ask to assess how the veteran is transitioning from military to civilian life? a. Have you been able to use your military experience to find a civilian job? b. Have you been able to find a leadership position in a local company? c. What hobbies have you been able to enjoy since leaving the military? d. What support have you recently received from the Veterans Benefits Administration?

ANS: A Veterans who were noncommissioned are typically high school graduates who often held nonleadership positions. They are more likely to experience a negative transition, as they may lack the guidance, experience, and knowledge needed to prepare for separating from the military. Some veterans can transition to a civilian job similar or identical to their military job; however, this is not true for all service members. Veterans continue to have difficulty translating their job experience, qualifications, and training to the civilian job market. The Veterans Benefits Administration (VBA) is an administrative arm responsible for unemployment and pension payments, home loans, vocational training, and educational benefits. DIF: Cognitive Level: Analyze (Analysis)

13. A nurse is caring for a veteran who served in Vietnam. Which exposure is the client most likely to report? a. Agent Orange b. Chromium c. Mustard gas d. Burn pits

ANS: A Vietnam veterans suffer health disorders related to exposure to Agent Orange—an herbicide used to kill the vegetation that provided cover for the enemy. Gulf War and GWOT veterans were exposed to a number of health threats in the desert, including chromium, burn pits, and heat stroke or heat exhaustion. WWII veterans who were in the Battle of the Bulge, fought in December 1944 through January 1945, were exposed to extreme cold and may have sustained cold injuries. Some volunteers were exposed to mustard gas experiments, in which the DoD evaluated equipment for their protection against mustard gas attacks. About 4000 soldiers were subjected to severe, full-body exposures during testing. DIF: Cognitive Level: Apply (Application)

2. A spouse of a veteran inquires as to if he will qualify for the Civilian Health and Medical Program of the Department of Veteran's Affairs (CHAMPVA). Which describes what criteria will need to be met? (Select all that apply.) a. The veteran has been rated permanently and totally disabled for a service-connected disability by a VA regional office b. The spouse is a survivor of a veteran who died from a VA-rated service-connected disability c. The veteran has been diagnosed with PTSD by a VA regional office d. The spouse is a survivor of a veteran who died in the line of duty e. The spouse has been diagnosed with a terminal illness f. The veteran has been diagnosed with a terminal illness

ANS: A, B, D The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a program in which the costs of some health care services for eligible civilian beneficiaries are covered by the VA. According to Benefits.gov (2017), to be eligible for CHAMPVA benefits and services, individuals must be in one of these categories: the spouse or child of a veteran who has been rated permanently and totally disabled for a service-connected disability by a VA regional office; the surviving spouse or child of a veteran who died from a VA-rated service-connected disability; the surviving spouse or child of a veteran who was at the time of death rated permanently and totally disabled from a service-connected disability; the surviving spouse or child of a military member who died in the line of duty, not because of misconduct (in most of these cases, these family members are eligible for TRICARE, not CHAMPVA). DIF: Cognitive Level: Apply (Application)

1. Which best describes the term "literally homeless"? (Select all that apply.) a. Lacking a fixed, regular, and adequate nighttime residence b. Lacking a family residence c. Living in a place not typically used for human sleeping d. Living in a temporary living accommodation such as a hotel e. Living full-time in a recreational vehicle f. Sleeping in an extended-care facility or hospital

ANS: A, C Literally homeless is described as individuals and families who lack a fixed, regular, and adequate nighttime residence and includes a subset for an individual who resided in an emergency shelter or a place not meant for human habitation and who is exiting an institution where he or she temporarily resided. The term "literally homeless" is not used to describe those lacking a family residence, living in a temporary living accommodation such as a hotel or recreational vehicle, or sleeping in an extended care facility or hospital. DIF: Cognitive Level: Remember (Knowledge)

1. A nurse is caring for an individual with intellectual and developmental disabilities (IDD). Which findings would be most concerning to the nurse? (Select all that apply.) a. Poor skin turgor b. Decreased appetite c. Increased urination d. No bowel movement for the past 3 days e. Symptoms of choking after taking a sip of water f. Recent seizure

ANS: A, D, E, F The term fatal four refers to four common medical conditions that could result in complications and fatality more frequently for the IDD population and other PWD. Nurses and primary care providers should be knowledgeable about the fatal four, which includes (1) constipation/bowel obstruction—as evidenced by no bowel movement for the past 3 days, (2) aspiration/gastroesophageal reflux disease (GERD)—as evidenced by choking on a sip of water, (3) dehydration—as evidenced by poor skin turgor, and (4) seizures—as complications related to these conditions could result in death if not assessed, diagnosed, and treated swiftly (Smith and Escude, 2015). DIF: Cognitive Level: Analyze (Analysis)

1. Which best describes the military culture? (Select all that apply.) a. A strong sense of service b. Altruism c. Egalitarianism d. A hierarchal class system e. Problem-focused actions f. Solutions-focused actions

ANS: A, D, F Military culture is one of structure and uniformity; it is governed by rules and standards. Though each branch of the military has a different mission, common core values and norms direct the behavior of all military members. These values include leadership, teamwork, loyalty, hierarchy, obedience, and discipline. Common norms among military personnel are a strong sense of service, a hierarchal class system, solutions-focused actions, unique dialogue and expressions, and a reluctance to show weakness. DIF: Cognitive Level: Remember (Knowledge)

14. A veteran has been diagnosed with chronic multisymptom illness. Which would most likely be part of the client's health history? a. History of active duty service during the Vietnam War b. Unexplained cognitive dysfunction c. History of severe hypertension d. Frequent episodes of dysuria

ANS: B Approximately 250,000 veterans of the 1991 Gulf War (about 25% to 32%) returned home with multiple varied, unexplained symptoms, including fatigue, dizziness, headaches, cognitive dysfunction, musculoskeletal pain, respiratory problems, rashes, and diarrhea. Popular media of the time referred to the disorder as Gulf War Syndrome or Gulf War Illness, although today the VHA refers to this cluster of symptoms as chronic multisymptom illness (CMI). DIF: Cognitive Level: Apply (Application)

13. Which best describes the current perspective on how communities should treat persons with disabilities (PWDs)? a. Be supportive of PWDs and try to reduce environmental barriers b. Maximize opportunities for PWDs to work and otherwise contribute to community life c. PWDs have civil rights just as other citizens do d. Recognize that PWDs deserve our support both financially and otherwise

ANS: B Contemporary disability policy minimizes this disadvantaged view and maximizes opportunities for PWDs to live productively in their communities. Early American public policy viewed PWDs as "deserving poor" who required governmental protection and provision, with little capacity for self-support or independence. DIF: Cognitive Level: Understand (Comprehension)

2. Which problem depends on the responses of other people and therefore cannot be measured? a. Disability b. Handicap c. Impairment d. Injury

ANS: B In comparing these concepts, an impairment affects a human organ on a micro level; disability affects a person on an individual level; and a handicap involves society on a macro level of analysis. Table 21.1 points out that both impairment and disability may be objective and measurable, whereas handicap is neither, because it is an experience related to the responses of other people. DIF: Cognitive Level: Understand (Comprehension)

11. Which statement best describes how firearm injuries are different in rural areas as compared with urban areas? a. In rural areas, firearm deaths occur more frequently because of purposeful, rather than accidental, shooting. b. In rural areas, firearm injuries occur more frequently in the home. c. In rural areas, firearm injuries occur more frequently during official hunting season, whereas the frequency does not vary in urban areas. d. In rural areas, firearm injuries are more frequently fatal than in urban areas.

