INTRO CH. 4
The nurse enters the client's room in the acute care unit immediately after the client experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take?
Position the client in a side-lying position.
Parents raising two school-aged children incorporate their religious beliefs into the family's daily life. The family's beliefs regarding religion include dietary considerations, worship practices, attitudes, and values. This is an example of which function of the family?
Socialization
The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?
The father is an engineer and the mother is an elementary school teacher.
The home health nurse is making an initial assessment visit to a family that consists of two parents and twin 3-year-old boys. During the interview, the nurse is most concerned if the client makes which statement?
The father states, "I don't discuss money matters with my wife because I don't want her to worry."
A nurse is assessing a family with adolescents. The family consists of a father, mother, a 13-year-old son, a 14-year-old son from a previous marriage, and a 16-year-old daughter. Which statement by the parents would lead the nurse to suspect a potential risk factor for altered health with this family?
"Our 16-year-old just seems to butt heads with us at every turn."
Which client requires priority intervention by a nurse providing care on a medical-surgical unit?
A postsurgical client who is feeling dizzy and has a heart rate of 45 beats/min
The nurse is caring for a client diagnosed with terminal cancer who wishes to use meditation and prayer to be cured. What is the appropriate nursing action?
Advocate for the client's choice.
What is an example of a community risk factor?
Children are kept inside on a sunny day due to a lack of recreational opportunities.
A community is defined as a social group that may or may not share common geographic boundaries yet interact because of
Common interests
A nurse is developing a plan of care for a client to meet the client's self-actualization needs. The nurse would focus on which area as most important?
Emphasizing the client's strengths
The nurse is aware that basic client needs must be met before a client can focus on higher ones. According to Maslow's hierarchy of human needs, which example would be the highest priority for a client after physiologic needs have been met?
Grab bars are installed in a client bathroom to facilitate safe showering.
Which are stressors that affect the health of the family?
Inadequate childcare services
A young couple who have been married less than a year are having difficulty with adjusting to parenting. What is a contributing factor to this level of maladjustment?
Limited time in learning to be a marital partner
A family that consists of two homosexual parents and three children living in the same house is an example of which type of family?
Nuclear
A nurse is planning education on self-administration of insulin to the client and the client's family members. The client asks the nurse why the family members are also included in the teaching. What should the nurse's response be?
"Family members are equally involved in planning and implementation of care."
A client comes to the health center for a follow-up visit. Assessment reveals that the client is experiencing problems ambulating and moving about due to degenerative joint disease; in addition, the client is feeling isolated due to the limitations in mobility. The client also reports feeling anxious about the future related to the mobility issues and being unable to fulfill the role as the major provider. Which need would the nurse identify as the priority?
Mobility
During the nurse's admission interview the client says, "I don't get too much rest because I am in nursing school and work full time to support myself and my kids." The nurse classifies this statement as an issue at which level of Maslow's basic needs?
Physiologic
The nurse is taking care of a client who is scheduled for a mastectomy. The client tells the nurse that the client is apprehensive about the operation and asks the nurse to read a passage from the Koran to help prepare the client for surgery. Which action by the nurse is the most appropriate?
Read the Koran passage to the client.
A nurse in the emergency department assesses a 3-year-old child with a fractured femur, a hematoma on the back of the head, and multiple 1-cm round scabs and blisters on the upper back. The parents state that their child sustained the injuries by falling out of a high chair. What is the best action for the nurse to take?
Report the suspected child abuse to Child Protective Services.
The nurse is explaining the expected developmental tasks of a typical family with adolescents. Which of the following would be incorrect for the nurse to include?
Adjustment to retirement
A nurse is conducting a community health assessment for high risk families. What risk factors should the nurse identify? Select all that apply.
New sibling was introduced two months ago. Family does not have health insurance. Home is located in an area with gang violence. Nearest acute care facility is 45 minutes away.
A nurse is working at a community clinic that serves mostly families with young children. What would be a priority intervention for clients in this developmental stage?
Setting up parenting classes
During the patient assessment, the client shares that the family attends church nearly every Sunday. Which function of the family does this represent?
Socialization
A nurse is evaluating a child for new onset of bedwetting. Which nursing action is the priority?
Collect a urine sample for the prescribed urinalysis (UA).
A nurse is reviewing a journal article about basic human needs and how they can be applied as a framework for prioritizing nursing care. Place the interventions listed below in order of priority, based on client needs. Use all options.
Ensuring adequate fluid intake Encouraging the client's spiritual practices Referring the client to a support group Encouraging the client to set attainable goals Providing education focusing on the client's strengths to maximize potential
The parents of a blended family have a baby boy age six months who is due for immunizations. The clinic closest to their home has recently closed, and they feel intimidated by the prospect of going to the large, university hospital near their home. Which type of factor is the primary influence on this aspect of the family's health?
Community health care structure
The community offers physician offices, a county health department, a community hospital, an assisted living facility, two nursing homes, and hospice. The nurse recognizes that these agencies represent which type of community factor?
Community healthcare structure
A client says, "I live in a small community on the northwest side of the city." Why does the nurse consider it significant that the client reports living in a community rather than a neighborhood?
Community indicates people who share similar characteristics.
A home health nurse is visiting a family after the recent death of their matriarch. The nurse observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. The nurse asks what is happening, and is told, "We are Jewish, and the family is 'Sitting Shiva'." This family is fulfilling which family function?
affective and coping functions
A client with persistent nausea is diagnosed with somatization. What is the appropriate nursing action when the client reports nausea?
sit with the client and ask them about their feelings
A nurse is caring for an adolescent who lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address?
Self-esteem needs
The nurse assists a postoperative client with ambulation. The nurse recognizes that assisting the client when performing this skill meets which of Maslow's basic human needs?
Safety and security
The nurse is assessing the communication style of the client. Communication is an example of which dimension of the individual?
Sociocultural dimension
