OB Chapters 1-3
The nurse is working with the 5-day-old baby boy of a young Jewish couple. What comment is not culturally sensitive? "What a beautiful little boy!" "I'll make sure he gets a blue blanket." "Oh, I see you have chosen not to have your baby circumcised." "He seems hungry. Go ahead and nurse him."
"Oh, I see you have chosen not to have your baby circumcised." Explanation: Ritual circumcision for Jewish babies takes place on the eighth day of life. All the other comments are acceptable.
A nurse educator is conducting a class on intimate partner violence for a group of new graduate nurses during orientation. Which statement by the educator best reflects current practice regarding these problems in women's health? "Asking every client about intimate partner and family violence is the best way to elicit accurate information." "Since families are more stable than in the past, nurses are not as concerned about these problems as they used to be." "The nurse should screen for these problems at every client encounter." "The nurse is not legally responsible for reporting suspected intimate partner violence."
"The nurse should screen for these problems at every client encounter." Explanation: Both child and intimate partner violence is increasing in incidence. Families are more mobile than in the past. Screening for child abuse (child maltreatment) or intimate partner violence should be included in all family contacts. Nurses must be aware of the legal responsibilities for reporting violence.
A pregnant woman arrives in the L & D unit following premature rupture of membranes along with her spouse, who insists on being present and demands only female nurses assess his wife. When obtaining history and assessment data, the spouse provides all the answers. What is the best approach for the nurse to handle this situation? Evaluate whether it is essential to stand up to the spouse or pacify him. Act as an advocate for the woman who has a male-dominant partner. Call security and then inform the spouse that staff members need to speak with the woman alone. Educate the spouse about his expected role in the birthing process.
Act as an advocate for the woman who has a male-dominant partner. Explanation: In many cultures, the man is the dominant figure. In a strongly male-dominant culture, if approval for hospital admission or therapy is needed, the man would prefer to give this approval. Since the woman is a nondominant member of the family, the nurse may have to act as an advocate for her with a more dominant partner. Security would be viewed as a threat and not appropriate at this time. To gain information from the woman, the nurse may need to confront the spouse about his role in the birthing process. It is not appropriate to educate the spouse because this is a long-standing family environment, and this is not the time to try to change the family culture toward females.
Personal space and distance is a cultural perspective that can impact nurse-client interactions. What is the best way for the nurse to interact with a client who has a different cultural perspective on space and distance? Remember not to intrude into the personal space of the elderly. Allow the client to adopt a position that is comfortable for him or her. Adopt a cultural preference similar to that of the client. Realize that sitting close to the client is an indication of warmth and caring.
Allow the client to adopt a position that is comfortable for him or her. Explanation: If the client appears to position himself or herself too close or too far away, the nurse should consider cultural preferences for space and distance. Ideally, the client should be permitted to assume a position that is comfortable to him or her in terms of personal space and distance. "Realizing" and "remembering" are not interactions. It is also incorrect to attempt to adopt someone else's cultural preference as this can be very uncomfortable for the nurse, which adds a barrier to nurse-client interactions.
A pregnant client and partner from a nondominant culture arrive at the facility. The client is in admitted in active labor. The client's partner tells the nurse, "I am going to work, so call me when the baby is born." Which response by the nurse demonstrates respect for the partner's culture? Tell the partner that all partners now stay during labor. Ask if the partner knows that they can stay with the client during labor. Tell the partner they are missing out on the opportunity of a lifetime by leaving. Insist that the partner stay during labor because the client will need their support.
Ask if the partner knows that they can stay with the client during labor. Explanation: When implementing care, the nurse needs to avoid forcing cultural values onto others. The nurse needs to appreciate that such values are ingrained and usually very difficult to change. The nurse also does not know the family's cultural value of work and should not assume that the newborn's birth is more important than work in that family's culture. The responses that "tell" or "insist" that the partner stay to support the client do not respect the family's culture.
The nurse is providing care to a woman who has just given birth to a healthy term neonate. The woman's partner arrives and asks about the neonate's status. Which action by the nurse would be appropriate? Answer the partner's questions honestly and without hesitation. Tell the partner that no information can be shared with him or her at this time. Ask the partner for identification first before sharing any information. Check the medical record for written client approval with whom to share information.
Check the medical record for written client approval with whom to share information. Explanation: In maternal and newborn health care, information is shared only with the client, legal partner, parents, legal guardians, or individuals as established in writing by the client or the child's parents. This law promotes the security and privacy of health care and health information for all clients. Therefore, the nurse needs to check the medical record for written documentation that allows the partner to have this information. Any other action would be inappropriate.