ANS: B In rural counties, nonfatal firearm injuries occur most often at home compared with urban counties, where injuries occur most often in the streets. DIF: Cognitive Level: Understand (Comprehension)

14. A professional strongly encouraged institutionalization, so the parents could focus on care of their other family members. Which suggestion would be appropriate for the nurse to make to the parents? a. As the expert pointed out, institutionalization will reduce family stress. b. The child has a right to an education in the least-restrictive setting. c. The child will eventually adapt to whatever choice the parents make. d. The choice of what to do is entirely the parents'.

ANS: B It is a given that it is the parents' choice. As an advocate for the child, the nurse can explain that children have a legal right to an appropriate public education based on the child's needs in the least-restrictive setting. This right is based on the Individuals with Disabilities Act (IDEA). DIF: Cognitive Level: Apply (Application)

1. Which person meets the legal definition of a veteran? a. A 32-year-old male who has been dishonorably discharged from the Army b. A 50-year-old female who retired from the Navy c. A 65-year-old male who served in the National Guard d. A 22-year-old female who is currently serving in the Air Force

ANS: B Legally, a veteran is an individual who has served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable. Any individual who completed service for any branch of armed forces is a veteran as long as they were not dishonorably discharged. Personnel serving in the National Guard are considered to be part-time employees and not active duty, full-time personnel. DIF: Cognitive Level: Understand (Comprehension)

10. Which best describes the prevalence of disabilities in U.S. children under age 15? a. About 5% b. About 10% c. About 15% d. About 20%

ANS: B More than 8% of U.S. children under the age of 15 have some kind of disability and about half of them were classified as having severe disabilities. DIF: Cognitive Level: Understand (Comprehension)

9. A veteran has recently been diagnosed with posttraumatic stress disorder (PTSD). Which information obtained from the client during a health history would align with this diagnosis? a. The client reports that he has a history of hypertension and hyperlipidemia. b. The client states that he served as a sniper during the Gulf War. c. The client states that he was stationed in Japan. d. The client reports that his wife has a substance abuse problem.

ANS: B PTSD is a mental illness that develops in some individuals who have experienced a shocking, frightening, or dangerous event. Factors that contribute to an individual developing PTSD include getting injured or seeing another person injured, viewing a dead body, feeling helpless, having little or no social support after a traumatic event, dealing with extra stress after the event (e.g., loss of a loved one, pain and injury), or having a history of mental illness or substance abuse. DIF: Cognitive Level: Apply (Application)

9. Which fact is noteworthy about adolescent males who are driving without a license in the countryside? a. Most had driver's education classes but have not yet earned the money to pay for their driver's license test. b. Most were Hispanic or black from a rural area. c. Most were practiced in driving large farm machinery and were just going from one section of the farm to another section. d. Most were practicing their driving skills with their parent in the car.

ANS: B Researchers studied the prevalence of unlicensed teenaged drivers compared with licensed drivers and found that they were more likely black or Hispanic and live in rural areas. There is not any research in the text that supports that the other responses are accurate. DIF: Cognitive Level: Understand (Comprehension)

4. A veteran is receiving veteran's health care benefits. Which department directly coordinates these benefits? a. Veterans Benefits Administration (VBA) b. Veterans Health Administration (VHA) c. U.S. Department of Veterans Affairs (VA) d. Civilian Health and Medical Program of the Department of Veteran's Affairs (CHAMPVA)

ANS: B The Department of Veterans Affairs has three subdivisions: the VHA, the Veterans Benefits Administration (VBA), and the National Cemetery Administration. The VHA provides all types of health care in every setting, including inpatient, outpatient, and long-term care. The VBA is an administrative arm responsible for unemployment and pension payments, home loans, vocational training, and educational benefits. The Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is a program in which the costs of some health care services for eligible civilian beneficiaries are covered by the VA. DIF: Cognitive Level: Apply (Application)

19. A nurse came limping into work with a huge cast on her right leg and asked to have an assignment for a week or two that did not require driving. The nurse said, "I never realized how difficult it is to get some places without two good legs. Now I know how persons with disabilities must feel!" Which would be the most appropriate response from the nursing supervisor? a. "I'm sure you'll be even more understanding and supportive now." b. "Not really; you'll be out of that cast in a few weeks." c. "What a great opportunity to attend some support groups for people with disabilities and share with us which ones are most helpful." d. "Why don't you just take some sick leave rather than try to work with that leg cast?"

ANS: B Those who have a temporary disability have a very different experience than those who are permanently disabled. Although they may experience frustrations, they view it as a temporary problem and a temporary setback. The other responses address this temporary disability as if it is similar to a permanent disability, which it clearly is not. DIF: Cognitive Level: Apply (Application)

2. Which are strategies the nurse should practice to provide effective care for persons with disabilities? (Select all that apply.) a. Apologize for slips of the tongue such as saying "Do you see?" to a blind person. b. Don't assume the client has a physical or cognitive deficit until you have validated it. c. Allocate additional time for care. d. Take hold of a blind person's arm to assist them in dangerous situations, such as crossing a busy street. e. Volunteer the most recent research findings related to the person's disability. f. Adopt the client's perspective as to what works best without bias.

ANS: B, C, F The acronym developed that spells ADVOCATE can help remind and guide the nurse of essential principles that are integral to the care of PWD. A—Advocate, D—Deficits, V—Vocation, O—Outcomes, C—Communicate, A—Assess, T—Transition, E—Empower. Effective strategies include not making assumptions about deficits before they have been validated; allocating additional time for care as necessary; adopting the client's perspective as to what works best without bias. Ineffective strategies include apologizing for errors, offering expert opinions or advise, and grabbing the arm of a person who is blind. DIF: Cognitive Level: Understand (Comprehension)

3. A veteran has been diagnosed with a mild traumatic brain injury (mTBI). Which symptoms would most likely be reported to the nurse? (Select all that apply.) a. Diarrhea b. Headaches c. Appetite loss d. Dizziness e. Increased thirst f. Memory problems

ANS: B, D, F Symptoms of mTBIs can include headaches, tinnitus, sleep disorders, irritability, memory problems, mood and anxiety disorders, suicidality, chronic pain, and dizziness or balance problems (Johnson et al., 2013). DIF: Cognitive Level: Apply (Application)

3. Which best describes how the Continuum of Care (CoC) concept determines the number of homeless? (Select all that apply.) a. By asking local police departments to visit areas where the homeless hide and report the number of people found there each March b. By conducting a point-in-time (PIT) homeless persons count every other January c. By making an educated guess based on anecdotal data d. By completing a statistical analysis of the Census Bureau data e. By reporting the number of homeless persons who use emergency shelters or transitional housing during the year f. By sending CoC personnel into the community to try to find hidden homeless

