Final Exam Evolve Questions

39.6. Changes in the health care system and nursing have occurred in the past few decades because of a shift in: a. educational preparation for advanced practice nurses. b. legislative initiatives. c. physician shortages. d. societal demands and needs.

ANS: D Changes in the health care system and nursing have occurred in the past few decades because of a shift in societal demands and needs. The role of the clinical nurse specialist (CNS) began in the early 1960s and grew out of a need to improve client care. As physicians moved to specialization, a gap was created in primary health care services (public health and primary care services). The NP movement of 1965 led to the preparation of nurses as primary care providers working within the nursing model of practice.

36.8. In the 1980s, a major contributor to the improvement of services for individuals with chronic and persistent mental illness was the establishment of: a. consumer advocacy groups for people with mental illness. b. community mental health centers. c. managed mental health care. d. National Institute of Mental Health (NIMH).

ANS: A Advocacy movements for people with mental illness, like those for individuals with other illnesses, arose in response to unmet needs. The National Alliance on Mental Illness (NAMI) was the first consumer group to advocate for better mental health services. This consumer advocacy group worked to establish education and self-help services for individuals with mental illness and their families. The efforts of NAMI gained momentum in the early 1980s. Political groups and legislative bodies responded with direct support. One example of such support was the funding of the Community Support Program (CSP) by the NIMH. The CSP provides grant monies to states to develop comprehensive services for individuals discharged from psychiatric institutions. These and similar efforts have helped bring consumers, families, and professionals together to work toward improving the treatment and care of persons with mental illness.

39.9. In proactively managing the role stressor of expanded liability, the APHN must understand that: a. the scope of the NP's and APHN's authority determines the liability standards applied. b. malpractice insurance carriers for advanced practice nurses offer similar policies. c. nurses functioning with a physician on site are more vulnerable. d. liability/malpractice insurance is required to practice as an NP or APHN.

ANS: A All nurses are liable for their actions. Because more legal actions are being brought in the judicial system that specifically concern NPs and APHNs, the importance of liability and/or malpractice insurance cannot be overemphasized. Although malpractice insurance may not be required to function as an NP or an APHN, most nurses carry their own liability insurance. Nurses who practice without a physician on site are particularly vulnerable. The scope of the NP's or APHN's authority determines the liability standards applied. The limits of each practitioner's authority are legislated by the individual states.

39.3. The purpose of professional certification is to: a. assure the public that advanced practice nurses have achieved an appropriate level of competence. b. determine competency for graduation from a community health advanced practice nursing program. c. establish a standardized national examination mandated for all community health advanced practice nurses. d. meet state board requirements for licensure as an advanced practice nurse.

ANS: A Certification is a means of assuring the public that nurses who claim to be competent at an advanced level have had their credentials verified through examination. Certification is not mandatory, but many state boards require certification for advanced practice nurses.

37.4. A truck driver says, "At first I was just using 'meth' at parties, but now I think about it all the time and how am I going to get some." The term that best describes this individual's use behavior is: a. drug addiction. b. drug dependence. c. recreational drug use. d. substance abuse.

ANS: A Drug addiction is a pattern of abuse characterized by an overwhelming preoccupation with using a drug (compulsive use) and securing its supply, and a strong tendency to relapse if the drug is removed. Frequently addicts are physically dependent on the drug, but there appears to be an added psychological component that is responsible for the intense cravings and subsequent relapse.

36.9. When considering the scope of mental illness in the United States, the community health nurse must understand that mental disorders are: a. indiscriminate. b. treated largely by specialty services. c. most frequent in African Americans. d. rarely a secondary problem.

ANS: A Mental disorders are indiscriminate. They occur across the life span and affect individuals of all races, cultures, genders, and educational and socioeconomic groups. Mental disorders can be a secondary problem among people with disabilities. Despite the prevalence of mental illness, only 25% of persons with a mental disorder obtain help for their illness in any part of the health care system, and the majority of people with mental disorders do not receive specialty mental health services at all. Caution is needed when discussing differences among racial and ethnic groups in the rates of mental illness. Studies addressing this issue are often limited and inconclusive.

39.8. An NP is employed at a small rural primary health clinic on a Hopi reservation in the Southwest as a member of the National Health Service Corps. This practice arena for the advanced practice nurse can best be described as: a. governmental. b. independent. c. industrial. d. private/joint.

ANS: A Positions for NPs and APHNs vary greatly in terms of scope of practice; degree of responsibility, power, and authority; working conditions; creativity; and reward structure. One alternative for NP and APHN practice is the government arena, which includes the National Health Service Corps, which places health providers in federally designated areas with shortages of health workers, and the Indian Health Service, which provides health services to Native Americans.

37.7. An occupational health nurse establishes a local business-sponsored smoking cessation clinic that incorporates the use of nicotine replacement therapy, behavioral treatments, and support groups. This strategy best exemplifies: a. population-focused tertiary prevention. b. individual-focused primary prevention. c. primary prevention education. d. secondary early detection.

ANS: A Tertiary prevention related to substance abuse focuses on the development of programs to help reduce or end substance abuse. Nurses can be active in smoking prevention programs for individuals as well as in community efforts to help people quit smoking. Fewer than 10% of those who try to quit smoking on their own are able to stop for a year. Interventions that include medications (nicotine replacement therapy) and behavioral treatments appear most promising. The most effective way to get people to stop smoking and prevent relapse is through multiple interventions and continuous reinforcement, and most smokers must make several attempts at cessation before they are successful.

4.6. The WHO initiative Health for All in the 21st Century can best be described as which of the following? a. Social justice initiative b. Primary care initiative c. National initiative d. Environmental initiative

ANS: A The Health for All in the 21st Century initiative is not a single, finite goal, but a strategic process that can lead to progressive improvement in the health of people. In essence, it is a call for social justice and solidarity to improve the economics and infrastructure of nations through a holistic approach to address determinants of health status and increase a community's responsibility for the health of its citizens. This may involve environmental initiatives and health promotion, education, and prevention initiatives aimed at the greater good of the population as a whole instead of serving the interests of individuals or select groups.

MULTIPLE RESPONSE 39.10. Major stressors frequently encountered by the APHN in the community include which of the following? (Select all that apply.) a. Conflicting expectations b. Liability c. Professional isolation d. Professional responsibilities e. Reimbursement issues

ANS: A, B, C, D NPs and APHNs need to identify self-care strategies to cope with predicable stressors related to the advanced practice role. Major stressors for NPs and APHNs fall into such areas as legal issues, professional isolation, liability, collaborative practice, conflicting expectations, and professional responsibilities. These stressors can lead to job dissatisfaction and thus must be proactively managed as part of role negotiation and the advance practitioner's professional accountability to self.

MULTIPLE RESPONSE 36.10. Environmental factors that place children at risk for mental health issues include: (Select all that apply.) a. crowded living conditions. b. genetic predisposition. c. lack of consistent caregivers. d. neighborhood violence. e. separation from parents.

ANS: A, C, D, E Children are at risk for disruption of normal development by biological, environmental, and psychosocial factors that impair their mental health, interfere with education and social interactions, and keep them from realizing their full potential as adults. Examples of environmental factors include crowded living conditions, violence, separation from parents, and lack of consistent caregivers.

4.7. Health problems exist throughout the world. In the United States, a current health concern is the appearance of new viral strains such as Hantavirus in the Southwest. This is an example of the difference in health care concerns between countries such as: a. United States and Canada. b. Sweden and Indonesia. c. Australia and Japan. d. Bangladesh and Zaire.

ANS: B Although health problems exist throughout the world, the health care concerns of less-developed countries differ from those of developed countries. Less-developed nations such as Bangladesh, Zaire, Haiti, Guatemala, most countries in sub-Saharan Africa, and the island nation of Indonesia, have more exotic-sounding health problems like Buruli ulcer, leishmaniasis, schistosomiasis, pediculosis, typhus, yellow fever, and malaria as well as the ongoing problems of measles, mumps, rubella, and polio. Current health concerns for developed nations such as the United States, Canada, Japan, the United Kingdom, Sweden, France, and Australia are problems like hepatitis, the appearance of new viral strains such as hantavirus, and large social yet health-related issues such as terrorism, warfare, violence, and substance abuse. AIDS remains a major global concern for all countries, developed or less developed.

39.7. An APHN problem solves in partnership with a community to solve health care access issues for the poor elderly in the community. The advanced practice role that best describes this intervention is: a. clinician. b. consultant. c. educator. d. researcher.

ANS: B Consultation is an important part of practice for NPs and APHNs. Consultation involves problem solving with an individual, family, or community to improve health care delivery. NPs and APHNs may serve as formal or informal consultants. Steps in the consultation process include assessing the problem, determining the availability and feasibility of resources, proposing solutions, and assisting with implementation of a solution. In working with the community, the APHN develops a relationship of collaborative partnership.

36.7. Research in neurobiology demonstrates that new learning actually changes brain structure, as exemplified by the effect of traumatic experiences on brain biochemistry. The use of both somatic and psychosocial interventions in the treatment of mental illness is supported by the scientific understanding of: a. blood-brain barrier. b. brain plasticity. c. serotonin reuptake. d. single-photon emission computed tomography.

ANS: B Mental illnesses are complex biopsychosocial disorders. The 1990s were considered the "decade of the brain" because great strides occurred through research in neurology, microbiology, and genetics that led to an understanding of the structural and chemical complexity of the brain. We have learned that the brain is not a static organ. The study of brain plasticity demonstrated that new learning actually changes brain structure. For example, traumatic experiences change brain biochemistry, as do significant positive experiences. This information supports the notion that both experience and psychosocial factors have effects on the causes and treatment of mental illnesses. Both somatic and psychosocial interventions need to be used in treating mental illness.

36.5. Many factors contribute to the fragmentation and access issues associated with the current mental health system. A community-oriented nursing strategy that can be used effectively to improve the quality of care for clients with persistent mental illness is: a. comprehensive client history taking and family interventions. b. agency networking and interagency collaboration. c. milieu therapy and psychobiological interventions. d. screening for signs of mental health disorders.

ANS: B Providing the range of services necessary to handle persistent mental illness is difficult without sufficient funds for health and social services. It is important for nurses and others working in community mental health centers to recognize the impact of changes in funding, changes in target populations, restructuring, and disagreements among professionals, agencies, and levels of government. This enables nurses to advocate for adequate services to meet the needs of individuals with severe and persistent mental illness. Some community-oriented nursing strategies that can be used to improve the care of clients with persistent mental illness include agency networking, interagency collaboration, and building of relationships.

36.1. To target populations at greatest risk for suicide, a community-based prevention program should consider outreach to: a. adolescent females, adults older than age 65 years, and men. b. depressed elderly men and persons with a prior history of suicide attempt(s). c. married men, elderly women, and adolescents with a family history of suicide. d. middle-aged men and healthy females with a family history of suicide.

ANS: B Suicide is the third leading cause of death of young persons between the ages of 15 and 25 years. Suicide was the eleventh leading cause of death in the United States in 2000, and the majority of those who commit suicide have a mental health or substance abuse disorder. Other risk factors are prior suicide attempt, stressful life events, and access to lethal methods. In the United States, men between the ages of 65 and 74 years are at the highest risk for suicide, and men account for 80% of all suicides among those older than age 65 years.

39.2. The strategy that is most appropriate for an APHN to consider when planning a population-focused health promotion program is to: a. contact the state health department to determine state-level health objectives. b. develop a collaborative relationship with community groups, leaders, and members. c. identify the target population and begin screening for participants. d. meet with community members and tell them about the program.

ANS: B The identified role characteristics of APHNs are population-level health care focus; ecological view, responsibility for health outcomes for populations, partnership/collaboration using an interprofessional approach, and leadership in practice.

37.3. A client acknowledges that his cocaine use is damaging his career and marriage, but the client has not investigated local treatment options. The nurse encourages the client to weigh the pros and cons of the drug problem and think about the solution to the problem, because the nurse recognizes that the client is in the change stage of: a. action. b. contemplation. c. precontemplation. d. preparation.

ANS: B The role of the nurse in assessing individuals is to determine their readiness for change in acknowledging a problem and seeking treatment and recovery. The stages of change are precontemplation, contemplation, preparation, action, and maintenance. The strategies used by the nurse depend on the specific stage of change the client is in. At the contemplation stage of change, the individual is aware that a problem exists and is seriously thinking of overcoming it, but has not yet made a commitment to take action. The nurse can encourage the individual to weigh the advantages and disadvantages of the problem and consider the solution to the problem.

MULTIPLE RESPONSE 4.10. A nurse in Mexico visits a village-based health post in her region to meet with the community volunteer and health committee that operate the health post. They intended to discuss the planning for next year's health promotion initiative and evaluate the recent family planning program. This best demonstrates the aim of the Declaration of Alma-Alta to emphasize which of the following? (Select all that apply.) a. Availability of chemotherapeutic agents b. Development of maternal and child health programs c. Involvement and training of community health workers d. Organized approach to health education e. Promotion and acceptance of traditional medicine

ANS: B, C, D, E Primary health care in global health is historically based on the Declaration of Alma-Ata (1978). The WHO's and the United Nations Children's Emergency Fund still actively promote primary health care as the strategy for achieving the goal of Health for All in the 21st Century. Several major components are identified for implementation of primary health care: an organized approach to health education that involves professional health care providers and trained community representatives; aggressive attention to environmental sanitation; involvement and training of community health workers; development of maternal and child health programs that include immunization and family planning; initiation of preventive programs aimed at local endemic problems; provision of accessible and affordable services for treatment of common diseases and injuries; availability of chemotherapeutic agents; development of nutrition programs; and promotion and acceptance of traditional medicine. In this example, only three of those components are evident.