Which action by the nurse in a community clinic would best meet a family's need of physical sustenance? Offering parenting classes to teenage mothers Providing weekly exercise classes for the neighborhood families Enrolling the pregnant mother in a WIC program Holding monthly educational sessions on nutrition
Enrolling the pregnant mother in a WIC program Explanation: Physical sustenance deals with meeting the basic needs of food, clothing, shelter and protection from harm of each family member. By enrolling the pregnant mother in WIC, her physical needs of nutrition are addressed. Parenting classes, nutrition classes, and exercise classes are all good ideas but do not directly address physical sustenance.
A 16-year-old adolescent whose weight is classified as obese is about to be discharged. The adolescent tells the nurse that they do not liking being obese and that the kids at school make fun of them. What is the most important thing the nurse should encourage the adolescent to do to lose weight? Decrease the amount of sugar in the diet by one-half. Exercise for 30 minutes each day. Allow your parents to be supportive throughout the process. Get an after-school job that you enjoy.
Exercise for 30 minutes each day. Explanation: The nurse will encourage the adolescent to perform regular daily exercise. The exercise can start off by walking for 30 minutes then increase to include more strenuous exercises such as jumping rope, running, or cycling. The plan needs to be easy to complete and allow for flexibility. The hope is that, once a specific routine is established, the adolescent will make a lifestyle change. Reducing sugar is also very important in the diet but other factors such as portion size and caloric intake also are important components of weight loss. Support is important in the weight-loss journey. Peers are very important to an adolescent because they spend a good deal of time with their peers. An after-school job is helpful for self-esteem and independence, which is a developmental task of adolescence, but working a job is not related specifically to weight loss.
A client who just learned she is pregnant says, "I can no longer eat strawberries, even though they are my favorite." What best explains this statement? It is related to the time of year. It is related to culture. It is related to finances. It is related to a food preference.
It is related to culture. Explanation: People from different cultures tend to eat different types of food. Some women may omit various foods during pregnancy because they believe a particular food will mark the baby (e.g., strawberries cause birthmarks, raisins cause brown spots). Food preferences, selections, and seasons do not explain her sudden omission of strawberries in her diet.
The nursing process is a scientific method and proven form of problem solving. It includes what component? Follow-up Planning Health teaching Documentation
Planning Explanation: The nursing process is a proven form of problem solving based on the scientific method. The nursing process consists of five components: Assessment, Nursing diagnosis, Outcome identification and planning, Implementation, and Evaluation.
Infant mortality rates are a good index of general health. Which of the following statements is true regarding a comparison of infant mortality rates of the United States to those of 30 countries with the lowest infant mortality rates?
The United States has a higher rate of infant mortality.
The nurse is planning care for an adolescent who recently fell skateboarding and developed a wound infection. The client is prescribed a wet-to-dry dressing to the wound and an antibiotic by mouth twice daily. The adolescent lives in a single-parent home. When assessing potential strengths of this adolescent, which strength is considered to be part of living in a single-parent environment? The parent is more organized, allowing for efficient wound care and antibiotic administration. The adolescent may be self-reliant and independent in completing needed care. A strong network of friends may be present, which provides support to the adolescent. Limited financial resources may be available, increasing the help provided by the state.
The adolescent may be self-reliant and independent in completing needed care. Explanation: Although all the options may be correct, single-parent families typically have special strengths. Living in a single-parent home may provide increased opportunities for self-reliance and independence. The adolescent developmentally is able to understand when an antibiotic is to be taken and how basic wound care is completed. There is nothing to identify that the adolescent would qualify for state benefits, the parent is organized or there is a strong network of friends.
The nurse uses family-centered care to care for children in a pediatric office. Upon what concept is family-centered care based? The child must be prepared to be his or her own source of strength during times of crisis. The family is the constant in the child's life and the primary source of strength. The wishes of the family should direct the nursing care plan for the child. The care provider is the constant in the child's life and the primary source of strength.
The family is the constant in the child's life and the primary source of strength. Explanation: Family-centered care involves a partnership between the child, family, and health care providers in planning, providing, and evaluating care. Family-centered care enhances parents' and caregivers' confidence in their own skills and also prepares children and young adults for assuming responsibility for their own health care needs. It is based on the concept that the family is the constant in the child's life and the primary source of strength and support for the child.
After completing an assessment, the nurse examines the information to develop a wellness diagnosis for the client to identify which potential goal? Chronic health problems The potential for improvement in health Acute health problems Potential problems
The potential for improvement in health Explanation: Wellness diagnosis identifies the potential for a client to move from one level of wellness to a higher level. The identification of potential, acute, and chronic health problems is part of the diagnostic process.