ANS: B, E CoCs are local systems responsible for providing a range of housing and related services that meet the U.S. Department of Housing and Urban Development guidelines for persons experiencing homelessness. CoCs conduct PIT counts of homeless persons on one night in January of every other year. In addition, CoCs are required to report the number of homeless persons who use emergency shelters or transitional housing throughout each federal fiscal year. DIF: Cognitive Level: Understand (Comprehension)

4. A veteran reports to the nurse that she believes that she may be suffering from PTSD. Which would the nurse anticipate the client experiencing during the past month? (Select all that apply.) a. Restless leg syndrome b. Difficulty sleeping c. Death of a parent d. Heightened awareness of her surroundings e. Negative feelings about oneself f. Avoiding communication with others from her troop

ANS: B, E, F To be diagnosed with PTSD, an individual must have experienced a "stressor criterion," which means that the person has been exposed to an event that is considered traumatic (Friedman, 2016). In addition, an adult must experience all of these symptoms for at least a month: at least one reexperiencing symptom (e.g., flashbacks, bad dreams, frightening thoughts); at least one avoidance symptom (e.g., staying away from places, events, or objects that are reminders of the experience; avoiding thoughts or feelings related to the event); at least two arousal and reactivity symptoms (e.g., being easily startled, feeling tense or on edge, difficulty sleeping, angry outbursts); at least two cognition and mood symptoms (e.g., trouble remembering key features of the event, negative thoughts about oneself or the world, distorted feelings of guilt or blame, loss of interest in enjoyable activities) (NIMH, 2017). DIF: Cognitive Level: Apply (Application)

2. Which best explains why there are so few hospitals in rural areas? a. Few nurses and physicians enjoy the rural lifestyle. b. Historically, hospitals began in large urban areas and have slowly expanded outward but have not yet reached all rural areas. c. Rural areas have very low population density. d. Rural residents do not trust hospitals, preferring to receive care from neighbors and friends.

ANS: C Although 75% of U.S. counties are classified as rural, they contain only 20% of the U.S. population. The population density is too low to support a large hospital. There are providers available to serve the population and residents are accepting of health care services, but not as many services are needed because of the lower population density. DIF: Cognitive Level: Remember (Knowledge)

6. Which best describes what happens when persons who work full-time and receive the typical minimum wage seek an apartment? a. Few clean and decent low-rent apartments exist. b. People do not like to rent to low-income persons. c. To afford housing, they need a job that pays at least three times minimum wage. d. There are not many trailer parks near their employment.

ANS: C An increasing number of low income people end up paying much more than they can afford for rent. Since 2007, the number of renters who pay more than half of their income for rent has increased dramatically. DIF: Cognitive Level: Understand (Comprehension)

22. Which best describes why some advocacy groups have taken a strong stand against physician-assisted suicide? a. Ethical belief that life is always preferable to death b. Emphasis that there is always hope for a research breakthrough or discovery of a new treatment intervention c. Fear that some persons may be "encouraged" to accept an early death merely because they are not valued by society for their contributions d. Helping someone die is murder, plain, and simple

ANS: C Because people have previously been killed because they had a disability, some advocacy groups, such as Not Dead Yet, have taken a strong stance against physician-assisted suicide, fearing it will lead to the early or forced death of people with disability. Ethical and personal beliefs and emphasizing the hope for a new treatment have not been stands taken by advocacy groups against physician-assisted suicide. DIF: Cognitive Level: Understand (Comprehension)

10. Which factors are most likely to contribute to homelessness? a. Intimate partner violence and substance abuse b. Scarcity of support systems and recent job loss c. Shortage of affordable housing and insufficient income d. Substance abuse and serious mental illness

ANS: C The text addresses three broad factors: (1) shortage of affordable housing, (2) insufficient income, and (3) scarcity of supportive services as societal conditions that contribute to homelessness rather than cause homelessness. Intimate partner violence, substance abuse, and serious mental illness are not identified as the broad factor contributing to homelessness. DIF: Cognitive Level: Understand (Comprehension)

1. Which is an accurate definition of impairment? a. A disadvantage resulting from a disability that prevents fulfillment of an expected role b. A restriction or inability to perform an activity in a normal manner c. A problem in body function or structure d. A defect that affects society on a macro level

ANS: C Disability is an umbrella term describing impairments, activity limitations, and participation restrictions. An impairment is a problem in bodily function or structure. A handicap is a disadvantage resulting from an impairment or disability that prevents fulfillment of an expected role. In a comparison of these concepts, an impairment affects a human organ on a micro level; disability affects a person on an individual level; and a handicap involves society on a macro level of analysis. DIF: Cognitive Level: Remember (Knowledge)

18. Which statement best describes how working on a farm is different from working in a factory? a. Factories have more dangerous dust than farming dust. b. Farm chemicals are more immediately fatal than most industrial chemicals. c. The worksite and the home are the same. d. Workers on farms, unlike those in factories, can bring dangerous substances home on their clothing, which expose their families.

ANS: C Farming is unusual because the home and the worksite are the same. Several types of farming activities are associated with higher-than-expected occurrences of acute and chronic respiratory conditions. Individuals with long-term exposure to grain dusts, such as grain elevator workers and dairy workers, have diminished respiratory function and increased frequency of respiratory symptoms. Occupational asthma and more exotic fungal or toxic gas-related conditions occur in higher frequency in agricultural than nonagricultural populations. Exposure risks to children and spouses may be heightened when farmers wear contaminated clothing and boots into the home, but the same can happen in several industries. DIF: Cognitive Level: Understand (Comprehension)

13. Which person will have the most difficulty in obtaining adequate support services to find a long-term home? a. An alcoholic homeless person b. A homeless person who has a limited support system and is unemployed c. A homeless person who has a mental illness and is an alcoholic d. A mentally ill homeless person

ANS: C For a sizable proportion of the homeless, severe mental illness exists along with the problems of alcohol or other types of substance use. Like physical health problems, serious mental illnesses and minor emotional problems occur more frequently among the homeless population than in the general population. High rates of alcohol and drug use exacerbate the existing acute and chronic physical and mental health problems. These coexisting problems can make it harder to assist the homeless person. DIF: Cognitive Level: Apply (Application)

16. A school nurse was asked to see Lisa, a student in the fourth grade who was rumored to be living in a car with her mother. Which would most likely have caused the teacher to become concerned? a. Lisa is not always respectful of the teacher. b. Lisa has not been doing her homework. c. Lisa is developmentally delayed. d. Lisa has behaved in a sexually inappropriate manner.