MULTIPLE RESPONSE 37.10. Marijuana (Cannabis sativa or C. indica) is the most widely used illicit drug in the United States. Which of the following are facts about marijuana of which the nurse should be aware? (Select all that apply.) a. It decreases appetite. b. Tolerance and physical dependence can develop. c. It is highly toxic. d. It can be a safe therapeutic agent. e. It may be contaminated.

ANS: B, D, E Compared with other psychoactive drugs, marijuana has little toxicity and is one of the safest therapeutic agents known. Because of its status as an illicit drug, however, there is little quality control, and a user may consume contaminated marijuana that may cause problems. Both tolerance and physical dependence can develop; however, withdrawal is benign. Side effects include dry and reddened eyes, increased appetite, dry mouth, drowsiness, and mild tachycardia. Adverse effects include anxiety, disorientation, and paranoia.

4.2. Canada is the leader in promoting a population health framework. Using such a framework, a state health department nurse with budgetary responsibility would determine that funding priorities should focus on: a. chronic disease surveillance and treatment programs. b. pediatric and adolescent primary care and nutrition programs. c. promotion of healthy lifestyles or improvement of social and physical environments. d. well and sick child clinics.

ANS: C A key to the success of a population health framework is the identification and definition of health issues and of the investment decisions within a population that are guided by evidence about what keeps people healthy. Therefore, a population health approach directs investments that have the greatest potential to influence the health of that population in a positive manner.

4.8. A major town in Zaire received a gift of retired intensive care unit monitoring equipment from a large specialty hospital in a developed country. Zaire was grateful for the donation because it would increase the technological capability to treat clients in the local hospital. However, over the next year, the monitors remained unused because personnel were not qualified to operate the monitors and no one was available to maintain or repair the equipment. This best explains the relationship between which two concepts? a. Disease prevention and health care planning b. Education and health promotion c. Global health and global development d. Primary health care and primary care

ANS: C Access to services and the removal of financial barriers alone do not account for the use of health care services. The introduction of health care technology from developed nations to less-developed nations has led to less than satisfactory results. Attention must be given to the basic needs of less-developed countries and the resources and services that the country can successfully sustain. When the focus is on the public health needs of less-developed countries, the infrastructures of the countries (economic, industrial, and technological) can be encouraged to grow in a sustainable manner.

39.4. One of the concerns faced by nurse practitioners (NPs) because of their direct care role is: a. facing consumer group opposition to added complexity in the health care system. b. obtaining employment and role negotiation. c. obtaining institutional hospital privileges. d. coping with staff nurse resentment of the advanced practice role and independent practice.

ANS: C Because of their direct care role, NPs in the community are more concerned than APHNs about institutional privileges. Historically, it was often difficult for NPs to obtain hospital privileges in facilities into which their clients were admitted. However, with the broadening scope of practice and professional responsibilities, more NPs are obtaining hospital privileges. An application process is generally required and reviewed by a group of physicians in the department of medicine. The criteria for NPs wishing to obtain hospital privileges vary by hospital and state; most hospitals, however, require that NPs have national certification.

4.9. The United States is engaged in a formal agreement with Indonesia to provide economic incentives and assistance in national defense in return for the protection of U.S. private investments in that region. Which bilateral organization is most likely involved in this agreement? a. Carnegie Foundation b. United Nations c. U.S. Agency for International Development d. U.S. Department of Defense

ANS: C Bilateral organizations or agencies operate within a single country and focus on providing direct aid to less-developed countries. All bilateral organizations are influenced by political and historical agendas that determine which countries receive aid. Incentives for engaging in formal arrangements may include economic enhancements for the benefit of both countries, national defense for one or both countries, or enhancement and protection of private investments made by individuals in these nations. The U.S. Agency for International Development is the largest of these and operates totally outside of the United States.

37.9. A client receiving morphine on a regular basis for pain management must be gradually weaned off the drug to avoid withdrawal symptoms. This best illustrates the state of neuroadaptation known as: a. biopsychosocial effects. b. drug addiction. c. drug dependence. d. substance abuse.

ANS: C Drug dependence is a state of neuroadaptation—a physiological change in the central nervous system—caused by the long-term administration of a drug. In drug dependence, continued use of the drug becomes necessary to prevent withdrawal symptoms. Drug addiction is a pattern of abuse characterized by an overwhelming preoccupation with the use and procurement of a drug and a strong tendency to relapse if the drug is removed. Although addicts frequently are physically dependent on a drug, there is also a psychological component that causes the intense cravings and relapse. In general, anyone can develop drug dependence as a result of regular administration of drugs that alter the central nervous system; however, only 7-15% of the drug-using population will develop a drug addiction.

4.4. A terrorist bombing at a local church has sent many victims to the local emergency department and resulted in several deaths. Following the event, an emergency department nurse seeks out other nurses who are having difficulty performing their jobs to speak about the event. The nurse is demonstrating the disaster response strategy of: a. allaying public concern and fear. b. assisting victims to think positively and to move to the future. c. identifying feelings that individuals may be experiencing. d. preparing personnel to be effective in a disaster.

ANS: C During the aftermath of a disaster or terrorism event, nurses can feel fear, hopelessness, and loss or bias, hatred, vengeance, and violence toward ethnic or religious groups that may be associated with terrorism. These feeling may compromise their ability to provide care for these groups. Yet the International Council of Nurses' (ICN) Code of Ethics for Nurses (2000) affirms that nurses are ethically bound to provide care to all people. One strategy to use in response to a disaster or terrorism event is to assist in identifying the feelings that nurses or others may be feeling. To accomplish this, the nurse can (1) explain that feelings of fear, helplessness, and loss are a normal reaction to a disruptive situation; (2) work with people and help them think of what they did that helped them overcome fear and helplessness in previous situations; (3) encourage people to talk to others about their fears; (4) encourage others to ask for help and provide resources and referrals; (5) remember that those in the helping professions may find it difficult to seek help; and (6) convene small groups in workplaces with counselors/mental health experts.

37.2. Primary prevention programs for adolescents at risk for ATOD problems should focus on: a. encouraging competitiveness and success in aggressive sports. b. encouraging focus on short-term solutions rather than long-term planning. c. screening and treating psychiatric disorders and influencing social norms. d. teaching adolescents to "just say no."

ANS: C Family-related factors such as genetics, family stress, parenting styles, and child victimization appear to be the variables with the greatest influence on substance abuse among adolescents. The presence of a psychiatric disorder (especially a mood disorder) and behavioral problems is also associated with substance abuse among adolescents; peer pressure is a less influential factor. Effective social influence-based prevention programs should focus on effective screening and treatment of psychiatric disorders and modification of social norms to reduce adolescents' social motivation to begin using ATOD.

36.3. A nurse has obtained state funding for the development of an adolescent treatment program that supports Healthy People 2020 mental health objectives. The program should address: a. reduction of adolescent suicide attempts and prevention of teen obesity and depression. b. reduction of eating disorder relapses and stress-related hypertension in teens and preteens. c. reduction of suicide attempts and eating disorder relapses, and assessment and treatment for adolescents in the juvenile justice system. d. treatment of eating disorders and increased access to mental health treatment in middle and high schools.

ANS: C Healthy People 2020 objectives that specifically address adolescents include (1) reducing the rate of suicide attempts by adolescents, (2) reducing the relapse rates for persons with eating disorders, and (3) ensuring that children in the juvenile justice system receive access to mental health assessment and treatment. The goal "Reduce the relapse rates for persons with eating disorders" does not specifically mention adolescents, but eating disorders are most common in female adolescents.

39.5. The statement that best reflects the Center for Medicare and Medicaid Services (CMS) model for direct reimbursement of NPs as Medicare providers is: a. certified family nurse practitioners (CFNPs) and certified pediatric nurse practitioners (CPNPs) require the supervision of a physician. b. NPs in federally qualified rural clinics qualify for direct reimbursement. c. regardless of the geographic setting, NPs receive 85% of the scheduled CMS fees for physicians. d. NPs receive a sliding fee schedule based on local third-party payer practices.

ANS: C Historically, the direct reimbursement models for NPs were driven by state statute. With the passage of the Rural Health Clinic Act of 1977, nurses serving in primary care roles in qualified rural clinics were authorized to receive Medicare and Medicaid reimbursement regardless of whether a physician supervised the nurses or not. Because more access to quality health care services was sought for rural areas, the list of reimbursed providers was expanded. In 1989, all CFNPs and CPNPs were added to the list regardless of whether they were supervised by physicians. In 1997, the National Reconciliation Spending Bill provided for direct reimbursement of all NPs regardless of geographic setting or physician supervision status; payment was at 85% of the Medicare physician fee schedule for a covered service. NPs can now apply to be Medicare providers.

4.5. In developed countries, nurses have an important leadership role in primary health care initiatives. Commitment to which of the following best demonstrates nursing's advocacy role in primary health care? a. Equality of health care b. Higher education for nurses c. Provision of direct client care d. Quality of care

ANS: C In developed countries, nurses are often viewed as one of the strongest advocates of primary health care through nursing's social commitment to health care equality.

37.5. A very toxic psychoactive drug that is a stimulant, causes tolerance to develop within hours, and has dangerous health impacts for those in the vicinity during use is: a. alcohol. b. crack cocaine. c. nicotine. d. volatile solvents.

ANS: C Nicotine is a stimulant to which the body quickly develops a tolerance. For regular smokers, tolerance develops within hours, compared with days for heroin or months for alcohol. Smoke is damaging when inhaled directly. Sidestream smoke, also called secondhand smoke, contains greater concentrations of toxic and carcinogenic compounds than mainstream or firsthand smoke.

39.1. The advanced public health nurse (APHN) is a licensed nurse and: a. baccalaureate degree prepared to apply the science of public and community health. b. master's or doctoral degree prepared to apply advanced practice nursing knowledge in the care of individuals and families in a fixed setting. c. master's or doctoral degree prepared to assume a leadership role in working with individuals, families, groups, or communities to improve the health of the whole community. d. primarily employed as a public health research leader, educator, and coordinator.

ANS: C The APHN is a masters-prepared nurse whose training is a synthesis of knowledge and research in nursing, public health, and other scientific disciplines. Such a nurse assumes leadership roles in applying the nursing process and public health sciences to achieve specific health outcomes for the community. Clients may be individuals, families, groups, or communities. The ultimate goal is improvement of the health of the community as a whole.

36.6. The Mental Health Study Act of 1955 ultimately resulted in a shift in the locus of care for persons with severe mental illness from large psychiatric wards in hospitals to community mental health clinics. The Community Mental Health Centers Act of 1963 provided matching funds to states for the establishment of community-based mental health clinics that provided five basic services. In addition to these basic five services, states were encouraged to offer: a. 24-hour emergency services and inpatient care. b. consultation/education for community agencies and professionals. c. diagnostic and rehabilitative precare and aftercare services. d. partial hospitalization and outpatient care.

ANS: C The Community Mental Health Centers Act formalized the concept of community mental health centers and mandated that these programs provide five basic services: inpatient services, outpatient services, partial hospitalization, 24-hour emergency services, and consultation and education services for community agencies and professionals. However, states were also encouraged to offer diagnostic and rehabilitative precare and aftercare services. Many community mental health centers, especially those in poor and rural areas, were unable to generate adequate funds to continue their startup programs. Funding did not follow the client to the community.

37.6. Some health care organizations, like the American Nurses' Association, American Public Health Association (APHA), and several state nurses' associations, passed formal resolutions to support the use of medicinal marijuana based on its low level of toxicity, dependence, or addiction, and therapeutic safety and benefits especially in the control of pain. These resolutions have impacted changes in state legislation but to date, despite formal petition in 2002 to remove cannabis from the Drug Enforcement Agency's (DEA) Schedule I of Controlled Substances, and an extensive review and report by the Department of Health and Human Services (DHHS) in 2010, a DEA final ruling has not been received. This collective action by health care organizations to influence policymakers to put the emphasis on health care instead of law enforcement can best be described as: a. assessment. b. advocacy. c. education. d. surveillance.

ANS: C The greatest challenge for nurses and nursing is to influence policy makers to put the emphasis on health care instead of law enforcement in addressing ATOD problems, which are a major health care problem in this country. Through evidence-based practice nurses can demonstrate the effectiveness of health promotion, disease prevention, and drug-education programs. Nurses can also provide accurate information about the effects of psychoactive drugs, guidelines for their use, and the negative impacts of taking a law enforcement approach to ATOD problems. In this case, working to ensure public access to the appropriate therapeutic/medicinal use of marijuana under the supervision of a physician is advocating for the availability of a safe and effective therapeutic agent for client treatment.

37.8. Americans rely heavily on prescription drugs and over-the-counter drugs to relieve or mask anxiety, tension, fatigue, and physical and emotional pain. Attitudes toward ATOD problems in our society today are influenced by this "quick fix" attitude, as well as by the myth that: a. alcoholism is a disease. b. any drug can be abused. c. biopsychosocial factors affect addiction. d. there are good drugs and bad drugs.

ANS: D Attitudes are developed through cultural learning and personal experiences. Attitudes toward ATOD problems are influenced by the way society inappropriately categorizes drugs as either good or bad. In the United States, "good" drugs are over-the-counter drugs or those prescribed by a health care provider as medicine, yet this makes them no less problematic or addictive. "Bad" drugs are illegal drugs, and people who use these drugs are considered criminals, regardless of whether or not the drug use has caused problems. Americans rely heavily on the "quick fix" and take pills to deal with their problems or negative feelings. Although alcoholism and drug addiction have been recognized as a disease, many people, including health care providers, have failed to change their attitudes and accept alcoholics and addicts as ill persons in need of health care.

36.4. The one common factor shared by ethnic and cultural groups such as African Americans, Asian and Pacific Islander Americans, and Native Americans with regard to mental health care is their: a. care-seeking behavior for symptoms of depression. b. higher than normal rates of anxiety disorders. c. increasing incidence of eating disorders. d. low utilization of mental health services.