A 2-year-old child has been diagnosed with leukemia. The child has been admitted to the hospital for the initiation of treatment. The family appears overwhelmed with the new diagnosis, and describe themselves as being "in a state of shock." In working with the family, a plan of care is established around which priority? altered family coping related to new illness of the child altered family function related to shifting dynamics and roles of family members altered family processes related to hospitalization of the child financial strain risk related to the cost of the child's treatment
altered family coping related to new illness of the child Explanation: The nurse is correct to assess the family situation and select a priority to develop a plan of care. All of the options could be priorities at different times in the treatment process. Because it is known that the family is not coping well with this new diagnosis and hospitalization, that is the priority to develop a plan of care. All the other options imply situations that are potential consequences of this change in the family.
While interviewing a client, a nurse assesses the client's reaction to health care and determines that the reaction reflects the client's preferred ways of acting based on traditions. Which term would the nurse use to document this information? ethnicity race culture cultural values
cultural values Explanation: Culture is a view of the world and a set of traditions that a specific social group uses and transmits to the next generation. Cultural values are preferred ways of acting based on those traditions. Ethnicity refers to the cultural group into which a person was born, although the term is sometimes used in a narrower context to mean only race. Race refers to a category of people who share a socially recognized physical characteristic. The term is rarely used today as the research on the human genome shows no basic differences in structure among people.
The number of single-parent homes has risen in the past several years. What effect does this have on the health of children? decreased financial resources to pay for health care services decreased health care costs decreased risk for health problems in children decreased concern for health care of children
decreased financial resources to pay for health care services Explanation: Single parents have fewer financial resources than two-parent households. Therefore, they have fewer resources to pay for health care services. Costs of health care and risk for health problems are not decreased, nor is the concern for health care among single-parent families.
A maternal-child health nurse is discussing maternal mortality with a group of nurses. Which condition would the nurse most likely include in the discussion as a leading cause of maternal mortality in United States? Select all that apply. gestational diabetes hemorrhage embolism pregnancy-related hypertension low-gestational-age infants
hemorrhage embolism pregnancy-related hypertension
A nurse doing an admission assessment on a new Chinese American client notices that the client will not make eye contact. The most likely reason for this is that it: is a sign of disrespect. is a sign of respect. implies the client is not interested. implies the client wants to avoid the nurse.
is a sign of respect. Explanation: Whether people look at one another when talking is culturally determined. Chinese Americans, for example, may not make eye contact during a conversation. This social custom shows respect for the position of the health care provider and is a compliment and not an avoidance issue.
A 19-year-old pregnant adolescent who experienced a rape has arrived in the hospital in active labor with no prenatal care. It is priority for the nurse to assess the client for which potential adverse health concern? sexually transmitted infections preeclampsia gestational diabetes alcohol or drug withdrawal symptoms
sexually transmitted infections Explanation: Any pregnant female who presents without any prenatal care may be at increased risk for adverse health conditions, which may include sexually transmitted infections (STIs). STI risk is higher for victims of rape. It is rare for a younger client to develop gestational diabetes or preeclampsia. There is no indication that the client has an alcohol or substance use disorder.
A 2-year-old child is hospitalized for asthma exacerbation. The parents tell the nurse that they have been treating the wheezing with traditional herbal medicines. How should the nurse respond? "Because herbal remedies are mild and natural you may continue giving these to your child while in the hospital if desired." "You will need to discontinue these remedies while your child is in the hospital to avoid any drug interactions." "Please tell me about how you use the herbal medications so we can assess for herb-drug interactions." "If these remedies worked then your child would not have needed hospitalization; there is no reason to continue them."
"Please tell me about how you use the herbal medications so we can assess for herb-drug interactions." Explanation: Herbal medicines can have interactions with prescribed medications; these should be included in the health history and assessed to determine if there are any herb-drug interactions or synergies. Herbal medicines are not always mild and must be properly assessed. Suggesting that the herbal medications are not working or requiring that they be discontinued does not provide for culturally safe and inclusive care.
The nurse is caring for a child from a different culture. Which statement(s) by the nurse demonstrates an understanding of how culture impacts a client? Select all that apply. "Culture can impact the diet a client follows." "Culture can impact who a client chooses to see for health care needs." "When a client moves to a different city, the client follows the cultural practices that are prevalent in the new city." "A client's cultural beliefs can impact spirituality and/or religion." "A client's cultural beliefs should be incorporated into the care a client receives.