ANS: C Homeless children experience STDs, physical and sexual abuse, skin disorders, anemia, drug and alcohol abuse, and unintentional injuries at higher rates than children in the general population. All children are not always respectful and do not always have their homework done and may act out behaviors seen on television. DIF: Cognitive Level: Apply (Application)

19. Which best describes the purpose of the Vulnerability Index? a. To identify those most at risk of becoming homeless b. To determine the underlying cause of homelessness among vulnerable populations c. To identify and prioritize the need for housing among the homeless d. To determine what resources should be provided for vulnerable populations

ANS: C Homeless service providers, concerned about the high risk for mortality among "street" homeless population constructed the Vulnerability Index, a screening tool for identifying and prioritizing the need for housing. DIF: Cognitive Level: Understand (Comprehension)

17. The male home health nurse parked his marked car in preparation for visiting the next client when a young female walked over to the car and asked him if he would like to have some fun. Which provides the best explanation for this behavior? a. The girl was skipping school and wanted money for entertainment. b. The male nurse was extremely young and attractive and looked like he had money. c. The girl may have hoped a nurse would give her enough money to eat. d. Young girls often engage in thrilling, if high-risk, behaviors.

ANS: C Homeless youth experience sexually transmitted diseases, physical and sexual abuse, skin disorders, anemia, drug and alcohol abuse, and unintentional injuries at higher rates than in the general population. Depression, suicidal ideation, and disorders of behavior, personality, or thought also occur at higher rates among homeless. Family disruption, school failures, prostitution or "survival sex," and involvement with the legal system indicate that homeless social health is severely compromised. Thus, it is most likely that the girl is hoping that the nurse would provide her enough money to eat. DIF: Cognitive Level: Apply (Application)

7. A veteran tells the nurse that he hates the VA health insurance program and wishes that he would be allowed to see the local doctor instead of traveling to the VA clinic. Which statement would be most appropriate to be made by the nurse? a. "I will check to see if your local doctor can be added to the list of approved providers." b. "Yes, you pay premiums for this health insurance and should be able to have a choose what providers you see." c. "The VA does not provide health insurance, rather this is a benefit that you receive for compensation for your service to our country." d. "The VA provides different benefit plans. Let me see if the local doctor is a provider on a different benefit plan."

ANS: C Many veterans do not realize that their care at their VA hospitals and clinics is not a type of health insurance. Instead, it is a benefit that they receive in compensation for their duty and service to the country. The difference between health insurance and VA health benefits is twofold. First, veterans do not have to "pay into" their VA benefits the way one would pay premiums for a health insurance plan. Second, the "coverage" received in the form of VA benefits is not transferable to other non-VA providers, except through formal contracts deemed appropriate by the VA and its providers. DIF: Cognitive Level: Apply (Application)

3. On the basis of all the work done by social scientists, approximately how many homeless persons should be expected and tolerated in our society? a. No more than 5% b. No more than 10% c. No more than 15% d. There should not be homeless persons in America.

ANS: D Kozol (1988) argued: "We would be wise to avoid the numbers game. Any search for the 'right number' carries the assumption that we may at last arrived at an acceptable number. There is no acceptable number. Whether the number is 1 million or 4 million, there are too many homeless people in America." DIF: Cognitive Level: Remember (Knowledge)

21. Which statement best reflects the model of justice U.S. health care is based on? a. All people are entitled to minimum standards of care. b. All people are responsible to help their neighbors. c. All people have a right to whatever their own efforts allow them to purchase. d. Like firefighting, police protection, libraries, and roads and highways, health care must be supported by tax money for the good of all who need such services.

ANS: C Market justice has been the dominant model and purports that people are entitled to valued ends (i.e., status, income, and happiness) according to their own individual efforts. Moreover, this model stresses individual responsibility, minimal collective action, and freedom from collective obligations other than respect for another person's fundamental rights. In contrast, under a social justice model, all people are equally entitled to key ends (i.e., access to health care and minimum standards of income). Consequently, all members of society must accept collective burdens to provide a fair distribution of these ends. DIF: Cognitive Level: Understand (Comprehension)

14. Which best describes a major difference between women who have always had shelter and women who have been homeless? a. Educational opportunities and attainment b. History of gender relationships (marriages, divorces) c. Level of involvement with physical and/or sexual abuse d. Skills necessary for paid employment

ANS: C Research has revealed the extraordinary histories involving substance abuse, criminal activity, serious mental health concerns, marital dissolution, escape from intimate partner violence, housing accidents, limited employment options or job loss, and poor physical health that prevented gainful employment, among women experiencing homelessness. High numbers of homeless women report histories of foster placement as children and exposure to violence as both children and adults. This research has not documented the differences in educational opportunities, gender relationships, and skills necessary for paid employment. DIF: Cognitive Level: Understand (Comprehension)

10. Which is particularly prevalent in rural areas (more so than in urban areas) of the South? a. Falls and motor vehicle accidents b. Less use of seatbelts and more drinking of alcohol c. Obesity and sedentary lifestyle d. Suicide and homicide

ANS: C Rural residents in the southern states are more likely to be obese, smoke more heavily if they do smoke, use smokeless tobacco, and engage in sedentary lifestyles. Rates of motor vehicle accidents and suicide are higher in rural areas, although not necessarily the South. Additionally, there is a decreased use of seatbelts and increased use of alcohol in rural areas; however, the textbook mentions that these rates are higher in the rural West than in the rural South. The rates of falls and homicide are not addressed in the textbook. DIF: Cognitive Level: Remember (Knowledge)

20. A mother has recently learned that her infant has been diagnosed with spina bifida. Which nutrient was lacking during gestation? a. Calcium b. Vitamin K c. Folic acid d. Vitamin D

ANS: C SB occurs when there is failure of the neural tube to close during the 28 day of gestation. SB is associated with deficits in motor, sensory, and physical differences that may be largely prevented with proper folic acid intake during gestation. Adequate folic acid supplementation is important for prevention of neural tube development. DIF: Cognitive Level: Apply (Application)

8. Which group of people is most likely to experience homelessness? a. Those who have a supportive family b. Those who have recently become unemployed c. Those who have substance abuse problems d. Those who frequently change jobs

ANS: C Some people experiencing homelessness have individual characteristics that, in interaction with the structural conditions of a shortage of affordable housing and insufficient income, perpetuate their homeless conditions. Supportive services for these people are deficient in quality and quantity. Some people need services to work and earn money. They are able to function in the workforce, whereas others need services to maintain their housing status. Included in this latter group are people whose serious chronic mental health and/or substance abuse problems preclude their functioning in the workforce and whose behaviors interfere frequently with their ability to obtain housing stability. People in this group need income assistance and comprehensive and accessible behavioral and physical health care. DIF: Cognitive Level: Apply (Application)

1. A family will most likely lose their primary nighttime residence within the next week. Which term best describes their situation in relation to homelessness? a. Homeless under other federal statutes b. Literally homeless c. Imminent risk of homelessness d. Fleeing/attempting to flee intimate partner violence

ANS: C The U.S. Department of Housing and Urban Development has issued regulations that summarized the statutory definitions in four descriptive categories. These four categories with their respective definitions include: Literally homeless: Individuals and families who lack a fixed, regular, and adequate nighttime residence, including a subset for individuals who resided in an emergency shelter or a place not meant for human habitation and who are exiting an institution where he or she temporarily resided; Imminent risk of homeless: Individuals and families who will imminently lose their primary nighttime residence; Homeless under other federal statutes: Unaccompanied youth and families with children and youth who are defined as homeless under other federal statutes who do not otherwise qualify as homeless under this definition; and Fleeing/attempting to flee DV: Individuals and families who are fleeing or are attempting to flee, DV, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member. DIF: Cognitive Level: Remember (Knowledge)

11. A nurse is caring for a veteran who has suffered a polytraumatic injury. Which would be the primary consideration for the nurse when working with this client? a. Use of an assistive device for ambulation may be necessary. b. Diagnosis of posttraumatic stress disorder will be likely. c. Physical and cognitive abilities to complete ADLs independently may be lacking. d. A psychiatric referral will be needed.