ANS: D Different populations use mental health services in unique ways. People may not seek mental health services in a formal system, they may drop out of care, or they may seek care at a much later stage of illness, which drives up the service costs. Such patterns of use appear to be the result of a community-based mental health system that is not culturally relevant, responsive, or accessible to select populations. African Americans, Asian and Pacific Islander Americans, and Native Americans have low rates of utilization of available mental health services. Asian and Pacific Islander Americans have the lowest rates of utilization of mental health services of any cultural group. Perception of what is a mental illness is one of the factors to consider in any discussion of mental health services for specific ethnic and cultural groups. Although the trend toward lower utilization among certain groups is supported by the data, one should remember that there is enormous diversity within all ethnic and racial groups in the United States.

4.1. The North American Free Trade Agreement, passed in 1994, allowed increased importation of goods and eased the movement of people throughout the United States, Canada, and Mexico. A health impact of this agreement for southern Texas has included: a. decrease in illegal immigration into the United States as a result of the improved Mexican economy. b. decrease in tuberculosis, cholera, and tetanus as a result of economic development. c. improved nutrition as a result of plentiful fresh vegetables and fruits in local markets. d. increase in respiratory and diarrheal disease as a result of colonias settlements.

ANS: D The colonias (colonies) are settlements of workers along borders in California, Arizona, New Mexico, and Texas. More than 40,000 Texans live in colonias along the southern Texas border. Environmental conditions in the colonias, such as lack of roads, transportation, water or electrical services, and access to primary care, have resulted in increased preventable infectious diseases (amebiasis, respiratory, and diarrheal diseases), environmental health hazards, and injuries associated with determinants of poverty, poor sanitation, and overcrowded conditions.

4.3. Mortality rates do not accurately describe the health status of populations in the world. The World Health Organization (WHO), in 2009, and World Bank, in 2005, developed an indicator—the global burden of disease—that combines losses from premature death with losses of healthy life that result from disability. The indicator represents: a. costs to the world of treating communicable disease in less-developed countries. b. economic cost of preventable early deaths. c. impact of disability on the international economic forecast. d. years in lost contribution to economic growth.

ANS: D The global burden of disease indicator utilizes the unit of disability-adjusted life-year (DALY). This unit measures the combined time lived with a disability and time lost as a consequence of premature death. The time lost because of premature mortality is calculated using standard expected years of life based on gender, whereas the reduction in physical capacity as a result of morbidity (disability) is measured using a six-point scale from 0 (perfect health) to 1 (death) that reflects the degree of dependence of the young and older adults on the adults in the population. The DALY represents life-years lost that could have contributed to the economic growth of a family or country as a consequence of premature death, disability, or loss of caregiver potential productivity/contribution.

37.1. A community assessment reveals a high incidence of alcohol-related chronic liver disease and cirrhosis in the local community. A primary prevention harm-reduction program would focus on: a. detoxification, addiction treatment, and codependency. b. drug education, drug treatment, and recovery. c. polysubstance abuse, assessment of recreational drug use, and drug testing. d. promotion of a healthy lifestyle and resilience factors, and drug education.

ANS: D The harm reduction approach to alcohol, tobacco, and other drug (ATOD) problems focuses on health promotion and disease prevention. Primary prevention for ATOD problems includes the promotion of healthy lifestyles and resiliency factors, and education about drugs and guidelines for their use. Nurses are ideally prepared to use health promotion strategies such as encouraging healthy alternatives to indiscriminate, careless, and often dangerous drug use practices and providing education about drugs to decrease harm from irresponsible or unsafe drug use.

36.2. The role of the community mental health nurse on a multidisciplinary team caring for clients with mental illness is best exemplified by which of the following? a. Providing psychometric testing, case management, and advocacy services b. Role-playing conflict management skills, dispensing medication, working with insurance companies to maximize reimbursement c. Teaching medication self-management, providing therapeutic counseling, providing family intervention d. Teaching medication management and self-management skills, coordinating care including assessment, referral, and follow-up

ANS: D The role of the nurse in community mental health includes serving as clinician, educator, and coordinator. The clinician role includes helping the client maintain or regain coping abilities that promote maximum functioning. The educator role includes teaching symptom self-management and medication management. The role of the coordinator must include case finding, referral, and follow-up to evaluate system breakdown and deficits.

31.1. A nurse is planning a training session for a new group of disability determination workers regarding the leading causes of severe disabilities in U.S. adults. The training should address: a. arthritis, heart disease, and back or spine problems. b. arthritis, lung disease, and back problems. c. back problems, heart disease, and pulmonary disease. d. genetic abnormalities, arthritis, and orthopedic pathology.

ANS: A According to the most recent data from the Survey of Income and Program Participation collected in 2010, approximately 18.7%, or 56.7 million civilian, noninstitutionalized men, women, and children in the United States reported a disability (vision, hearing, ambulating, cognitive, self-care, and/or independent living). 47.5 million U.S adults have a disability. The top three disabilities in the United States are arthritis or rheumatism, back or spine problems, and heart trouble.

22.5. A case manager employed by a health maintenance organization is charged with discontinuing home health services for a disabled homebound elderly client in an effort to reduce costs. The case manager reviews the client's record and determines that home health services are still indicated for this client. The ethical dilemma faced by the case manager is: a. beneficence. b. justice. c. nonmaleficence. d. veracity.

ANS: A Beneficence—"doing good"—becomes an ethical dilemma when the insurer's goal of containing costs supersedes the case manager's duty to improve health and relieve suffering. This ethical tenet of nursing practice to act in the best interest of the client also involves fidelity to the nurse-client trust relationship. Duty to clients to secure benefits on their behalf and to limit unnecessary expenditures can create dilemmas when the goals are not uniform. Advocacy on this client's behalf with accurate and updated information based on sound assessment, evidence-based practice, and liability risk management could produce a favorable outcome for all parties. The incorrect action would be to do nothing.

22.2. During a home visit, a case manager for a community health center notes marked pitting edema, shortness of breath, and increased fatigue in a 52-year-old male client who lives alone. The client is admitted to the hospital, where he is diagnosed with congestive heart failure. The case manager works with the hospital's utilization manager to devise a discharge plan. The case manager's most logical next step would be to: a. assess the client; obtain information on the scope of services covered by the benefit plan for the client; if needed services are not covered, seek to identify and arrange for the resources to provide these services. b. call the client, reintroduce himself or herself, and explain his or her role as a case manager for homebound clients. c. discuss with the family their schedule of availability to offer care in the client's home; ensure that the client has daily visits by family members. d. investigate the availability of local support and rehabilitation services for clients with congestive heart failure; contact the client's family.

ANS: A Case management has been described as a set of logical steps and process of interaction within a service network that ensures that a client receives needed services in a supportive, effective, efficient, and cost-effective manner. The National Case Management Task Force defines case management as a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services to meet an individual's needs, using communication and available resources to promote quality cost-effective outcomes. Case management has been defined in the public health nursing literature as the establishment of an appropriate plan of care based on assessment of the client/family and coordination of the necessary resources and services for the client's benefit. Therefore, a critical role of the case manager is to help clients obtain the care they need to achieve a maximum level of health. The nurse needs to understand what the client's insurance covers (broker). If necessary services or equipment is not covered by insurance, the nurse may act as an advocate (facilitator) and connect the client with other resources in the community (coordinator) if available.

19.4. Community and public health nurses (PHNs) practicing in rural locales consistently note which of the following characteristics of their practice environments? a. Broad scope of practice, independence and autonomy, and opportunity for community involvement b. Expanding scope of practice, plentiful resources, and increased opportunity for less formal interactions c. Lack of autonomy and independence, along with greater flexibility than in an urban practice d. Narrower scope of practice and focus than in an urban practice

ANS: A Characteristics of nursing practice in rural environments include broad, diverse, and/or intergenerational scope of practice, greater independence, public status and autonomy, and a greater opportunity for community involvement than in many urban practice environments.

7.3. A nurse is conducting a diabetes self-management group-education session. When participants are asked to remove their shoes, two male clients look at the floor and leave their shoes and socks on their feet. An effective intervention is for the nurse to: a. clarify that no one has to remove his or her shoes unless he or she wants to and continue foot inspection and foot care instruction. b. explain that everyone must learn to do foot inspection to manage their diabetes. c. loudly and slowly repeat the instructions for all participants to remove their shoes. d. stop the group session, pull the two gentlemen aside, and apologize to them.

ANS: A Exposing one's foot in public is not considered appropriate in all cultures. In some cultures, it is considered rude to display the sole of the foot. In the scenario described, the nurse should give the group permission to comply or not comply with the previous instructions and proceed with the class. Ideally, a nurse should become familiar with the values of the target population(s) before asking anyone to remove an article of clothing in a group setting. Integrating cultural awareness and knowledge allows the nurse to demonstrate cultural skill in meeting the needs of culturally diverse groups.

30.4. To detect the presence of the leading cause of disease burden for women in the United States, a screening program for women would include: a. blood pressure screening, mammography, and dietary assessment. b. testing for HIV/AIDS and sexually transmitted diseases. c. pap smear, screening for smoking, and assessment for exposure to violence. d. questions about a family history of depression, employment status, and chronic diseases.

ANS: A Chronic disease has become a public health problem of great proportions with the most common and costly chronic diseases being heart disease, diabetes, stroke, cancer, and arthritis. Chronic disease is the leading cause of preventable deaths, disability, and decreased quality of life. Heart disease is the leading cause of death for both men and women. Uncontrolled hypertension leads to heart attack, stroke, kidney damage, and a host of other complications and only two-thirds of people with hypertension are aware that have high blood pressure because there are no associated symptoms. Cancer is the second leading cause of death in the United States. Early screening and detection, promotion of healthy lifestyles, expanding access to services, and improving cancer treatments will help reduce the burden of cancer and disparities. Screening activities (secondary prevention) make a difference in death rates and early detection can promote a cure, whereas late detection typically ensures a poor prognosis. Overweight and obesity are topics addressed numerous times in Healthy People 2020 because of their link to many chronic health diseases (risk factor for diabetes and heart disease). A dietary assessment, along with physical and psychological assessments, helps nurses to identify women at-risk for appropriate referrals.

22.7. In case management, it is unlikely that any single professional has the expertise, knowledge, or skills required to achieve success. The synergy produced by all involved parties (client, providers, payers, family/significant others, and community organizations) can result in successful outcomes. These statements relate to the sequential process of: a. collaboration. b. communication. c. cooperation. d. negotiation.

ANS: A Collaboration is achieved through a developmental process carried out in a sequence, yet it is reciprocal among those involved. Teamwork and collaboration require extensive skill sets to achieve successful outcomes. No single professional has the expertise required for all aspects. Synergy among all parties involved is required. Although communication is essential to collaboration, it is not sufficient to create or maintain collaboration.

7.9. The nurse is educating her Nigerian client regarding the prenatal services available through the maternal-child health clinic. The client is interested in confirming her pregnancy at this visit but does not see the need for ongoing visits because childbirth is viewed as a natural process in her culture. The nurse negotiates with the client to structure a strategy to achieve a healthy pregnancy outcome that uses the clinic's resources in a manner that is satisfactory to the client. This is an example of: a. cultural accommodation. b. cultural brokering. c. cultural preservation. d. cultural repatterning.

ANS: A Culture is defined as a set of beliefs, values, and assumptions about life that are widely held among a group of people and that are transmitted intergenerationally. Culture is important to nurses because it helps them to understand the beliefs and practices clients bring to the clinical setting, their expression of concerns, and the type of health care they are pursuing. Quality of care means that positive health care outcomes are achieved. Failure to focus care according to the client's values and ideas is likely to increase cost and decrease quality. Care that is not culturally competent may lead to increased cost of health care and decrease the opportunity for positive client outcomes. Techniques such as cultural accommodation can ensure that a positive health outcome is achieved while providing for the cost-effective use of limited resources. Failure of clients to keep scheduled appointments with clinics may reflect a cultural preference for the type and frequency of contact with the health care system. Understanding the type of health care service that the client is seeking can ensure that opportunities to negotiate compliance with treatment can occur to the satisfaction of both parties so that precious resources can be managed effectively.

7.5. Bruising and swelling on a client's face and torso are noticed by a nurse during a prenatal examination. The client's exchange-student husband, who speaks for the client, tells the nurse his wife deserved the bruises. The client looks at the floor and shakes her head in agreement. The nursing student leaves the examination room angry and confused, experiencing what can best be described as: a. culture shock. b. prejudice. c. ignorance. d. racism.

ANS: A Culture shock is the feeling of helplessness, discomfort, and disorientation experienced by an individual attempting to understand or effectively adapt to a cultural group whose beliefs and values are radically different from those of the individual's own culture. There are cultures in which it is considered acceptable for men to hit their wives and/or children. The nurse can consult with the nursing supervisor or clinic social worker, who can intervene on the client's behalf with the cooperation of a community advocate from the client's culture of origin.

7.4. A nurse who is ethnocentric in interacting with a client of a different culture: a. most likely has little previous experience with the client's culture and is uncomfortable with people from other cultures. b. is appreciative of the client's cultural beliefs. c. accommodates the client's cultural beliefs when planning care. d. imposes the nurse's value system on the client.

ANS: A Ethnocentrism, an inhibitor to developing cultural competence, is the belief that one's own cultural beliefs are the standards that should be used to judge people from other cultures. Ethnocentric nurses are unfamiliar and uncomfortable with that which is different from their own culture. Their inability to accept different worldviews often leads them to devalue the experiences of others and judge them to be inferior, treating those that are different from themselves with suspicion or hostility. The belief in one's own superiority, or ethnocentrism, may lead to "cultural imposition." Cultural imposition is the act of imposing one's cultural beliefs, values, and practices on individuals from another culture. By developing an approach of "cultural relativism" nurses recognize that clients have different approaches to health care, and that each culture should be judged on its own merit and not on the nurse's personal beliefs. Nurses use "cultural awareness and knowledge" to overcome unfamiliarity and discomfort with cultures outside of their own. Nurses who may have ethnocentric beliefs can avoid inhibiting behaviors/actions such as cultural imposition by developing cultural competence.

