NUR162 CH4 prepU

An adolescent confides in the school nurse that she is arguing daily with her mother, and she often wonders if her mother loves her. The school nurse recognizes that the student faces which of the following risk factors for altered family health?

A psychosocial risk factor

A nurse is planning education on self-administration of insulin to the client and his 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."

The nurse is admitting a 38-year-old male client to the oncology unit whose religious background is different from her own. The nurse is assessing how the client's religion may affect his health care needs. Which question by the nurse is the best way to consider the client's religious practices in the plan of care?

"What can we do to help you meet any religious needs you may have?"

A nurse has the Petty Family as a client, who consists of a wife, husband, and their 4-year-old daughter. The husband has been unemployed for 8 months, and they lost their apartment. The family has been staying in neighborhood shelters and, on occasion, with the husband's father for a night or two. When evaluating this family, the nurse identifies this family as which type?

A homeless family

A nurse is prioritizing care for patients in a hospital setting. Place the following examples of interventions to meet human needs in order from highest-level needs to lower-level needs based on Maslow's hierarchy.

A nurse provides nutrition for a patient through a feeding tube. A nurse places a No Smoking sign on the door of a patient who is receiving oxygen. A nurse includes family members in the care of a patient. A nurse prepares a room for a clerical visit requested by a patient. A nurse helps a patient focus on her strengths following a diagnosis of breast cancer.

Nursing, as a profession, has long held the belief that providing nursing care to an individual patient means providing nursing care to the entire family. What does this mean when put into a holistic framework of patient care?

Active participation by individuals and families in health promotion is integral to this framework of patient care.

An 85-year-old man is being transferred from his house to a nursing home by his wife. What is the first action the nurse should take to help reduce the stress of relocation on the client?

Assess the client's usual lifestyle and daily activities.

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

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

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

Extended family.

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

Family members

The nurse in the adolescent in-patient psychiatric unit is interviewing the family of a 16-year-old client admitted for depression and threatened suicide. What assessment information is most essential for the nurse in determining the affective and coping function of the family?

Family patterns of communication

A community health nurse is providing care to several farming families in a rural community. Which of the following would be most important for the nurse to integrate into the plans of care for these families?

Family structures may change over time.

A nurse in a wellness center is presenting a class on integrating holistic therapies with traditional health care. The nurse talks about the trend in health care to treat each client in a manner that reconnects their total being. Which of the following would best be considered a holistic approach to health?

Physical, emotional, and spiritual well-being

The nurse enters the client's room in the acute care unit immediately after he experiences a generalized tonic-clonic type seizure in bed. What is the first action the nurse should take?

Position the client in a side-lying position.

What is the focus of community based nursing?

Promoting and maintaining the health of individuals and families.

The nurse provides the mother of a toddler with the phone number for the Poison Control Center. Which level of Maslow's hierarchy of needs is the nurse addressing?

Safety and security needs

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

Which basic needs area of Maslow's hierarchy of human needs is met when the nurse arranges for the client's clergy to visit after visiting hours?

Self-actualization needs

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

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

The nurse is conducting a family assessment of a traditional family. Which assessment data cue describes the socioeconomic status of the family?

The father is an engineer and the mother is an elementary school teacher.

The nurse is implementing care for several clients. Which of the following clients is the nurse helping to reach the highest level of Maslow's hierarchy of basic human needs?

The nurse provides privacy for the client and family during times of prayer.

Family assessment of a father, mother, and four children has suggested the presence of several risk factors. Which of the following aspects of the family's structure and function would be considered a psychosocial risk factor?

The parents have a tumultuous relationship with frequent separations in the past.

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

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

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

Urine output of 1500 ml in 24 hours

The nurse on the elective surgery floor receives a report from the LPN/LVN that describes the client's abdominal wound dressing as having a moderate amount of yellowish and bloody drainage on it and a very foul smell. In planning for a dressing change, it is most important for the nurse to perform which action?