ANS: C The term polytrauma refers to two or more injuries sustained in the same incident, affecting multiple body parts or organ systems, and resulting in various kinds of impairments and functional disabilities. Polytrauma is often the result of a blast-related event, and frequently includes TBI. For example, a soldier who has lost a limb, suffered a TBI, and lost his eyesight from a rocket-propelled grenade attack is said to have a polytraumatic injury. Care for veterans with these injuries is especially complicated because of the presence of several overlapping physical and cognitive impairments affecting their ability to perform ADLs. The primary consideration would relate to the client's impairments in completing ADLs. DIF: Cognitive Level: Analyze (Analysis)

7. Which factor would prevent a homeless person from accepting employment adequate to pay for housing? a. Could not complete an employment application because of lack of mailing address b. Hope for a better position than the service positions available c. Lack of adequate resources to pay for other necessities d. Prefer to receive a handout than to have to work

ANS: C There are homeless people who are able to function in the workforce. The lack of affordable housing in combination with insufficient income results in people having to spend much of their income on rent and leaves them without adequate resources for other necessities, such as food, clothing, and health care. This situation substantially increases their risk for homelessness. DIF: Cognitive Level: Remember (Knowledge)

17. A veteran is receiving treatment for posttraumatic stress disorder (PTSD). As part of the therapy, the veteran identifies negative thoughts and emotions while focusing on specific sounds and movements. Which trauma-focused therapy is the client receiving? a. Cognitive processing therapy b. Prolonged exposure therapy c. Eye movement desensitization and reprocessing d. Cognitive behavioral therapy

ANS: C There are variations of trauma-focused therapies. These include (1) prolonged exposure therapy (where the individual is repeatedly questioned by the therapist about the trauma to encourage control of the thoughts and feelings to reduce fear of the memories); (2) cognitive processing therapy, which involves talking with the therapist about the negative thoughts and beliefs and development of strategies to manage the recollection of the trauma in a way that is less upsetting; and (3) eye movement desensitization and reprocessing, which involves identification of the negative thoughts, emotions, and feelings while focusing on specific sounds or movements, helping the brain work through the traumatic memories. Friedman noted that the most successful interventions include cognitive-behavioral therapy and medication (e.g., selective serotonin reuptake inhibitors such as sertraline [Zoloft] and paroxetine [Paxil]). DIF: Cognitive Level: Apply (Application)

12. Which group is the fastest-growing component of the rural population? a. Disabled adults b. Elderly women c. Hispanic children d. Retirees

ANS: C Today, the proportion of Hispanic children is the fastest-growing component of the rural population, regardless of region. DIF: Cognitive Level: Remember (Knowledge)

2. Which strategies have been used to improve the collection of prevalence data for the homeless population? (Select all that apply.) a. Urban Institute study b. Homeless Assistance Report c. Continuum of Care (CoC) concept d. Homeless Information Management System (HMIS) e. Census Bureau f. Education for Homeless Children and Youth program

ANS: C, D Two strategies used by the U.S. Department of Housing and Urban Development in the efforts to strengthen the nation's efforts to reduce homelessness, including improvement in collecting prevalence data, are the CoC concept and the HMIS. The Census Bureau and Urban Institute study were historically used to collect data on the homeless population. Data collection improvements have been made since these studies were completed. The Department of Education uses the Education for Homeless Children and Youth program to collect data on homeless youth. DIF: Cognitive Level: Remember (Knowledge)

5. Which statements about veteran suicide are accurate? (Select all that apply.) a. Veteran suicides most likely occur from prescription drug overdose. b. An average of 50 veterans each day die by suicide. c. The suicide rate of veterans is higher than that of the general population. d. The majority of veterans who die from suicide are age 50 or older. e. The age group that has the highest suicide rate among female veterans is age 18 to 29 years old. f. The age group that has the highest suicide rate among male veterans is age over age 50.

ANS: C, D, E Among male veterans, suicide rates were highest in the 18 to 29 and 75 and older age groups, whereas suicide rates for females were highest in the 18 to 29 age group. An average of 20 veterans died by suicide each day. Veterans accounted for 18% of all deaths by suicide among U.S. adults although veterans only account for 8.5% of the U.S. population. Risk for suicide was 21% higher among veterans compared with U.S. civilian adults after adjusting for differences in age and gender. Approximately 67% of all veteran suicides resulted from firearm injuries. Approximately 65% of all veterans who died by suicide were age 50 or older. DIF: Cognitive Level: Understand (Comprehension)

4. Which disorders are experienced at a higher rate by homeless adults when compared with the general population? (Select all that apply.) a. Hepatitis b. Diabetes c. Asthma d. HIV/AIDS e. Hypertension f. Alcoholism

ANS: C, E, F Chronic disorders experienced at higher rates than in the general population include hypertension; musculoskeletal disorder; gastrointestinal problems; respiratory problems (asthma, chronic bronchitis, emphysema); neurological disorders, including seizures; and poor dentition. Like physical health problems, serious mental illnesses and minor emotional problems occur more frequently among the homeless population than in the general population. High rates of alcohol and drug use exacerbate the existing acute and chronic physical and mental health problems. The rates of hepatitis, diabetes, and HIV/AIDS are not seen at a higher rate among the homeless adult population. DIF: Cognitive Level: Understand (Comprehension)

12. Which describes the most important need of every school-aged child with a disability? a. A teacher who understands the child's needs b. An advocate within the school system c. An assessment with comparison with developmental milestones d. An individualized education plan (IEP)

ANS: D A child should have all of the above items, an advocate in the school nurse, a teacher who understands, an assessment including comparison with developmental milestones, as all of these are components of an IEP with goals, cooperatively developed with the parents, to help the child succeed in school. The IEP describes the goals, as well as any special support needed to help achieve them. The IEP is the most comprehensive answer. DIF: Cognitive Level: Understand (Comprehension)

4. Which represents the largest group of homeless adults? a. Minorities b. Disabled c. Females d. Males

ANS: D Among all sheltered homeless adults in 2015, approximately 62.1% were men; 37.9% were women. The sheltered homeless population is younger than the general population. Most homeless adults were between 31 and 50 years of age; 22.3% were less than 18 years of age; and 4% were older than 62. In the general population, 18% were over age of 62. Minorities comprised 61.9% of the total sheltered population. Adults with disabilities were over three times more likely to be experiencing sheltered homelessness than adults without disabilities. DIF: Cognitive Level: Remember (Knowledge)