38.2. Nurses must be aware of the incidence of incest, its signs and symptoms, and the psychological and physical trauma it causes. One fact relevant to comprehensive nursing assessment is that incest: a. occurs in all races, religious groups, and socioeconomic classes. b. often occurs in father-son relationships. c. occurs only in father-daughter relationships. d. never occurs in stepparent-child relationships.

ANS: A Father-daughter incest is the type of incest reported most frequently, and stepfathers are considered the most common perpetrators of father-daughter incest. Very little is known about female perpetrators, but mothers do engage in child sexual abuse. Incest occurs in all races, religious groups, and socioeconomic classes. Nurses must be aware of this fact to conduct comprehensive assessments that take into account the incidence of incest, signs and symptoms, and the psychological and physical trauma it causes.

33.6. A recent movie release portrays a female drug user living with her abusive boyfriend, who has two children by different women, in a rundown inner city neighborhood with high levels of poverty and unemployment. This portrayal best describes the influence of which class of factors on societal responses to poverty and homelessness? a. Cultural b. Environmental c. Political d. Social

ANS: A Individual perceptions of poverty and poor persons are rooted in social, political, cultural, and environmental factors. Societal responses to poverty and homeless persons (what actions are taken to assist them) are deeply rooted in history, and that history has helped to shape cultural attitudes. Cultural attitudes affect, and are affected by, the discourses in various media. Portrayals of poor people as lazy and shiftless folk, desperate persons, criminals, and slackers living off of public assistance influence what we believe to be true about poor persons.

31.4. The role of the community-oriented nurse working with the special needs population is largely influenced by which of the following? a. Community awareness of and commitment to meeting the needs of people with disabilities b. Educational institutions in the community c. Number of people with disabilities in the community d. Nurse's attitude toward people with physical challenges

ANS: A Many factors influence the role of the community-oriented nurse in any given community. A major influence is the community's awareness of those who are disabled and its commitment to addressing their health needs. However, a nurse who becomes aware of and committed to meeting the needs of the physically compromised can use the principles of community-oriented practice to initiate long-term improvement of services in his or her community.

30.5. In comparison with women, men: a. incur more work-related injuries. b. experience lower survival rates in the first year after myocardial infarction. c. metabolize alcohol more efficiently. d. more actively initiate preventive health care interventions.

ANS: A Men are often employed in dangerous jobs and incur more work-related injuries than women. Men do not participate in health care to the same level as women, apparently because of the traditional masculine gender role learned through socialization. Men are socialized to ignore pain, be self-reliant, and be achievement oriented. Large numbers of men do not receive the health screenings intended to prevent and identify disease.

10.9. When a nurse evaluates the completeness and accuracy of information made available to community residents regarding the impact of rezoning of land parcels for industrial use, the nurse can best be described as: a. advocating for ethical choices. b. communicating risk. c. controlling environmental damage. d. volunteering for service on state boards.

ANS: A Nurses, using sound risk communication skills as trusted communicators, advocate for environmental justice. Ethical issues likely to arise in environmental health decisions are: Who has access to information and when? How complete and accurate is the information? Who is included in the decision making and when? What and whose values and priorities are given weight in decisions? How are short-term and long-term consequences considered?

38.9. When working with battered women, the nurse needs to know that research suggests that the response to abuse is a process that moves from: a. commitment to the relationship to leaving to start a new life. b. emotional degradation to financial dependence to dominance. c. heated argument to hitting to battering. d. self-blame to fear to terror.

ANS: A Nursing research suggests that the response to battering is a process that occurs over time in which the victim's emotional and behavioral reactions change. At first there is a great need to minimize the seriousness of the abuse, ascribe external blame, accept the partner's remorse, blame oneself, experience a moral conflict about leaving, hide the violence, placate the partner, and lose the sense of self, until finally concern about children or personal fear of death tips the balance to a decision to leave the abusive relationship.

13.3. A school nurse notes that 60 children have missed days of high school because of pertussis this past year and this rate has been relatively constant for the past 5 years. The nurse plans to work with the community to increase awareness of the seriousness of this disease for children younger than 6 months of age and to raise and maintain the immunization rates, because in this community the pertussis is: a. endemic. b. epidemic. c. pandemic. d. sporadic.

ANS: A Pertussis (whooping cough) is caused by the bacterium Bordetella pertussis. It is highly contagious and is considered endemic in the United States. Endemic means that the disease is constantly present within a geographic area or population. Vaccination against pertussis, delivered in combination with diphtheria and tetanus vaccination, is a part of the routine childhood immunization schedule. The increase in adolescent and adult pertussis is alarming not because of the increased morbidity—cases are mild or inapparent in these groups—but because these individuals serve as a reservoir of infection for infants, especially those younger than 6 months of age, who are the most vulnerable to pertussis and the most likely to suffer complications resulting in hospitalization and death.

13.4. The World Health Organization (WHO) developed the Five Keys to Safer Food campaign in 2001 to address the problem of foodborne and waterborne diarrheal diseases worldwide. This campaign emphasizes which of the following practices? a. Keep clean, separate raw and cooked, cook thoroughly b. Never use raw, always cook, buy better c. Wash, cut, cook, and throw away d. Wash, cover, and always refrigerate

ANS: A Protecting the nation's food supply from contamination by virulent microbes is a multifaceted issue that is and will continue to be incredibly costly, controversial, and time-consuming to address. The specter of terrorist threats to the food supply adds an additional layer of complexity. However, much foodborne illness, regardless of the causal agent, can be easily prevented through simple changes in food preparation, handling, and storage. WHO estimates that 2.2 million people, most of them children, die annually from foodborne and waterborne diarrheal diseases in less-developed countries. In 2001, WHO initiated a new campaign entitled Five Keys to Safer Food, a simplified version of an earlier campaign that includes the following elements: keep clean, separate raw and cooked, cook thoroughly, keep food at safe temperatures, and use safe water and raw materials.

19.9. When determining whether a geographic area is rural or urban, the nurse should recognize that: a. rural and urban areas by their nature occur on a continuum. b. rural regions have fewer than six persons per square mile. c. rural residents feel isolated. d. rural areas are recreational, retirement, and resort communities.

ANS: A Rural and urban residencies are not opposing lifestyles. Rather, they occur on a rural-urban continuum ranging from living on a remote farm, to living in a village or small town, to residing in a larger town or city, to living in a large metropolitan area with a core inner city. Although some communities may seem geographically remote, the residents who live there may not feel isolated. For the affluent, the term rural may bring to mind recreational, retirement, and resort communities in the mountains, seashore, or lake country. For the less affluent, it may mean an impoverished Indian reservation or migrant labor camp. Therefore rural may be a state of mind.

34.9. A cultural belief and an environmental factor that may increase the risk of potential pesticide exposure for some migrant workers are: a. hot-cold balance and housing. b. cuarentena and distance from health care services. c. need to achieve high productivity and transportation challenges. d. disease causality and proximity to the farm fields.

ANS: A Some migrant workers may not shower when they return from the fields as a result of cultural beliefs about being exposed to cooler water while feeling hot from working. Inadequate housing that lacks showers and/or adequate laundry machines also prevent farmworkers from washing pesticides off themselves and their clothing in a timely manner. This exposes the farmworker and the entire family to the risk of pesticide exposure.

31.5. A person who is limited in independent living skills, economic self-sufficiency, and self-help ability would meet the definition of: a. developmentally disabled. b. dual-diagnosed. c. impaired. d. physically disabled.

ANS: A The Centers for Disease Control and Prevention (CDC)'s National Center on Birth Defects and Developmental Disabilities defines developmental disability as a long-term impairment that originates during development and up to age 22 years and lasts throughout the person's lifetime. The disability must limit the person in at least three of the following areas: self-help, language, learning, mobility, self-direction, independent living, and economic self-sufficiency.

13.5. An American takes a long-awaited vacation in sunny Mexico, spending days on the beach eating fresh raspberries from a nearby vendor and drinking bottled water. The tourist may be altering: a. agent-host-environment interaction. b. circadian rhythms. c. herd immunity. d. host resistance.

ANS: A The balance among agent, host, and environment is often precarious and may be unintentionally disrupted. Changes in the characteristics of any of these factors may result in disease transmission. Many travelers are at risk for foodborne and waterborne diseases and should be careful to eat only thoroughly cooked foods prepared under reasonable hygienic conditions. Eating foods purchased from street vendors may not be wise. Fruits that can be peeled immediately before eating, such as bananas, are less likely to be a source of infection. Dairy products should be pasteurized and appropriately refrigerated. Only potable water (safe to drink) should be consumed, such as boiled water or bottled water. Other diarrheal diseases may not be related to viral or bacterial infective agents and may be the result of stress, fatigue, schedule changes, and consumption of unfamiliar foods.

22.3. A community health nurse is serving as a case manager for premature infants receiving home health care. The case manager arranges for an in-home apnea monitor and daily home visits by a registered nurse who specializes in high-risk pediatrics. The case manager is demonstrating which of the following case manager roles? a. Consultant and coordinator b. Mentor and liaison c. Monitor and reporter d. Standardization monitor and negotiator

ANS: A The case manager is responsible for fulfilling a variety of roles. The nurse is acting as a consultant when working with suppliers to arrange for the apnea monitor. The nurse is acting as a coordinator when arranging for needed heath care services such as daily home visits by a specially trained pediatric registered nurse.

33.8. When working with the poor or homeless, to develop effective nursing interventions the nurse should evaluate clients and populations in the context of: a. environment. b. improvement in the quality of services. c. human dignity. d. nursing theories.

ANS: A The foundation of nursing theories is the assumption that human beings have inherent dignity and worth. Nursing is based on valuing individuals, promoting health, respecting and restoring dignity, and improving the quality of life of individuals, families, and aggregates. Conflicts in values, beliefs, and perceptions often arise when nurses work with persons from different social, cultural, and economic backgrounds. A lack of agreement between the professional's and the client's perceptions of need can lead to conflict. As a result of this conflict, clients may fail to follow the prescribed treatment protocol. The nurse may then inaccurately interpret the client's behavior as resistance, lack of cooperation, or noncompliance. Nurses should evaluate clients and populations in the context of the environment to develop effective nursing interventions. Care must be multidimensional and should include consideration of biological, psychological, social, political, cultural, environmental, economic, and spiritual factors.

7.6. A PHN in a maternal-child health clinic encounters a client from Ethiopia. The clinic typically sees Hispanic clients. The nurse should first conduct: a. general cultural assessment. b. head-to-toe assessment. c. in-depth cultural assessment. d. nonverbal communication assessment.

ANS: A The nurse proceeds with a systematic identification and documentation of the culture care beliefs, meanings, values, symbols, and practices of individuals and groups within a holistic perspective, which includes worldview, life experiences, environmental context, ethnohistory, language, and diverse social structure influences. Cultural assessments should focus on those aspects relevant to the presenting problem, necessary intervention, and participatory education. During initial contacts with clients, nurses should perform a general cultural assessment to obtain an overview. In-depth cultural assessments are conducted over a period of time. This gives the nurse and client time to get to know each other and is especially beneficial to the client because it allows the client to see the nurse in a helping relationship.

13.8. When a situation exists in which there is potential contact with blood or body fluids, health care workers must always perform hand hygiene and wear gloves, masks, protective clothing, and other indicated personal protective barriers. The underlying reason for requiring these practices, known as universal precautions, is that: a. blood and body fluids of all clients need to be handled as if they were infected. b. effective infection control surveillance programs are in place. c. health care settings are reservoirs of infection. d. health care workers do not effectively use hand hygiene.

ANS: A The practice of universal precautions is a policy relevant for all health care settings. In 1985, in response to concern regarding the transmission of HIV infection during health care procedures, the Centers for Disease Control and Prevention recommended implementation of a universal precautions policy in all health care settings. This policy requires that all blood and body fluids from all clients be handled as if they were infected with HIV or other blood-borne pathogens.

30.8. To improve the health of frail elderly, community-based nursing programs will need to address: a. racial/ethnic and sociological disparities. b. culture, ethnicity, and race. c. media and marketing initiatives that target elderly concerns regarding quality of life and degree of disability. d. national vital statistics on morbidity and mortality.

ANS: A The prevalence of frailty in the older population poses a major public health dilemma since the majority of this group will reside in a community setting, placing new demands on health care systems, family caregivers, and community resources. To improve the health of frail elderly, community-based nursing programs will need to address racial/ethnic and socioeconomic disparities.

38.8. Violent crimes in the United States include rape, robbery, homicide, and assault. Although rates are decreasing, the long-term consequences of victimization reveal troubling trends that best support the realization that violence must be addressed as which of the following? a. Community and public health problem b. Legal and political concern c. Medical and health care concern d. Nursing concern

ANS: A Violence should be considered a community and public health problem because violence results in significant mortality and morbidity, contributing to health care costs; exposure to violence as either a victim or witness can predict violent behavior in the future (violence begets violence); health care professionals have been slow to develop a response to violence; community factors contribute to violence; and evidence-based interventions have demonstrated that violence can be decreased or prevented and the community's capacity to respond to violence can be increased.

31.7. During an Individuals with Disabilities Education Act (IDEA) screening to detect mental or psychological conditions in young school-age children, a child is identified as having a cognitive disability. The school nurse should now consider this child to be at greatest risk for: a. abuse or neglect. b. age-inappropriate friendships. c. embarrassment. d. physical inactivity.