Wash her hands before and after the dressing change.

The community environment affects the well-being of the individual and the family. Which of the following is the health responsibility of the family?

Maintain a healthy lifestyle

The nurse is caring for an 85-year-old, female client hospitalized for dehydration. The nurse notices that the patient is shivering and takes the client's temperature. She notes an oral temperature of 97.8°:F (36.6°:C). The client also says that she is "chilly." What action, if taken by the nurse, is most appropriate?

Offer the client an extra blanket.

The wife of a comatose client wishes to wash the client's hair. Washing the client's hair meets which basic human need?

Physiologic

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

• Marrying and starting a family

A nurse is caring for a 78-year-old male patient who has been hospitalized following a stroke. Which nursing action has the highest priority for this patient?

Measuring the patient's I&O during recovery

A comprehensive definition of family is that it is a social group with members who share common values, interact over time, and ...

Occupy specific positions

Which intervention performed by the nurse is most appropriate for assisting a client in meeting safety and security needs based on Maslow's Hierarchy of Needs?

Providing the mother the phone number for the Poison Control Center

Once physiologic needs are met, nurses can concentrate on meeting self-actualization needs of patients. What are examples of self- actualization needs according to Maslow's hierarchy of needs? (Select all that apply.)

• A nurse attains a master's degree in nursing by going to school in the evening. • A student nurse takes a course in communication to improve her ability to relate to patients. • A nurse subscribes to several nursing journals to stay abreast of developments in the profession

The nurse is teaching a group of nursing students about how health of community members is affected. Which community characteristics affect the health of individuals? Select all that apply.

• Education programs • Communication facilities • Transportation services • Recreation programs

The nurse is reviewing the medical records of the Clifford Family who has experienced varying life crises. The nurse identifies which of the following as health risk factors? Select all that apply.

• Grandma Opal Clifford dies at the age of 98. • Shirley Clifford is pregnant at the age of 15. • Mr. Clifford is exposed to asbestos at work.

The nurse recognizes that many factors place the family at increased risk for altered health. Which items represent lifestyle risk factors for altered family health? Select all that apply.

• Ingestion of high fat foods • Smoking by parents • Inadequate dental hygiene

The nursing student asks the instructor to explain what a community is. Which statement by the instructor would be inappropriate?

"Communities have few effects on the health of the individuals that live there."

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 home health nurse is visiting the Goldstein family after the recent death of their matriarch. She observes that the family is dressed in black, all of the mirrors are covered, and that the immediate family is sitting on square wooden boxes instead of chairs. She asks Mr. Goldstein's cousin what is happening, and he says, "We are Jewish, and the family is 'Sitting Shiva' for my aunt." This family is fulfilling which family function?

Affective and coping functions

A nurse who is using DuVall's conceptual framework to assess a family with two parents and three children must first determine the

Age of the oldest child

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

Common interests

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 of the following factors 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

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

Community resources available to patients.

The home health nurse is making an initial visit to a client's home. During the visit she observes the mother cooking dinner, the father watching television with a child on his lap, and the grandmother in a rocking chair reading the Bible. The nurse recognizes this family structure as which of the following?

Extended family

The nurse makes a home visit to evaluate a 3-week-old baby. Upon arrival at the family's home, the nurse discovers that the parents of the baby are a lesbian couple. When planning appropriate nursing interventions for this family, which of the following must the nurse do first?

Confront personal biases about this type of family structure.

Which nursing diagnosis is the priority according to Maslow's hierarchy of basic needs?

Constipation related to decreased mobility

The nurse is planning interventions to promote the health of a family with young children. Which family task does the nurse need to consider when planning interventions?

Coping with loss of energy and privacy

The nurse has developed a strong therapeutic partnership with a 44-year-old electrician who suffered severe burns while working on an industrial site. Which of the nurse's following actions most directly addresses the patient's self-actualization needs?