6. A client reports hearing loss and tinnitus following military duty in the Gulf War. Which term would best describe this client's injury? a. Posttraumatic stress disorder b. Polytrauma c. Traumatic brain injury d. Service-connected disability

ANS: D A service-connected disability is a disease or injury that was incurred as a result of or during the veteran's active duty, or one that was aggravated by military service. Posttraumatic stress disorder is a mental illness that develops in some individuals who have experienced a shocking, frightening, or dangerous event. A traumatic brain injury is a disruption of brain function caused by an external mechanical force, including blunt force trauma, penetration by a foreign object, acceleration or deceleration movements, and pressure waves from explosive blasts. The term polytrauma refers to two or more injuries sustained in the same incident, affecting multiple body parts or organ systems, and resulting in various kinds of impairments and functional disabilities. Polytrauma is often the result of a blast-related event and frequently includes TBI. DIF: Cognitive Level: Apply (Application)

23. Which best describes a proposed strategy to address the lack of health care professionals in rural communities? a. Advertise that there are more men than women in many rural areas to attract female nurses who want to be wives and mothers b. Offer free housing and office space to a professional who will come to live in the community c. Pay extremely high salaries to professionals willing to relocate d. Support local students obtaining an education while continuing to live at home

ANS: D A solution proposed for the shortage of health care providers is for rural communities to "grow their own." A rural community, a group of small communities, or a county could support local students attending college and recruit students currently attending professional schools. The students make a commitment to work in the community in return for monetary support for their educations. DIF: Cognitive Level: Understand (Comprehension)

18. Which best describes the role of the suicide prevention coordinator (SPC) at the VHA center? a. Serve as a hotline responder for the National Veterans Crisis Line b. Create a suicide prevention safety plan for the client c. Provide counseling for suicidal veterans d. Assist veterans to access timely mental health care

ANS: D A suicide prevention coordinator (SPC) works at every VHA center. The SPC's primary role is to help veterans access timely mental health care, particularly in times of crises, and to assist health care treatment teams with managing the care of suicidal veterans. SPC's maintain weekly contact with the veteran and ensure that the veteran's treatment team works with him or her to develop a suicide prevention safety plan that helps the veteran cope with suicidal ideation. The National Veterans Crisis Line provides veterans with immediate access to mental health crisis intervention and support 24 hours a day/7 days a week. Hotline responders are not SPC's, instead they are trained in suicide prevention and crisis intervention and assist callers by initiating dispatch of emergency services to callers in imminent suicidal crisis and refer veterans to VA suicide prevention coordinators to ensure that veterans are connected to local mental health care. DIF: Cognitive Level: Understand (Comprehension)

17. Which is the most frequent cause of farm fatalities and nonfatal injuries? a. Manure pits (methane poison) b. Power take-off augers c. Storage silos d. Tractors e. Very old and barely functioning trucks

ANS: D Agricultural machinery is the most common cause of fatalities and nonfatal injuries of U.S. agricultural workers, including on-farm fatalities among youth under 20 years of age (CDC, NIOSH Program, 2012). Tractors contributed to 12% of the deaths. Fatalities on farms were 20.2 per 100,000 workers in 2012, with tractor overturns being the leading cause of death. DIF: Cognitive Level: Remember (Knowledge)

24. A nurse is using an upstream intervention when working with the homeless population. Which public health intervention will the nurse most likely use? a. Case management b. Outreach c. Surveillance d. Community organizing

ANS: D Although nurses may use all interventions at all three levels, community/public health nurses working more upstream, at the system level, employ collaboration, coalition building, community organizing, advocacy, social marketing, and policy development and enforcement. In contrast, community/public health nurses—working downstream with individuals, families, or groups—use surveillance, disease and other health event investigation, outreach, screening, case finding referral and follow-up, case management, delegated functions, health teaching, counseling, and consultation. DIF: Cognitive Level: Apply (Application) MULTIPLE RESPONSE

1. Which best describes the recent population trend in rural America? a. The number of residents in rural areas of the United States is at one of its lowest levels ever recorded. b. Urban population rates increased from 2010 to 2015 as agricultural opportunities diminished. c. Nonmetro population rates have been steadily increasing because of increasing job growth. d. Population growth or loss in rural areas varies widely depending on available economic opportunities.

ANS: D Although the urban growth rate has been steadily climbing since 1890, with numbers of urban dwellers surpassing those in rural areas around 1920, the number of rural residents is the highest in the country's history (U.S. Department of Agriculture [USDA], 2016). In 2010 to 2015 population loss in nonmetro areas occurred in the United States as a whole. In 2014 nonmetro populations stabilized after 4 years of decline, likely related to improved rural employment growth (USDA, 2016). Opportunities for population growth and economic expansion vary widely from one nonmetro county to the next, and new regional patterns of growth and decline have emerged in recent years. DIF: Cognitive Level: Understand (Comprehension)

5. Which best describes the problem with the Section 8 housing program? a. Direct access to an apartment in a public housing facility is faster and easier. b. Most renters prefer the program to make direct payment to apartment owners willing to rent to them. c. Section 8 housing is essentially slum housing, and no one wants to live there. d. Supply is vastly less than the demand.

ANS: D Although these programs are intended to alleviate housing problems for low-income renters, the demand for these assisted housing programs has far exceeded the supply. Section 8 housing does not provide direct access to an apartment in a public housing facility or provide payment directly from the program to apartment owners. Section 8 housing provides affordable housing through the U.S. Department of Housing and Urban Development and is not slum housing. DIF: Cognitive Level: Understand (Comprehension)

12. Which individual would be described as being "doubled up"? a. An individual who has two chronic conditions b. An individual who has recently been released from prison c. An individual who maintains two jobs to avoid being homeless d. An individual who is forced to live with friends

ANS: D An individual may be considered to be homeless if that person is "doubled up," a term that refers to a situation where individuals are unable to maintain their housing situation and are forced to stay with a series of friends and/or extended family members. The other responses do not accurately describe being "doubled up." DIF: Cognitive Level: Apply (Application)

4. Which factor would cause a geographic area to be called a frontier area? a. Arbitrary distinction recognizing the Great Plains, Intermountain areas, and Alaska b. Geographically located in the West, specifically the Great Plains states c. High death rate from use of guns (homicide or suicide) d. Population of fewer than six persons per square mile

ANS: D Areas are classified as rural for populations with fewer than 45 persons per square mile and as frontier for geographic areas with fewer than six people per square mile. Many counties of the Great Plains, Intermountain West, and Alaska are designated frontier. Not all mountain areas are rural (the Appalachian mountain area is not), and geographic location alone does not make an area rural. DIF: Cognitive Level: Understand (Comprehension)

23. Which best describes a downstream intervention to solve the problem of homelessness? a. Improved use of community resources b. Increased employment opportunities c. Increased affordable housing d. Improved treatment of mental illness