ANS: A While all individuals with disabilities are at risk for abuse and neglect, children, the elderly, and women are at particular risk. According to the U.S. Department of Health and Human Services, risk factors for the abuse/neglect of disabled children can be stratified to societal factors, such as believing disabled children are asexual or do not feel pain; family or parental factors, which include the child being viewed as different, parents who are embarrassed by their disabled child, or families with inadequate social support or resources; as well as child-related factors, which include being male, having challenging/difficult behaviors, or requiring extensive physical care.

33.7. A nurse case manager identifies a potential health outcomes concern for a 1 year old with special needs living in an impoverished neighborhood, because this child is at increased risk for: a. developmental delays. b. ear infections. c. frequent colds and infections. d. irritability.

ANS: A Young children (0-5 years of age) are at highest risk for the most harmful effects of poverty. Good nutrition during the first years of life is crucial for normal cognitive development. Unfortunately, many children live in poverty during their early childhood years. The brain is directly affected by environmental stimulation during a critical time that extends from the prenatal period through early childhood. Among the risk factors that impede cognitive development in young children are inadequate nutrition, maternal substance abuse, maternal depression, environmental hazards, trauma, and abuse. Unfortunately, poor children often have greater exposure to risk factors such as these. Poverty increases the likelihood of chronic diseases, injuries, traumatic death, developmental delays, poor nutrition, inadequate immunization levels, iron-deficiency anemia, and elevated blood lead levels.

MULTIPLE RESPONSE 10.1. The role of the nurse who wants to become more active in environmental health could include which of the following? (Select all that apply.) a. Assessing farmworkers for pesticide exposure and providing pesticide risk education b. Conducting epidemiologic investigations as a public health nurse (PHN) c. Developing corporate policy to protect workers from unsafe levels of toxic agents d. Organizing the local community to encourage landlords to remove lead-based paint e. Working as a skilled risk communicator for a local chemical manufacturer

ANS: A, B, C, D, E Nurses can have a vital role in reducing environmental risk, educating workers and/or the community, and helping to eliminate risks in the local community. As nurses learn more about the environment, opportunities for integration of such work into their practices, educational programs, research, advocacy, and policy work will become evident and will evolve.

MULTIPLE RESPONSE 33.10. Effects of homelessness on health care outcomes can be devastating and may include which of the following? (Select all that apply.) a. Higher incidence of acute and chronic disease b. Higher risk of physical trauma c. Crisis-oriented health care, usually in emergency departments d. Reduced eligibility for entitlement/assistance programs e. Lack of awareness of care options

ANS: A, B, C, E Homelessness is correlated with poor health outcomes. The incidence of acute and chronic illness, acquired immune deficiency syndrome (AIDS), and trauma is significantly higher among homeless persons. Although homeless persons are at higher risk for physiological problems, they have greater difficulty accessing health care services. Health care is usually crisis oriented and sought in emergency departments, and those who access health care have a hard time following prescribed regimens. Health problems of homeless clients are often directly related to poor preventive health care services. In addition to facing challenges related to self-care, homeless people usually give lower priority to health promotion and health maintenance than to obtaining food and shelter. They spend most of their time trying to survive. Just getting money to buy food is a major challenge. Although some homeless persons are eligible for entitlement programs such as Temporary Assistance for Needy Families (TANF), Women, Infants, and Children (WIC), or Social Security, others must beg for money, sell plasma or blood products, steal, sell drugs, or engage in prostitution. Barriers to treatment include lack of awareness of treatment options, lack of available space in treatment facilities, inability to pay for treatment, lack of transportation, nonsupportive attitudes of service providers, and lack of coordinated services.

MULTIPLE RESPONSE 19.1. Depression among rural residents appears to be more persistent and endemic. Which of the following factors may contribute to this level of depression? (Select all that apply.) a. Delays in seeking mental health services b. High rate of poverty c. Gaps in the continuum of mental health services d. Sufficient number of mental health services e. Tolerance for destructive coping mechanisms

ANS: A, B, C, E There appears to be more persistent, endemic depression among rural residents. Factors that relate to this level of depression are the high rate of poverty, economic difficulties, economic recession, geographic isolation, insufficient number of mental health professionals, delays in seeking treatment, tolerance of destructive coping behaviors, lack of trust in mental health professionals, and gaps in the continuum of mental health services.

MULTIPLE RESPONSE 13.1. Emerging infectious diseases may arise as a result of factors operating singly or in combination, and these factors may include which of the following? (Select all that apply.) a. Environmental changes b. Host behavior c. Improved surveillance d. Microbial adaptation e. Public health infrastructure deterioration

ANS: A, B, D, E Emerging infectious diseases are those for which the incidence has actually increased over the past several decades or has the potential to increase in the near future, and these include both new and known infectious diseases. New viruses may appear as a result of microbial adaptation, activities and behaviors of human hosts, and environmental changes. Relevant environmental changes include such things as weather changes, deforestation, urbanization, and industrialization. Human activities and behaviors that influence the spread of these diseases include increased use of daycare centers, illegal drug use, changing sexual behavior, use of modern modes of transportation, use of air conditioning, immigration, and global travel.

MULTIPLE RESPONSE 30.9. Diabetes mortality rates continue to rise for all ethnic and socioeconomic groups, but evidence shows that which of the following are true? (Select all that apply.) a. Addressing the diabetic epidemic involves more than a focus on individual factors. b. Community-based education programs have done little to address the problem. c. Complications and mortality rates are highest among low-income and minority groups. d. Selection of healthy food options is both an availability issue and an education issue. e. Standard of living does not affect decision making.

ANS: A, C, D Diabetes is a serious public health problem and is epidemic in the United States. One in 12 adults in the United States has diabetes, and for every three people who have been diagnosed with diabetes, there is another who does not know he or she has it. Research supports the importance of also addressing social and economic factors related to health and well-being when treating diabetes. These social determinants of health include the characteristics of clients' communities, such as income distribution, educational level, and segregation. This broader perspective also includes attention to policies that affect the availability of healthy foods.

MULTIPLE RESPONSE 30.10. A community-oriented nurse is developing goals for a community health center's senior center. The goals should focus on which of the following? (Select all that apply.) a. Meeting social and recreation needs b. Helping elders accept the inevitability of the debilitation of aging c. Maximizing functional status and minimizing functional decline d. Implementing secondary and tertiary prevention measures

ANS: A, C, D Senior centers were developed in the 1940s to provide social and recreational activities. Now many centers are multipurpose, offering recreation, education, counseling, therapies, hot meals, and case management, as well as health screening and education. Nurses caring for elder populations strive to help maximize functional status and minimize functional decline. Senior centers are effective platforms for nurses to provide interventions related to primary, secondary, and tertiary prevention, health promotion and maintenance, and disease prevention. Senior centers are multipurpose and provide safe, stimulating recreational opportunities. Many of the changes traditionally associated with aging can be delayed or prevented by positive health practices and proactive intervention.

MULTIPLE RESPONSE 7.10. A nurse overhears the doctor saying, "Let's not give the client codeine, he's Asian." The nurse reflects on the comment and determines that the doctor is which of the following? (Select all that apply.) a. Culturally competent b. Prejudiced c. Ethnocentric d. Unable to assess pain based on culture e. Planning care based on racial enzymatic differences

ANS: A, E Biological variations distinguish one racial group from another. These differences may occur in the areas of growth and development, skin color, enzymatic differences, and susceptibility to disease. Research findings suggest that sensitivity to codeine varies with ethnic background. Asian men experience significantly weaker effects from use of the drug than do European men. Asian men are missing an enzyme called CYP2D6 that allows the body to metabolize codeine into morphine, which is responsible for the pain relief provided by codeine. When an individual is missing the enzyme, no amount of codeine will lessen his or her pain, and other pain-reducing medications should be explored.

34.2. The nurse case manager in a migrant farmworker clinic assesses this vulnerable population from the perspective of occupational and environmental risks related to: a. contaminated water, applied chemicals, and unfamiliar farm equipment. b. naturally occurring plant substances, pesticides, and fear of injury reporting. c. traffic accidents, weather, lack of worker supervision, and inadequate sewage. d. weather, pesticides, and strict enforcement of occupational regulations.

ANS: B Annually agricultural work ranks in the top four most dangerous occupations in the United States. Migrant farmworkers are exposed to weather because they work outside in the elements, very often for long hours, and typically live in inadequate housing. Exposure to both naturally occurring plant substances and applied chemicals such as pesticides places farmworkers at risk of immediate health problems (contact dermatitis, allergies, and conjunctivitis) and long-term health effects (lung diseases and cancer). Workers may not receive adequate training regarding the use of mechanical equipment, and the equipment may not be properly maintained. The workers' low educational level may impede their ability to comprehend essential training or warnings. In most states, migrant farmworkers are not protected by the same occupational health regulations and worker's compensation benefits as workers in other industries. Workers may fear loss of their jobs if they report injuries and may not be able to afford personal protective equipment.

31.3. Physically compromised individuals often experience poverty, as do other special population groups. The impact of poverty on the onset of disability can best be expressed by which of the following statements? a. Being underinsured through the workplace limits options for health care services. b. Low income can increase the risk of preventable disability. c. Successful insurance settlements for injury claims limit the financial impact of disability. d. Transportation for persons with limited mobility affects access to health care services.

ANS: B Being physically disabled places the individual and his or her family at risk for decreased income potential. Persons with low income have less access to health care throughout their lives and are less likely to participate in all levels of prevention. Therefore, they are at greater risk for the onset of disabling conditions and for more rapid progression of disease processes. Those living in poverty could also be at greater risk for disabling conditions resulting from lifestyle choices, such as accidental injuries; tobacco, alcohol and drug use; and inadequate nutrition.

31.2. Children with chronic health problems face challenges in school because of: a. difficulty gaining access to public school education. b. embarrassment and self-imposed social isolation. c. increased special education costs in public schools. d. psychological distress related to the severity of their disability.

ANS: B Children with chronic health problems often experience embarrassment regarding the demands of their disability and the regimens required to manage it. Having to explain why they must attend to special needs could call unwanted attention to them and their condition. School-age classmates may be reluctant to be close friends with children with chronic illnesses because they may fear that any chronic disease or disability is contagious. Children who receive respect and positive feedback from their families and peers have stronger feelings of self-worth than those who feel socially isolated from others.

13.7. In an effort to address West Nile virus, a community increased livestock immunization, began a vector control program, and initiated a community campaign to eliminate standing water reservoirs. This best exemplifies communicable disease control through: a. health education. b. multisystem approach. c. improved public health infrastructure. d. reduction of environmental hazards.

ANS: B Communicable diseases represent an imbalance in the usually harmonious relationship between the human host and the environment. This state of imbalance provides the infectious agent an opportunity to cause illness and death in the human population. Given the many factors that can disrupt the agent-host-environment relationship, a multisystem approach to the control of communicable diseases must be developed.

33.2. Which of the following best represents the concept of homelessness as crisis poverty? a. Man with chronic alcoholism and drug abuse living in a halfway house b. Recently unemployed man evicted from his apartment c. Teenager living on the streets and abusing drugs d. Woman with schizophrenia who is living in a shelter

ANS: B Crisis poverty is a conception of homelessness that views the homeless as people whose lives are generally marked by hardship and struggle. For this group, homelessness is often transient or episodic. Their homelessness may result from lack of employment opportunities, lack of education, obsolete job skills, and/or domestic violence.

7.2. A new group of migrant farmworkers has arrived in a community. The local public health nurse (PHN) realizes that an important step before scheduling clinic services is to: a. consult the public health staff regarding their scheduling preferences. b. learn about the farmworkers' concept of time and their work schedule to determine when and how services can best be scheduled. c. review written materials about the farmworkers' culture of origin. d. visit the farmworker camp and tell the camp leaders when clinic services will be available.

ANS: B Culturally competent nursing care includes designing services that are culturally appropriate for the specific client and based on the client's cultural norms and values. The concept of time varies depending on a client's culture of origin. When possible, clinic operating times and scheduling policies should respect the community's preferences.

19.7. When using the health measure of death rates for working adults, the nurse could expect to find the highest death rates in which areas? a. Large metropolitan areas b. Most rural and highly populated urban areas c. Most rural and suburban areas d. Small suburban and all urban areas

ANS: B Death rates for working-age adults are higher in the most rural and the most highly populated urban areas. The highest death rates for children and young adults are found in the most rural areas. Residents of rural areas have the highest rates of death as a result of unintentional injuries in general and because of motor vehicles injuries in particular. Homicide rates are the highest in the central counties of large metropolitan areas.

10.7. The monitoring and public reporting of air quality in a local community to assist individuals with asthma or other respiratory conditions best illustrates the application of: a. compliance and enforcement. b. environmental epidemiology. c. secondary prevention. d. toxicology.

ANS: B Epidemiologic studies enable us to understand the strength of the association between exposures and health effects, such as the relation between air pollution and asthma exacerbation.

22.9. The insurer's risk manager has informed an independently contracted case manager that a liability risk related to experimental treatment and technology was identified in a recent recommendation made by the case manager. Which of the following is the best example of action by a case manager that might be associated with potential liability risk related to experimental treatment and technology? a. Inappropriately recommending that treatment be curtailed when treatment was actually needed b. Failing to apply the contractual definition of "experimental" treatment found in the client's insurance policy c. Substituting the case manager's clinical judgment for that of the insurer's medical director d. Upcoding intensity of care or intervention requirements

ANS: B For case managers, liability concerns exist when three conditions are met: (1) the provider had a duty to treat (i.e., provide reasonable care); (2) a breach of contract occurred through an act of omission; and (3) the act of omission caused injury or damage to the client. Five general areas of risk are liability for managing care, negligent referrals, use of experimental treatment or technology, breach of confidentiality/security, and fraud and abuse. With regard to the use of experimental treatment and technology, the case manager is obligated to apply the contractual definition of "experimental" treatment found in the client's insurance policy (certificate of coverage), because this a legally binding document between the insurer and the insured.