Discussing the patient's strengths and dialoguing with him about his body image

Based on the nursing assessment, the nurse formulates the following nursing diagnoses for the client. Which nursing diagnosis reflects Maslow's level of self-esteem needs?

Disturbed Body Image related to inability to cope with left leg amputation

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

Duvall

A client who was admitted to a drug treatment center 3 days ago is boasting to the other residents that he used drugs for 2 years, and that his former employer never suspected that he was using drugs. Which action, if taken by the nurse, would be most appropriate for this client?

Have the client assume responsibility for the cleanliness of the dayroom.

The nurse is assessing a family parented by a 60-year-old grandmother and her three school-age grandchildren. The nurse is aware that which problem may occur in a single-parent family at a greater level than in other types of families?

Increased financial concerns

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

Read the Koran passage to the client.

The nurse is assigned to take care of a client with rheumatoid arthritis. She notices that the client is wearing a copper bracelet. When she asks him about the bracelet, he says, "I believe that the bracelet will relieve the arthritis pain in my hands." Which action by the nurse is the most appropriate?

Respect the client's beliefs associated with the copper bracelet and allow him to wear it.

The nurse performs an assessment of the client and the family to have a better understanding of client and family needs. Which of the following is an individual need?

Safety

The nurse is conducting a home assessment and suggests that the client's family remove scatter rugs from the home and increase the lighting. Which basic human need is being addressed by the nurse's suggestions?

Safety and securing

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

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

Setting up parenting classes

During the nursing assessment, the client shares that the family attends church nearly every Sunday. Which function of the family does this represent?

Socialization

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

Sociocultural dimension

A couple with adolescent children is most likely to focus on which of the following developmental tasks?

Strengthening marital relationships

The nurse receives an 8-year-old girl in the pediatric unit following a tonsillectomy. Which assessment finding requires immediate intervention by the nurse?

The client makes a rattling noise when she breathes through her mouth.

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."

The nurse recognizes that the community affects the ability of individuals to meet basic human needs. Which example is not a characteristic of a healthy community?

The number of assaults increased 2% over the last year.

Which of the following actions by the nurse demonstrates the nurse's efforts to meet the client's self-actualization needs?

The nurse arranges for the client's clergy to visit after visiting hours

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

Washing hands before and after providing the client care

Which are stressors that affect the health of the family?

Well-funded school systems and inadequate childcare services.

The family is a social group whose members share common values, occupy specific positions, and interact with each other over time. Which of the following is considered the basic unit of human society?

Family

A nurse working with patients in a community is aware that which of the following is a true statement related to environmental factors in that community?

Barriers to accessing health care within a community may include lack of transportation.

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

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

A home healthcare nurse is performing a home visit to a 58-year-old man and his 56-year-old wife who receives home chemotherapy as part of her treatment regimen for breast cancer. The nurse will recognize that this family is likely to be engaged in which of the following development tasks?

Maintaining ties with older and younger generations

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

Report the suspected child abuse to Child Protective Services.

Place the following nursing interventions in order of priority according to Maslow's hierarchy of basic needs.

The nurse teaches the client about foods high in fiber. The nurse teaches the daughter how to administer the client's insulin. The nurse assists the client in making a phone call to the client's daughter. The nurse positions the bed of the Muslim client who is bedfast toward Mecca.

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

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

A nurse is providing family-centered care to patients in a community health care clinic. Which statements about the family unit are accurate? (Select all that apply.)

• The family is a buffer between the needs of individual members and society. • Duvall (1977) identified critical family developmental tasks and stages in the family life cycle. • The nuclear family is composed of two parents and their children.

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

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

The nursing instructor is discussing holistic health care with her nursing students. The instructor talks about the different factors the nurse must consider when creating a holistic plan of care. What are these factors? (Mark all that apply.)

• The patient's developmental life stage • The patient's emotional context • The patient's physiologic health condition