ANS: D Building on McKinlay's "river" metaphor, McKinlay and Marceau (2000) purport that government and private efforts to address homeless health care problems largely focus on "pulling the bodies out of the river of homelessness." Such downstream interventions aimed at treating or alleviating health care problems, such as physical disease and mental illnesses, are worthy and needed. However, these interventions when used alone are far less adequate in alleviating homeless people's social health problems. To improve the social health of the homeless, it is necessary to go upstream and focus on the primary contributors to homelessness itself (i.e., lack of affordable housing, inadequate income, and insufficient services). DIF: Cognitive Level: Apply (Application)

20. Which are the most frequent problems suffered by the chronically homeless? a. Chronic conditions such as hypertension, bronchitis, and emphysema b. HIV/AIDS and other sexually transmitted diseases, tuberculosis, and hepatitis C c. Respiratory infections, trauma, and skin disorders d. Severe mental illness and substance abuse disorders

ANS: D Chronically homeless people may well have many physical conditions, but the primary problems that lead to their homelessness are severe mental illness and substance use disorders. DIF: Cognitive Level: Remember (Knowledge)

20. A nurse is explaining why migrant farmworkers experience cultural barriers when trying to receive care. Which would the nurse include in this explanation? a. "As illegal immigrants, they are not eligible for tax-paid health care." b. "Families who travel in isolation seeking agricultural work do not mix with their employers or other members of the community." c. "Mexicans who speak primarily Spanish and cannot understand English." d. "Usually perceived as outsiders, they are from many countries and cultures."

ANS: D Cultural, linguistic, economic, and mobility barriers all contribute to the nature and magnitude of health problems observed in farmworkers. Cultural and linguistic barriers are the most overt because many of the communities where farmworkers work consider them outsiders. A common misconception among U.S. health care providers is that these farmworkers are from Mexico, with Spanish as their primary language. Farmworkers originate from many communities in Mexico, the Caribbean, and Central and South America, and they may speak English, the language of their home country, or several languages. DIF: Cognitive Level: Apply (Application)

9. Which best describes the proportion of the U.S. population that is made up of persons with a long-lasting condition or disability? a. The number is about 5% and increasing. b. The number is about 10% and stable. c. The proportion is about 15% and stable. d. The proportion is almost 20% and increasing.

ANS: D In 2012, approximately 18.7 of those aged 5 years and older had a long-lasting condition or disability. As acquired age-related conditions occur during the lifespan, disability prevalence and disability severity levels rise with aging. In the United States, there is a shifting demographic of individuals living beyond the age of 65. Further, it is important for health care policy makers and health care providers to recognize that the prevalence of disability is increasing. DIF: Cognitive Level: Remember (Knowledge)

9. Which best describes how health care professionals are involved in the problem of homelessness? a. Homeless persons make everyone uncomfortable when they beg for handouts. b. Homeless persons often live in emergency departments and clinics. c. Poverty leads to crimes, and health care professionals can be attacked and robbed outside health care facilities. d. Serious illnesses or disability creates high medical bills, which may lead to homelessness.

ANS: D In 2013, of households with an annual income less than $25,000, 21.6% had no health insurance. Lack of health insurance is a significant factor in creating homelessness. A serious illness or disability can lead to a downward spiral as a result of job loss, use of savings to pay for care, and inability to pay rent. DIF: Cognitive Level: Analyze (Analysis)

15. A public health nurse is working in a rural clinic. On the basis of risk, which would be the priority group for care? a. African American adults b. Adolescents c. Elderly women who live alone d. Migrant and seasonal farmworkers (MSFW)

ANS: D In general, MSFW may have the poorest health of any aggregate in the United States, and the least access to affordable health care. Eighty-five percent of the MSFW are Hispanic, Latino, or African American. DIF: Cognitive Level: Apply (Application)

14. Which employment opportunities are among the most dangerous? a. Food processing, textiles, and transportation b. Highway construction, ranching, and public utilities c. Large mechanized factory positions d. Mining, forestry, and fishing

ANS: D Industries with the highest death rates were mining, agriculture, forestry, and fishing, followed by construction, transportation, and public utilities. DIF: Cognitive Level: Remember (Knowledge)

10. Which statement about military sexual trauma (MST) is accurate? a. MST is more common among male veterans. b. The majority of women who report MST state the perpetrator was an intimate partner. c. An Army veteran is at greatest risk to report MST. d. Insomnia is more severe among veterans who report a history of MST.

ANS: D MST is more common among women veterans, with 32.4% reporting MST compared with 4.6% of their male counterparts (Klingensmith et al, 2014). It is estimated that in one of seven women who report MST, the trauma was perpetrated by an intimate partner (Mercado et al, 2015). Insomnia is more common and more severe among veterans who report a history of MST (Jenkins et al, 2015). One of the risk factors/characteristics of veterans experiencing MST is being a Navy veteran, not Army. DIF: Cognitive Level: Understand (Comprehension)

8. A young woman rolled her wheelchair up the ramp into the clinic to the desk where the intake nurse greeted her. Which should be the nurse's first response? a. "How can I help you?" b. "Who came with you today?" c. Compliment her on her skill with the wheelchair d. Sit so the nurse is at wheelchair level with the young woman

ANS: D Nurses who demonstrate understanding of the issues confronting people with disabilities should approach them at wheelchair level, listening to understand. Moving to wheelchair level should be the first action that the nurse takes before beginning a conversation with the client. DIF: Cognitive Level: Apply (Application)

19. A veteran has received special training to provide recovery-oriented support to other veterans within the VHA health system. Which role will the veteran most likely fulfill? a. Peer counselor b. Suicide hotline responder c. Suicide prevention coordinator d. Peer support specialist

ANS: D Peer support specialists are veterans who have been trained to provide recovery-oriented support and outreach that encourages other veterans to utilize VHA health services, particularly mental health, to assist with their recovery. The suicide prevention coordinator's primary role is to help veterans access timely mental health care, particularly in times of crises, and to assist health care treatment teams with managing the care of suicidal veterans. Hotline responders are trained in suicide prevention and crisis intervention and assist callers by initiating dispatch of emergency services to callers in imminent suicidal crisis and refer veterans to VA suicide prevention coordinators to ensure that veterans are connected to local mental health care. DIF: Cognitive Level: Apply (Application)

8. Which would be true for a county to be defined as having persistent poverty? a. Being in poverty over the last 10 years b. Being in poverty over the last 20 years c. Being in poverty over the last 25 years d. Being in poverty over the last 30 years

ANS: D Persistent poverty is defined as counties where the population has been in poverty over the last 30 years. DIF: Cognitive Level: Remember (Knowledge)

3. From which causes are rural residents twice as likely to die from in comparison with urban residents? a. Chronic diseases, especially cardiac problems and cancers b. Diabetes from the higher incidence of obesity c. Respiratory diseases (from pesticides and herbicides) d. Unintentional injuries

ANS: D Residents of rural areas are nearly twice as likely to die of unintentional injuries, including motor vehicle accidents, when compared with their urban counterparts. The rates of chronic diseases, diabetes, and respiratory diseases are more similar to that of urban residents. DIF: Cognitive Level: Remember (Knowledge)

17. Which statement about Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) is correct? a. SSI is funded through disability trust fund monies. b. To qualify for SSDI, the person with disabilities must have limited income and resources. c. SSDI recipients receive Medicaid health benefits. d. Persons with disabilities who receive SSI may receive a state supplement.