30.2. Counseling regarding hormone replacement therapy (HRT) should include the following information: a. menopause is a result of hormone deficiency, and therefore HRT is appropriate for all women to treat all symptoms. b. HRT should be used to prevent osteoporosis only among women who are unable to take non-estrogen medication. c. research concludes that HRT does prevent heart disease in menopausal women. d. HRT should be considered for prevention of osteoporosis in all women.

ANS: B For decades, many U.S. women used HRT, even though HRT remained untested by rigorous scientific study. A clinical trial launched in 1991, the Women's Health Initiative, set out to test specific effects HRT had on women's health, especially its effect on heart disease and osteoporosis. Researchers concluded that HRT did not prevent heart disease and that to prevent heart disease women should avoid smoking, reduce fat and cholesterol intake, limit salt and alcohol intake, maintain a healthy body weight, and be physically active. Scientists also concluded that HRT should be used to prevent osteoporosis only among women who are unable to take non-estrogen medications.

10.5. A community health nurse manager has integrated exposure history elements into the assessment practices of the health department that are relevant to the urban industrial community served. This strategy indicates that the nurse manager is aware of the relationship between: a. community strengths and weaknesses. b. environment and human health/disease. c. toxicology studies conducted by the Environmental Protection Agency and the environment. d. federal and state environmental regulations.

ANS: B Understanding the relationship between the environment and human health and disease has become more important over the years. The environment is now known to play a role as a determinant of health status, an explanation of disease, an influence on health risk, and a cause of human toxicity and the ever-increasing burden of potentially toxic synthetic chemicals that our bodies carry.

34.5. A migrant worker comes to the migrant health clinic holding the abdomen and complaining of empacho. The nurse may encounter this complaint when dealing with migrant workers who are: a. natives of Guatemala. b. natives of Mexico. c. natives of Panama. d. newly arrived from Haiti.

ANS: B Four common folk illnesses that a nurse may encounter when working with clients from Mexico are mal de ojo (evil eye), susto (fright), empacho (indigestion), and, for infants, caida de moller (fallen fontanel). Symptoms and folk treatments may vary depending on the individual's or family's place of origin in Mexico. When experiencing a folk illness, the traditional Mexican individual would prefer to seek care from a folk healer. The more common healers are curanderos, herbalists, and espiritualistas. The most common herbs used by the folk healers are chamomile (manzanilla), peppermint (yerba buena), aloe vera, nopales (cactus), and epazote. The nurse needs to ask clients what herbs and other remedies they have tried to help with their symptoms. Use of some herbs with prescribed medication may be contraindicated, and the nurse needs to include that information in client counseling. Any client counseling should incorporate awareness of and sensitivity to the client's culture.

30.1. To develop a baseline for a presentation at the local women's club about the status of women's health in the community, a community-oriented nurse researches national vital statistics to establish the leading cause of women's deaths in the United States. In the United States, the leading cause of death for women is: a. cancer. b. heart disease. c. stroke. d. infectious disease.

ANS: B Heart disease is the leading cause of death for both men and women. The lifetime risk for stroke is higher in women (~1 in 5) than men (~1 in 6). Since women live longer than men and strokes increase with age, more women are likely to die from stroke than men. Cancer is the second leading cause of death in the United States surpassed only by heart disease.

33.1. A nurse volunteering at a local homeless shelter notes that many of the clients have acute and chronic illnesses and are in need of primary health care services. The most effective strategy to consider when networking with homeless individuals, families, or populations is to: a. form a community partnership to establish a clinic for homeless persons. b. create a trusting environment and establish a therapeutic relationship. c. collaborate with the local United Way to obtain funding for primary care services. d. dialogue with local clergy to address the unmet primary care need for homeless persons.

ANS: B Nurses need to be able to work with poor and homeless clients to promote, maintain, and restore health. Nurses must be prepared to look at the whole picture: the person, the family, and the community interacting with the environment. In working with the homeless, it is important to create a trusting environment. Trust is essential to the development of a therapeutic relationship with poor or homeless persons. Many clients and families have been disappointed by interactions with health care and social systems. They are now mistrustful and see little hope for change. Establishing a trusting relationship lays the foundation for a more comprehensive assessment of clients' perception of their health care needs and a determination of factors that may contribute to their current health status issues.

19.5. Nurses practicing in rural communities often observe that protecting client confidentiality is a unique challenge because: a. nurses' family members expect nurses to share client information when something serious is happening to a community member. b. nurses in rural areas are well known to their service populations and are often approached by their clients in social and other settings with requests for counsel and advice. c. professional nurses in rural areas often work in more than one role in the community, which reduces their professional credibility. d. rural residents do not expect nurses to keep client information confidential because "everyone knows everyone" and his or her family.

ANS: B Nurses practicing in rural areas are obligated to maintain client confidentiality just as they would in an urban setting. However, nurses are often asked for health information and advice in nonclinical settings. Nurses must be especially sensitive and exercise creativity to maintain client confidentiality when approached in public settings.

19.8. A district health nurse is assigned to two rural communities in the state. To achieve the best outcomes possible in reducing the health disparities for the large number of frail elderly clients in the two counties, the nurse should consider using what community-oriented nursing approach? a. Assessment b. Case management c. Geriatrics d. Tertiary prevention

ANS: B Nurses working in rural areas, including those working with migrant workers, have opportunities to use community-oriented nursing skills. One of the first and most important is that of prevention. Given the barriers to receiving health care in rural areas, the ideal situation is to prevent health disruptions whenever possible. Case management and community-oriented primary health care are two effective models for addressing some of these deficits and reducing rural health disparities.

10.6. The Superfund Amendments and Reauthorization Act (SARA) increased the involvement of the states and their citizens in the cleanup of toxic waste sites and stressed the importance of permanent remedies and innovative treatment technologies. Another important aspect of this federal legislation was that it: a. provided for the appointment of state emergency response commissions. b. increased focus on the human health problems related to hazardous waste sites. c. established a new safety standard of reasonable certainty of no harm that is to be applied to all pesticides used on food. d. reduced the amount of pollution by mandating cost-effective changes in production, operation, and raw materials use.

ANS: B SARA changes included an increase in the size of the trust fund; encouraged greater citizen participation in decision making on how sites should be cleaned up; increased state involvement in every phase of the Superfund program; increased focus on human health problems related to hazardous waste sites; established new enforcement authorities and settlement tools; stressed the importance of permanent remedies and innovative treatment technologies in the cleanup of hazardous waste sites; provided for Superfund actions to consider standards in other federal and state regulations; and established the federal Agency for Toxic Substances and Disease Registry. This act amended the Comprehensive Environmental Response, Compensation, and Liability Act with provisions for a broader community-level involvement and public health mission to address the effects of hazardous waste sites on people.

13.2. A 6-year-old is brought to the emergency department with a full-body rash and fever. During the nursing assessment, which of the following findings would be most relevant to recognizing the case as potential smallpox rather than varicella? a. Fever has responded to acetaminophen, and the child is playful when temperature is not elevated. b. Fever of 101°F was present for several days before the rash appeared. c. Low-grade fever (100°F or less) has been present ever since the rash became obvious. d. Rash is primarily on the trunk of the body.

ANS: B Smallpox is associated with a sudden onset of fever, severe body aches, and occasional abdominal pain and vomiting, as in influenza. The rash, which is centrifugal with same-stage lesions in all areas but most abundant on the face and extremities, follows 2-4 days after the fever begins decreasing. With chickenpox, the rash is centripetal, with lesions most abundant on the trunk or in areas covered by clothing; the rash is present at the onset of symptoms, such as a slight fever with mild constitutional symptoms, and can appear as multiple crops of lesions at various stages of development (maculopapular lesions, vesicular lesions, or granular scabs).

38.5. Professional nursing organizations recommend that all women be routinely screened for domestic violence when they: a. come to the emergency department with physical trauma. b. come to any health care setting. c. repeatedly visit their primary care provider with symptoms of depression or anxiety. d. report increased financial stress in the home.

ANS: B Studies indicate that only a small percentage of battered women in emergency departments and other health care settings are identified as such and treated for the abuse, despite the significant prevalence of domestic violence. Battered women seek treatment in a number of ways and may be unaware of the relationship between their symptoms and the violence in their lives. Professional nursing associations (e.g., American Nurses Association; Emergency Nurses Association; Association of Women's Health, Obstetric and Neonatal Nurses; American College of Nurse-Midwives) recommend that all women be routinely screened for domestic violence each time they come to a health care setting. For the battered woman and the staff to begin to make the connection between her life situation and the presenting complaints, the nurse must ask direct questions in a supportive, open, and concerned manner.

10.3. A college health nurse is working with students, faculty, and staff to improve environmental air quality. To address the primary cause of air pollution on campus, the nurse plans a precautionary intervention. Which of the following interventions best demonstrates an appropriate approach? a. Encourage the use of electric cars and scooters on campus b. Increase the use of bicycles, foot-powered scooters, rollerblades, and walking as the primary mode of transportation on campus c. Make the entire campus a no-smoking zone d. Establish a policy to reduce electricity consumption in university buildings by raising the thermostat to 78° in the summer and lowering the thermostat to 70°in the winter

ANS: B The burning of fossil fuels to power automobiles and buses and to generate electricity is the single greatest source of air pollution in the United States. While reducing the use of electricity on campus is helpful, the single biggest source of campus air pollution is the cars and buses used to drive to and around campus. Decreasing their use is also an application of the precautionary principle.

19.3. A community-oriented nurse newly assigned to a rural community learns that the characteristics of rural and small town life include: a. consistent employment, formalized professional interactions, and openness to people new to the community. b. informal social and professional relationships, acquaintance of residents with most other members of the community, work of many residents in high-risk occupations, and often a lack of openness to newcomers. c. lack of anonymity, fractured family systems, role of churches as socialization centers, and mistrust of newcomers. d. tendency of residents to work in safety-oriented occupations, preference for autonomy rather than working as a community, and work in agriculture-related factories.

ANS: B The characteristics of rural life include such things as more space; greater distances between residents and services; cyclic/seasonal work and leisure activities; informal social and professional interactions; access to extended kinship families; high proportion of residents who are related or acquainted; lack of anonymity; confidentiality challenges; significant number of small, family-owned businesses; economic orientation to land and nature; higher prevalence of high-risk occupations; town center orientation; role of churches and schools as socialization centers; and a preference for "insiders" and mistrust of newcomers ("outsiders").

38.6. In following the principles of nursing interventions with violent families, nurses should: a. avoid provoking the perpetrator by initially suggesting that the victim leave the relationship. b. indicate zero tolerance for any further violence, degradation, or exploitation of family members. c. provide assurances that the family's confidentiality will not be violated. d. threaten to report child abuse to the authorities.

ANS: B The five principles of providing care to families who are experiencing violence include intolerance for violence, respect and care for all family members, safety as a first priority, absolute honesty, and empowerment. Nurses must clearly indicate that any further violence, degradation, and exploitation of family members will not be tolerated, but that all family members are respected, valued human beings. However, everyone must understand that the safety of every family member is the first priority. In all states, nurses are required by law to report child abuse, even when it is only suspected, and in most states they must also report elder abuse and felony assaults. Referral to protective service agencies should be viewed as enlisting another source of help. Absolute honesty about what will be reported to officials, what the family can expect, what the nurse is entering into the records, and what the nurse is feeling is essential.

33.5. A nurse working in a clinic in an inner city with high poverty and unemployment rates recognizes the need for programs for women because impoverished women are at higher risk for: a. decreased access to social services. b. poorer health status. c. exposure to environmental toxins. d. poorer academic success.

ANS: B The relationship between poverty and health is significant. Poverty presents a formidable obstacle to positive health across the life span. Those in lower income groups have poorer health status, and those with poor health have decreased ability to work and improve their socioeconomic status.

31.8. Women with disabilities may be at higher risk for abuse because women with disabilities are: a. less exposed to multiple caretakers. b. less likely to have access to resources. c. more independent. d. socially unattractive.

ANS: B Women and girls with disabilities face many challenges and often have to face "double discrimination." There is worldwide gender discrimination in such areas as access to housing, education, training, employment, and salary equity. Being female also places one at risk for sexual exploitation, abuse, neglect, and violence. Women with disabilities are at increased risk of this type of abuse because of the powerlessness of women in many parts of the world, the lack of resources, and women being undervalued.

MULTIPLE RESPONSE 31.9. A nurse conducting a home visit for a child with cerebral palsy observes the child gazing out of the window into the neighborhood. The nurse should provide guidance to the parents regarding: (Select all that apply.) a. adjusting the school schedule to keep the child occupied with studies. b. community attitudes about interacting with children with disabilities. c. opportunities for organized and spontaneous play. d. physical activity needs to avoid obesity.

ANS: B, C, D Greater emphasis has been placed on increasing children's physical activity to avoid childhood obesity, but children with any type of a disability continue to be less physically active and at greater risk of obesity than their healthy peers. This is a result of the relative lack of available opportunities for disabled children to participate in organized and spontaneous play. Additionally, nondisabled children and their parents may have negative attitudes about interacting or playing with disabled children.

MULTIPLE RESPONSE 34.10. The community health nurse can serve as an advocate for the vulnerable migrant population by engaging in which of the following actions? (Select all that apply.) a. Becoming culturally and linguistically competent b. Collecting necessary data on migrant workers' lifestyle and health status c. Educating communities about the migrant workers in their areas d. Educating policymakers about successful programs for migrant workers e. Using lay health workers to provide health education in migrant camps

ANS: B, C, D Nurses can serve as social and political advocates for migrant populations. Educating communities regarding these individuals, collecting necessary data on their lives and health, and communicating with legislators and other policymakers at local, state, and national levels are necessary actions that nurses are prepared to undertake.

MULTIPLE RESPONSE 38.10. When conducting a nursing assessment of a child, the nurse should be aware that indicators of potential or actual child abuse may include which of the following? (Select all that apply.) a. Cognitive impairment b. Unusual fear of the nurse and others c. Injuries not mentioned in history d. Seems to need to take care of the parent e. Evidence of general poor care

ANS: B, C, D, E A national survey estimated that in 2011, 742,000 unique reports of children and adolescents who were subjected to neglect, medical neglect, physical and sexual abuse, and emotional maltreatment. Of these children, 78% were victims of neglect; 18% were victims of physical abuse, 10% were sexually abused, and 8% were psychologically maltreated. The remaining 2% were medically neglected. This is probably a conservative figure, since only the most severe cases are reported. Careful assessments through both observation and discussion can help in determining the presence of indicators that require further investigation. When conducting a nursing assessment of the child, the nurse should be aware of indicators of potential or actual abuse in the child as well as indicators in the family and its environment.

MULTIPLE RESPONSE 31.10. Conditions that may lead to disability typically are the focus of primary prevention activities. However, all three levels of prevention apply to physically compromised clients, primarily because the focus should be on which of the following? (Select all that apply.) a. Addressing the client's perception of himself or herself in terms of the disability b. Establishing lifelong, health-promoting behaviors c. Integrating appropriate complementary and alternative medicine treatments d. Overcoming barriers to disease prevention activities e. Preventing complications from the effects of immobility and the disease process

ANS: B, D, E Many health promotion and disease prevention needs are similar across the life span. However, the specific problems encountered and interventions required to deal with the needs of persons with disabilities vary depending on age, the specific disabling condition, and developmental status. Health promotion is a multidimensional concept that applies to all individuals regardless of disability. Both health-promotion and disease-prevention programs for persons with disabilities should focus on preventing the complications from the effects of immobility and the disease process. The complications of immobility and the disease process must be prevented to ensure optimal independent and healthy living, so that the individual with disabilities has the opportunity to lead a productive and happy life.

38.7. Community-level factors that influence violence and human abuse are: a. bullying, gangs, and corporal punishment. b. job boredom and unemployment rate. c. population density, sense of cohesiveness, and diversity. d. poverty, recreational facilities, and access to health care.

ANS: C A community's population, resources, and facilities can influence violence and human abuse. Density, poverty, and diversity are population-level factors that affect the incidence of violence and are related to issues such as overcrowding, lack of economic opportunity, racial tension, and overt racism. A community sense of cohesiveness may reduce crime, provide support, and promote harmony. Community resources and facilities provided to residents offer socially acceptable outlets for a variety of feelings, including aggression, but their presence alone does not prevent violence or crime.

34.3. The definition of a migrant farmworker includes which of the following? a. Farmer who helps his neighbors on their farms after his own crop fails b. High school student who works part time at his uncle's rose farm c. Teenager who moved with his family ten times in 2 years to work different crops d. Woman who works in the crop fields in the summer and at a grocery store in thewinter

ANS: C According to the Department of Labor, a migrant farmworker is a seasonal farmworker who had to travel to do the farm work and was unable to return to a permanent residence within the same day. A seasonal farmworker returns to his permanent residence, worked in agriculture for at least 25 days or parts of days and did not work year round only in agriculture.

30.6. Although all men are at risk for developing prostate cancer, those at greatest risk are men who: a. have erectile dysfunction. b. fail to undergo prostate-specific antigen testing or digital rectal screening. c. are African American. d. have multiple sex partners.

ANS: C According to the National Cancer Institute, approximately 15% of men will be diagnosed with prostate cancer in their lifetime. It is the most common non-skin cancer and the second leading cause of cancer deaths in the United States. African American men have higher rates of prostate cancer compared to all races. Prostate cancer is linked to changes in the DNA of a prostate cancer cell and high levels of male hormones, but the exact cause of prostate cancer is unknown.

30.7. A new primary health clinic is established in a predominantly African American neighborhood to address the top causes of mortality in the local adult population. The nurse at the clinic uses a community-focused nursing process to plan interventions aimed at reducing the incidence of: a. cardiovascular accident, lung cancer, and alcoholism. b. depression, alcohol abuse, and obesity. c. heart disease, stroke, and homicide. d. mental illness, drug and alcohol abuse, and heart disease.

ANS: C African Americans in 2009 had the highest death rates from heart disease and stroke compared with other racial and ethnic populations. They also had the highest death rates from homicide, with rates among African American males highest across all age groups among males (Centers for Disease Control and Prevention (CDC) Health Disparities and Inequalities Report, 2013).

13. 9. Although infectious disease epidemics are still the major cause of death worldwide, they have subsided in the United States because of improvements in nutrition and sanitation, the discovery of antibiotics, and the development of vaccines. Infectious diseases have not vanished, however, and remain a continuing cause of concern. Healthy People 2020 has a number of objectives aimed at reducing these illnesses because of the morbidity, mortality, and costs associated with infectious diseases. One such costly disease trend related to an increase in the performance of invasive diagnostic and surgical procedures, the use of broad-spectrum antibiotics, and treatment with immunosuppressive drugs is the rise of: a. Escherichia coli 0157:H7. b. multisyndrome effect. c. health care-associated infections. d. severe acute respiratory syndrome.

ANS: C Although infectious diseases may not be the leading cause of death in the United States at the beginning of the twenty-first century, they continue to present varied, multiple, and complex challenges to all health care providers. One trend in the United States is the rise of health care-associated infections. Pennsylvania, the first state in the country to examine the costs of these infections, reported that health care-associated infections led to $2 billion in additional hospital charges and at least 1500 preventable deaths in 2004. Health care-associated infections are acquired during hospitalization or develop within a hospital setting and were previously known as nosocomial or hospital-acquired infections. The performance of invasive diagnostic and surgical procedures, the use of broad-spectrum antibiotics, and treatment with immunosuppressive drugs, along with the original underlying illness, leave hospitalized clients particularly vulnerable to infection by virulent agents carried by other clients and indigenous hospital flora transmitted by health care staff.

30.3. At the request of a local senior women's group, a nurse is developing an osteoporosis primary prevention program. An appropriate strategy for the program would be to: a. design a nurse-directed program instead of a peer-directed program. b. encourage exercise and consideration of HRT. c. promote diets rich in calcium and vitamin D and daily weight-bearing exercise. d. promote swimming and supplementation with calcium and vitamin D.

ANS: C Among women older than age 50 years in the United States, approximately one in two will experience an osteoporosis-related fracture at some point in their lifetime. Primary prevention measures include consumption of a diet rich in calcium and vitamin D, and supplementation with calcium and vitamin D only if needed. Weight-bearing exercise is also important in maintaining bone density. Weight-bearing exercise includes activities such as walking, running, stair climbing, and weight lifting. Swimming is not a weight-bearing exercise. Limiting alcohol consumption and avoiding smoking are also important. Community-oriented nursing includes empowerment of community members as peer educators and change agents.

22.6. A community health nurse involved in care management would most likely: a. develop, conduct, and evaluate health teaching programs in primary care. b. manage the staff at a free clinic. c. monitor the health status, resources, and outcomes for an aggregate. d. provide immunizations to migrant workers.

ANS: C Care management is a continuing process in which a case manager establishes systems and monitors the health status, resources, and outcomes for an aggregate—a targeted segment of the population or group.

7.8. A community-based hospice nurse has an Asian male client with terminal-stage cancer. The client complains that he is in continuous pain and receives no relief from the codeine prescribed by his primary care physician (PCP). Because this nurse is culturally competent with Asian clients, the nurse contacts the client's PCP to discuss replacing this medication with another pain-reducing drug. The nurse's action can best be described as an example of: a. cultural accommodation. b. cultural assessment. c. cultural brokering. d. cultural repatterning.

ANS: C Cultural brokering is an action used by nurses in delivering culturally competent care. Cultural brokering is advocating, mediating, negotiating, and intervening between the client's culture and the biomedical health care culture on behalf of the client.

31.6. The nurse assesses a client with paraplegia and cataracts. The client holds a full-time job and engages in several hobbies. The nurse documents that the client has: a. dual diagnoses. b. functional limitations and is wheelchair bound. c. visual and physical limitations. d. visual impairment and physical disability.

ANS: C Functional limitations occur when individuals experience difficulty performing basic activities of daily living because of their disability. Examples of functional limitations include difficulty standing, walking, climbing, grasping, and reading. Emphasis is placed on the level of function rather than on the purpose of the activity, so that functional limitation can be associated with the disability.

33.4. Within the impoverished older adult population, the most vulnerable group may be: a. elderly couples living in poverty with serious chronic illnesses. b. elderly men with alcoholism and limited incomes. c. homeless older adults. d. newly widowed, low-income elderly women.

ANS: C Homeless older adults are the most vulnerable of the impoverished older adult population. They have long lived in poverty, have fewer supportive relationships, and are likely to have become homeless as a result of catastrophic events. Life expectancy for homeless older adults is significantly lower than that for older housed adults. Permanent physical deformities, often secondary to poor or absent medical care, are common among homeless older adults. Homeless older adults suffer from untreated chronic conditions, including tuberculosis, hypertension, arthritis, cardiovascular disease, injuries, malnutrition, poor oral health, and hypothermia. As with younger homeless persons, older adults who are homeless must focus their energy on survival, which leaves little time for health promotion activities.

19.6. A rural health nurse who is planning programs to address the population's needs should recognize that, in general, rural populations: a. engage in physical activity during leisure time. b. engage in preventive health behaviors. c. perceive their overall health as less favorable. d. use seat belts.

ANS: C In general, people in rural areas have a poorer perception of their overall health and functional status than those in urban areas.

13.1. A local health department in the Midwest reports cases of certain diseases to the state health department for inclusion in the National Notifiable Diseases Surveillance System (NNDSS). From the perspective of community-level disease monitoring, which of the following 3-year trends in incidence rates for hepatitis A would be of local, state, and national interest? a. 2012 = 2/100,000; 2013 = 3/100,000; 2014 = 1/100,000 b. 2012 = 4/100,000; 2013 = 8/100,000; 2014 = 6/100,000 c. 2012 = 12/100,000; 2013 = 8/100,000; 2014 = 31/100,000 d. 2012 = 16/100,000; 2013 = 24/100,000; 2014 = 9/100,000

ANS: C In this community's report, the incidence of hepatitis A in 2014 was more than double the incidence in 2012. At the community level, a disease may occur in endemic, epidemic, or pandemic proportions. An epidemic is the occurrence of disease in a community or region at a rate in excess of normal expectations. Although people tend to associate large numbers of cases with epidemics, even one case can be termed an epidemic if the disease is considered to have been previously eliminated.

34.6. An undocumented migrant farmworker has been diagnosed with TB. The local health department initiates treatment by dispensing the first month's supply of medication and educates the client on the need to continue treatment for 6-12 months. A major challenge that the client may face to ongoing treatment for TB is: a. affordable care. b. discrimination. c. fragmented services. d. language barriers.

ANS: C Many factors limit adequate provision of health care services to migrant farmworkers, such as lack of knowledge regarding services, inability to afford care, lack of availability of services, lack of transportation, inconvenient hours of health service facilities, mobility and difficulty in tracking the client, discrimination, lack of documentation, lack of English language skills, and cultural aspects of health care. When migrant families move from job to job, their health records do not typically go with them, which leads to fragmentation of services in such areas as TB treatment, chronic illness management, and immunization.

34.7. The local hospital emergency department has recently noted an increase in gastroenteritis cases among migrant farmworkers. The local health department is informed of the rise in cases and schedules a case mapping of: a. bars frequented by migrant workers. b. farm fields employing migrant workers. c. housing for migrant workers. d. restaurants frequented by migrant workers.

ANS: C Migrant farmworkers often have trouble finding decent and affordable housing. Housing conditions vary between states and localities. Because housing may be expensive, 50 men may live in one house or three families may live in one trailer. Not only may conditions be crowded, but also housing may lack individual sanitation, bathing, or laundry facilities; provide poor cooking/refrigeration facilities; and lack window screens, fans, or heaters. Infectious diseases caused by poor sanitary conditions at work or home, poor-quality drinking water, and contaminated foods may take the form of acute gastroenteritis and parasite infestations.

38.4. In caring for a rape victim/survivor, the nurse should be aware that the client will initially exhibit: a. anger and fear with repeated recounting of the sequence of events during the assault. b. crying, shouting, and hysteria followed by helplessness and self-blame. c. different responses that vary from client to client and may include emotional withdrawal, silence, and/or repeated verbal description of the event. d. symptoms of early onset posttraumatic stress disorder.

ANS: C People react to rape differently, depending on personality, past experiences, background, and support received after the trauma. Some survivors cry, shout, or discuss the experience. Others withdraw and fear discussing the attack. A noncritical atmosphere should be created in which survivors are encouraged to talk about what happened and to express their feelings and fears. The nurse needs to engage in nonjudgmental listening.

13.6. An example of secondary prevention of infectious disease is: a. malaria chemoprophylaxis. b. Pneumocystis carinii pneumonia chemoprophylaxis for people with AIDS. c. quarantine. d. restaurant inspections.

ANS: C Secondary prevention interventions related to infectious disease prevent the spread of disease. Primary prevention interventions prevent the occurrence of disease, and tertiary prevention interventions reduce the complications and disabilities of disease through treatment and rehabilitation. Secondary prevention activities center on rapid identification of potential contacts of a reported case. Contacts may be identified as new cases and treated or classified as possibly exposed and given appropriate prophylaxis. Public health laws also assist in secondary prevention because they require investigation of certain disease cases and initiation of preventive measures for individuals affected by a reported case or outbreak of communicable disease. These interventions can include quarantine and can be applied to the entire community if the exposure potential is deemed great enough, as could happen with an outbreak of smallpox or epidemic influenza.