ANS: D SSI is funded through general tax revenues, whereas SSDI is funded through disability trust fund monies (Social Security taxes paid by workers, employers, and self-employed workers). To qualify for SSDI, the person with disabilities must be "insured" through Federal Insurance Contributions Act (FICA) earnings of self, parents, and/or spouse, and to qualify for SSI, the person with disabilities must have limited income and resources. SSDI recipients receive Medicare health benefits, and SSI recipients receive Medicaid health benefits. Some states may elect to pay a state supplement to some persons with disabilities in SSI programs, whereas in SSDI programs persons with disabilities are never provided with state supplements. DIF: Cognitive Level: Understand (Comprehension)

6. A nurse is completing an assessment of a client who states that his chronic obstructive pulmonary disease (COPD) has worsened, and he is no longer able to do his own grocery shopping. Which stage of the NADP model is the client experiencing? a. Pathology b. Impairment c. Functional limitation d. Disability

ANS: D The NAPD model provides an alternative framework for viewing four related and distinct stages in the disabling process. Pathology at the cellular and tissue levels may produce impairment in structure or function at the organ level. An individual with an impairment may experience a functional limitation, which restricts their ability to perform an action within the normal range. The functional limitation may result in a disability when certain socially defined activities and roles cannot be performed. Although the model appears to indicate unidirectional progression from pathology to impairment, to functional limitation, to disability, stepwise or linear progression may not occur. Disability prevention efforts can limit or reduce many of the risk factors or stages in the disabling process. DIF: Cognitive Level: Apply (Application)

2. Which is the largest branch of the U.S. military? a. Navy b. Marine Corps c. Coast Guard d. Army

ANS: D The U.S. Army is the largest branch of the military, making up 39% of all military personnel. Other branches of the service include the Air Force, the Navy, the Marine Corps, and the Coast Guard. DIF: Cognitive Level: Remember (Knowledge)

2. Which best describes the recent trends in homelessness? a. The number of homeless individuals in school is decreasing. b. The number of homeless individuals is increasing. c. The number of homeless families is increasing. d. The number of homeless families is decreasing.

ANS: D The U.S. Department of Housing and Urban Development reported the following numbers of people in the total population and subpopulations who used shelters or transitional housing between October 1, 2015 and September 30, 2016: 355,212 individuals, a decrease of less than 1% between 2015 and 2016; 194,716 people in families with children, a decrease of 5% between 2015 and 2016. DIF: Cognitive Level: Understand (Comprehension)

7. A young man rolled his wheelchair up the ramp into the clinic to the desk where the intake nurse greeted him. After welcoming him to the clinic, which should be the initial question asked by the nurse? a. "Are you a vet home from the war?" b. "Can I help you into the treatment room to see the nurse practitioner?" c. "Do you have any family with you to help today?" d. "What brings you to the clinic today?"

ANS: D The client should be asked what is needed just as any other client would be. A veteran would more probably be at a Veterans Affairs (VA) clinic, and there is nothing in the statement to imply that the clinic is part of the VA medical system. Because the man made it into the clinic, it is doubtful he would need help into the treatment room. Not all persons live with families. The handicap may be unrelated to why he is at the clinic. He may be ill or merely need immunization or other health promotion activity. DIF: Cognitive Level: Analyze (Analysis)

8. A veteran has been diagnosed with an immersion foot injury. Which finding should the nurse anticipate when completing an assessment on the client? a. A foot that is deformed b. A foot that is unable to tolerate immersion in water c. A foot that the client is unable to bear weight on d. A foot that has occasional numbness

ANS: D The major cold injuries veterans suffer include frostbite, nonfreezing cold tissue damage, immersion foot (formerly called trench foot), and hypothermia. Cold injuries may result in long-term health problems, including the following signs and symptoms (at the site of exposure): changes in muscle, skin, nails, ligaments, and bones; skin cancer in frostbite scars; neurological injury with symptoms such as bouts of pain in the extremities, hot or cold tingling sensations, and numbness; vascular injury with Raynaud phenomenon with symptoms such as extremities becoming painful and white or discolored when cold. DIF: Cognitive Level: Apply (Application)

15. Which veteran is most likely to experience homelessness? a. A 40-year-old single female b. A recently divorced 25-year-old male c. A recently divorced 30-year-old female d. A 35-year-old single male

ANS: D The majority of homeless veterans are single males between the ages of 31 and 50. Only 9% of homeless veterans are females. Marital status is not reported as one of the risk factors that relate to incidence of homelessness. DIF: Cognitive Level: Understand (Comprehension)

11. A nurse is caring for an individual with disabilities. Which would put this client at risk for the fatal four? a. A history of falls b. Immobility c. Anorexia d. A history of constipation

ANS: D The term fatal four refers to four common medical conditions that could result in complications and fatality more frequently for the IDD population and other PWD. Nurses and primary care providers should be knowledgeable about the fatal four, which includes (1) constipation/bowel obstruction, (2) aspiration/gastroesophageal reflux disease (GERD), (3) dehydration, and (4) seizures, as complications related to these conditions could result in death if not assessed, diagnosed, and treated swiftly (Smith and Escude, 2015). The etiology of the fatal four includes polypharmacy, improper positioning, obesity, and dysphagia. DIF: Cognitive Level: Apply (Application)

16. Which problem was the Ticket to Work and Work Incentives Improvement Act (TWWIIA) designed to address? a. Employers trying to avoid hiring persons with disabilities b. Employers resenting being forced to hire persons with disabilities c. Persons with disabilities not being able to receive on-the-job training d. Persons with disabilities not seeking employment for fear of losing their health care and other governmental supports

ANS: D Typically, people with disabilities could qualify for such benefits as health care, income assistance programs, and personal care attendant services only if they chose not to work. To address employment and benefit issues for persons with disabilities, in December 1999, the TWWIIA was signed into law. The TWWIIA reduced people with disabilities' disincentives to work by increasing access to vocational services and provided new methods for retaining health insurance after returning to work. DIF: Cognitive Level: Understand (Comprehension)

15. Which factor is the primary motivator for young (homeless) women engaging in survival sex? a. Peer influence b. Pursuit of drugs c. Coercion by perpetrators d. Desperation to meet basic needs

ANS: D Young (homeless) women involved in survival sex (participating in sexual acts in exchange for money, food, lodging, clothing, or drugs) are motivated primarily by desperation to meet basic needs, including a place to stay, food, and money, and one third mentioned that peers commonly were influential in decisions to engage in survival sex. Others were influenced by coercion (10%) or pursuit of drugs (10%) (Warf et al., 2013). DIF: Cognitive Level: Remember (Knowledge)