34.8. A community health nurse seeks to enhance the health promotion and health-service-seeking behaviors of the migrant farmworkers in local apple orchards. An evidence-based strategy that would be effective for this mobile population is educating: a. advocacy groups for migrant farmworkers. b. local policymakers. c. migrant lay health workers. d. workers seeking care at the migrant health clinic.

ANS: C The nurse can teach health-promotion strategies and strategies for obtaining health services to members of the migrant community, who, in turn, become empowered as lay health care workers to provide education and outreach to the migrant community as it moves from place to place. Several migrant health programs have recruited migrant workers to serve as outreach workers and lay camp aides to assist in outreach and health education of the workers. Outreach programs succeed because they recognize the diversity of vulnerable groups and the need for flexibility in the provision of services. Because these outreach workers are members of the migrant community, they are trusted and know the culture and the language. Nurses can be a part of the planning and teaching for outreach programs.

7.7. A Public Health Service nurse employed by the Indian Health Service is working with a client diagnosed with cancer. The client uses sweat lodges to "cure the disease." The nurse understands the need for the client to use traditional healing practices. The nurse is integrating her knowledge of the cultural organizing factor of: a. biological variations. b. communication. c. environmental control. d. space.

ANS: C The nurse understands that in the client's culture, disease is often perceived as a disharmony with other forces, and clients may look to hot or cold treatments to resolve or cure a cancerous condition. Clients may use the mind-body-spirit connection to heal from within. Such cultures rely on naturalistic solutions such as herbs, hot and cold treatments, and acupuncture to resolve or cure a cancerous condition.

34.4. The migrant clinic's mobile van program provides health education through lay health workers; screening for pesticide illness, tuberculosis (TB), and diabetes; pregnancy testing; and treatment for some acute and chronic illnesses typically seen in this vulnerable population. In dealing with this population's beliefs about disease causality, this program demonstrates the application of the health promotion and disease prevention principle of: a. advocacy. b. cultural competency. c. outreach. d. primary prevention.

ANS: C The same principles of health promotion and prevention apply to migrant farmworkers as to the rest of the U.S. population. However, health promotion and disease prevention as presented by nurses may be difficult concepts for migrant workers to embrace because of their beliefs regarding disease causality, their irregular and episodic contact with the health system, and their lower educational level. Health promotion begins by informing the farmworker family about health topics and the resources available to improve health. Several migrant health programs have recruited migrant workers to serve as outreach workers and lay camp aides to assist in outreach and health education of the workers.

34.1. In caring for migrant workers and their families, the nurse should first assess the migrant workers' lifestyle, especially their current: a. communicable diseases. b. educational level. c. housing arrangements. d. pesticide exposure.

ANS: C The way of life of migrant farmworkers and their families is stressful. They often have trouble finding decent and affordable housing. Available housing is often overcrowded and lacking in individual sanitation, bathing or laundry facilities, window screens, and fans or heaters. Housing may be located in hazardous areas next to fields or farm machinery. Housing may be rundown or structurally deficient. Some families may be living in cars or tents when housing is unavailable. All of these factors impact the health status of migrant families and need to be understood by the nurse to direct further assessment.

33.9. To provide effective care and advocacy for individuals, families, and populations living in poverty, nurses must first: a. apply epidemiologic principles for prevention. b. develop resource expertise in the community. c. examine their personal beliefs, values, and experiences. d. understand the federal criteria and guidelines for poverty.

ANS: C To provide effective care and advocacy for individuals, families, and populations living in poverty, nurses need to understand poverty as a concept with historical, social, political, economic, biological, psychological, and spiritual dimensions. Understanding the concepts of poverty and homelessness begins with an examination of one's own beliefs, values, and personal experience.

10.8. When applying the nursing process to environmental health, the nurse would: a. conduct an assessment focused on the client's presenting problem. b. coordinate interventions with the primary care provider of record. c. examine criteria that are limited to the client's immediate responses. d. include outcome measures that involve mitigation and elimination of the contributing factors.

ANS: D If the nurse suspects that the client's health problem is being influenced by environmental factors, the nurse should follow the nursing process and note the environmental aspects of the problem in every step of the nursing process. For instance, in goal setting, the nurse should include outcome measures that relate to mitigation and elimination of the environmental factors.

10.2. An occupational health nurse practitioner's physical assessment of a factory worker identifies an acute-onset pruritic dermatitis extending over the face, hands, neck, and forearms. The nurse's priorities should be to: a. contact factory senior management, educate workers about their exposure, and clean the area. b. contact the Occupational Safety and Health Administration immediately and remove the offending chemical in the work environment. c. immediately evacuate the worker's nearby workspace and treat the worker and other exposed workers. d. treat the client and obtain a comprehensive exposure history; if an on-site environmental exposure is suspected as the cause, screen other at-risk workers and ensure that the environmental risk is identified and eliminated.

ANS: D A careful history should be taken using the I PREPARE (Investigate potential exposures, Present work, Residence, Environmental concerns, Past work, Activities, Referrals and resources, Educate) model. The client should be appropriately treated. If an on-site environmental exposure is suspected, other at-risk workers should be screened and treated as needed. The environmental cause should be resolved, either by removing the offending chemical or reducing it to safer levels. Factory safety policies should be followed, reviewed, and changed if needed. State and federal agencies should be notified as required.

19.2. A community health nurse is prioritizing health-promotion activities with the local rural community. An understanding of the health status and health risks of the rural community would lead the nurse to give priority to: a. aerobic exercise classes and an exercise class for seniors with arthritis. b. English as a second language program using health promotion literature as reading materials. c. mentoring program to increase adult literacy. d. motor vehicle and farm accident prevention project and prenatal care outreach program.

ANS: D All of the health-promotion activities mentioned would be helpful for a rural community. However, health-promotion activities should be prioritized according to the most common causes of morbidity and mortality for the population served. Rural residents are at increased risk of injury and death secondary to motor vehicle accident and farm-related occupational injuries. Rural residents also have increased rates of infant and maternal morbidity and mortality.

22.1. A home health case manager is charged with identifying opportunities for health promotion and illness prevention. The fulfillment of this charge would best be demonstrated when the case manager: a. collaborates with a local chaplain to ensure that the spiritual needs of cancer clients are addressed. b. refers a new diabetic client to a nutrition counselor for dietary teaching. c. teaches a school nurse how to care for a client who will be returning to school and will require new asthma treatments. d. tracks the immunization status of clients and facilitates access to immunization when needed.

ANS: D Case management involves assessment—in this case, screening—and arrangement for delivery of services. Primary prevention includes case management to identify at-risk clients and arrange for services to prevent disease. Through nurse management activities, general community deficiencies in the quality or quantity of health services are often discovered. Case management activities with individual clients and families will reveal the broader picture of health services in and health status of the community. Community assessment, policy development, and assurance activities that frame the core functions of public health actions are often the logical next step in the nurse case manager's practice to intervene at the community level to make changes. Therefore, the core components of case management and the nursing process are complementary. The nursing process function of assessment is complementary to the case management process function of case finding and includes such activities as applying screening tools according to program goals and objectives.

7.1. A nurse asks a couple who are new parents for their baby's full name. The parents reply that they are only supposed to give the baby its first name. The most appropriate response for the nurse is to: a. tell the couple that they are the child's parents and it is up to them to name their baby. b. explain to the couple the state's bureau of vital statistics deadline for completing the birth certificate. c. give the couple the paperwork and ask when the baby will have a name. d. express interest and ask the couple to share how their new baby will receive its name.

ANS: D Dealing effectively with immigrant populations includes learning about how the community deals with common events and what their traditional practices are. In some cultures, it is not the parents but their spiritual leader or a more senior family member who gives a baby its name. Nurses should engage in cultural encounters to learn about a client's culture and practices.

33.3. Deinstitutionalization of chronically ill individuals from publicly funded psychiatric hospitals had the unintended consequence of: a. moving clients to readily available community-based care. b. shortening hospital stays in mental health facilities. c. increasing the funding for community-based services. d. increasing the number of homeless persons.

ANS: D Deinstitutionalization of chronically mentally ill individuals from public psychiatric hospitals increased the number of homeless persons. The intent was to move clients from public psychiatric hospitals to community-based treatment centers. However, adequate community-based services were not funded. Few of the intended community mental health centers were ever built.

10.4. Campaigns to decrease the inequitable burden of environmental risks on the poor and people of color in the United States strive to apply the ethical principle of: a. societal justice. b. nonmaleficence. c. compliance and enforcement of the Environmental Protection Agency Regulatory Act. d. environmental justice.

ANS: D Environmental health risks notably have disproportionately affected poor people and people of color in the United States. Low-income citizens and people of color are more likely to live near a hazardous waste site, and increased incidence of childhood lead poisoning and increased rates of childhood asthma are seen in these groups. Environmental justice is the principle of assuring that no group is more at risk of harmful exposure than another.

10.1. A nurse identifies higher-than-normal levels of lead when screening a 3-year-old child. The nurse works with the local health department to put together a team to address the environmental issues responsible for the child's abnormal lead level. Team members should include the following specialists: a. epidemiologist, pediatric specialist, and sanitarian. b. laboratory specialist, contractor whose bid for lead reduction work is the lowest, and public health lead reduction specialist. c. public health sanitarian, pediatric generalist, and plumbing inspector. d. specially trained housing inspector, pediatric specialist, lead-based paint intervention team, and laboratory specialists to test the child's home and the surrounding neighborhood.

ANS: D Environmental health-risk identification and risk-reduction intervention require a multidisciplinary team. The team members needed to address an elevated lead level in a child include a specially trained housing inspector, a sanitarian familiar with lead health risks, a nurse practitioner and/or physician trained to intervene in cases of pediatric lead exposure, and housing specialists trained to reduce lead-based paint risk in the home.

19.1. A clinic has received funds to pay for clinic visits for farm residents who live in frontier or rural, nonmetropolitan statistical areas. Which of the following client(s) would qualify to receive this special funding? a. Client who lives next to a ranch in a town of 1200 people b. 70-year-old client residing in an assisted living facility in a rural area c. Apple grower who lives in a 100-square-mile county with a population of 19,900 d. Soybean grower and his wife who live in a 400-square-mile county with a population of 39,501

ANS: D Farm residency denotes living outside "city limits" and involvement in agriculture. Frontier regions have fewer than six persons per square mile; rural communities have fewer than 20,000 residents or fewer than 99 persons per square mile. Nonmetropolitan statistical areas are regions without a central city of 50,000 or more citizens. The soybean grower and his wife make their living in agriculture (farm resident), and the county where they live has fewer than 99 persons per square mile (rural).

38.3. In conducting a nursing assessment of new parents the nurse should be aware of the warning signs of actual or potential abuse, including: a. history of adolescent depression and suicidal thoughts. b. intermittent religious affiliations. c. lack of legal marital status. d. verbal aggressiveness or detachment.

ANS: D Nurses are in key positions to predict and deal with abusive tendencies. By understanding the factors contributing to the development of abusive behaviors, nurses can identify abuse-prone families and target specific interventions to eliminate or minimize the risk for abuse through primary prevention strategies.

38.1. The most effective primary prevention intervention to reduce the incidence of child abuse is: a. adolescent role playing of the realities of parenting. b. education of grandparents on the risk factors and indicators of child abuse. c. provision of parenting classes for college students. d. provision of parenting and conflict-management classes for survivors of child abuse.

ANS: D Parents who were themselves abused or witnessed abuse or other types of family violence are at markedly higher risk of abusing their own children. Primary prevention of abuse includes strengthening individuals and families so they can cope more effectively with multiple life stressors and demands, and reducing the destructive elements in the community that support and encourage violence. Strengthening parenting skills and teaching successful conflict resolution are specific areas to target to provide new learning and correct earlier childhood influences.

22.8. Members of an extended family are in conflict over the treatment plan for the family's 90-year-old matriarch, who has developed indications of advanced dementia. The case manager is using conflict resolution strategies to allow the parties involved to develop trust, credibility, and distance from the issue at hand, as well as to retain personal dignity. The nurse is demonstrating a knowledge of the strategic process of: a. advocating. b. clarifying. c. cooperating. d. negotiating.

ANS: D Techniques for conflict management involve a range of active communication skills. These skills are directed toward learning all parties' needs and desires, detecting their areas of agreement and disagreement, determining their abilities to collaborate, and assisting in discovering alternatives and activities for reaching the goal of mutual benefit with limited loss. Negotiating is a strategic process used to move conflicting parties toward an outcome and has several stages that allow the parties to develop trust, credibility, and distance from the issue, while retaining personal dignity. All of these factors are important when attempting to move parties toward the creation of new solutions or options through relearning, brainstorming, reflective thinking, and problem-purpose-expansion techniques (systematic problem solving approaches).

22.4. A community health nurse is the case manager for a homebound client recovering from a hip replacement. The nurse works with the client and his family to prioritize needs and services, and to address these care needs. These activities represent which step in the nursing process? a. Assessment and planning/outcome b. Diagnosis and planning c. Implementation d. Planning/outcome

ANS: D The case management process function of problem prioritizing and planning to address care needs is complementary to the planning/outcome step of the nursing process.

MULTIPLE RESPONSE 22.1. A nurse performing home hospice case management notes the increasing number of hospice clients who lack caregivers in the home environment. The nurse identifies the potential need for a hospice house facility to meet the needs of these clients. The case management process frequently reveals larger picture issues such as which of the following?(Select all that apply.) a. Community cost concerns b. Community conflict resolution skills c. Community satisfaction d. Community weaknesses in quality of services e. Community weaknesses in quantity of services

ANS: D, E Case management activities with individual clients and families very often reveal the larger picture of health services and health status of a community. General community weaknesses in the quality and quantity of services often are discovered. The nurse can then intervene at the community level to initiate changes. In this case, the nurse identified a deficiency in the quality of hospice services to individuals who did not have a caregiver in the home environment and the parallel concern of the lack of hospice-related facilities to meet the needs of these clients to achieve a quality dying process.