"A client's cultural beliefs can impact spirituality and/or religion." "A client's cultural beliefs should be incorporated into the care a client receives. "Culture can impact who a client chooses to see for health care needs." "Culture can impact the diet a client follows." Explanation: Culture is a set of traditions and beliefs held by groups of people. Beliefs, diet, language, values, religion and spirituality are included in culture. Some cultures utilize folk healers to provide health care. The nurse should incorporate a client's beliefs as much as possible into care. When a client moves to a different location, the client tends to bring cultural beliefs and does not necessarily follow all the cultural practices of the new location.
The nurse educator has completed a presentation on caring for babies born to mothers with a substance use disorder. Which statement by a participant would indicate the need for further education? "Babies born to mothers with a substance use disorder tend to be small for gestational age." "Babies born to a mother with a substance use disorder don't have any difficulty eating." "Mothers with a substance use disorder are at a higher risk for having a child with physical abnormalities." "When a pregnant woman suffers from a substance use disorder, the child may suffer from withdrawal symptoms when born."
"Babies born to a mother with a substance use disorder don't have any difficulty eating." Explanation: Babies born to mothers with a substance use disorder tend to be small for gestational age. They may also suffer from withdrawal symptoms and are at a higher risk for both physical and mental abnormalities. They may also suffer from problems eating, such as a decreased ability to suck. Some of the problems of the baby may not be immediately apparent, because these problems can also encompass cognitive and skill-attainment delays.
While reviewing a woman's compliance with prenatal care, a nurse notes that which comment made by the woman may be a result of poverty rather than a cultural difference? "In my culture, many women crave pica foods throughout the pregnancy." "I just don't understand why I have to give up alcohol when I am pregnant." "I wish I could afford fresh fruits for vitamin C because I just don't remember to take those prenatal vitamins." "I can't rest in the afternoon since I work all day, and then I have to pick my children up from day care."
"I wish I could afford fresh fruits for vitamin C because I just don't remember to take those prenatal vitamins." Explanation: Many characteristic responses described as cultural limitations are actually the consequences of poverty (e.g., parents seeking medical care for their children late in the course of an illness or a woman not taking prenatal vitamins during pregnancy). Solving these problems may be a question of locating adequate financial resources and may not be related to cultural differences. Reducing alcohol intake may be an addiction problem. Many women work when they are pregnant and cannot take an afternoon rest. Working may or may not be due to poverty, so the nurse will have to ask additional questions before concluding the woman lives in poverty.
A 2-year-old child is hospitalized for asthma exacerbation. The parents tell the nurse that they have been treating the wheezing with traditional herbal medicines. How should the nurse respond? "Please tell me about how you use the herbal medications so we can assess for herb-drug interactions." "If these remedies worked then your child would not have needed hospitalization; there is no reason to continue them." "Because herbal remedies are mild and natural you may continue giving these to your child while in the hospital if desired." "You will need to discontinue these remedies while your child is in the hospital to avoid any drug interactions."
"Please tell me about how you use the herbal medications so we can assess for herb-drug interactions." Explanation: Herbal medicines can have interactions with prescribed medications; these should be included in the health history and assessed to determine if there are any herb-drug interactions or synergies. Herbal medicines are not always mild and must be properly assessed. Suggesting that the herbal medications are not working or requiring that they be discontinued does not provide for culturally safe and inclusive care.
The nurse is mentoring a group of graduate nurses on potential positions available at the health care facility. A male nurse expresses interest in working in pediatric care. A colleague states, "Children relate better to women—they are used to their mothers and want nurses like them." When reviewing the response with the colleague, which response is accurate? "You exhibited bullying by not supporting the interest in pediatrics." "We must avoid that type of comment as it presents a stereotype." "We cannot say those types of statements as they are taboo." "I am sad you discouraged the nurse from that department. That is harassment."
"We must avoid that type of comment as it presents a stereotype." Explanation: The nurse is most correct to identify that the comment was stereotyping. Stereotyping means expecting a person to act in a characteristic way without regard to his or her individual traits. It is generally derogatory in nature. The statement did not identify an uncomfortable topic or taboo. The statement does not constitute either harassment or bullying.
A 6-year-old foster child has lived with the same foster family for over 2 years. The family has decided to adopt this child. The parents have noticed that after being told they are adopting this child, the child is on his best behavior. He picks up his toys without being told, feeds the dog every night without reminders, and works on "homework" as soon as he comes home from school. The nurse shares that this is normal and often referred to as what phase in the adoption process? "kill them with kindness" phase "testing strategy" phase "honeymoon behavior" phase "afraid of abandonment" phase
"honeymoon behavior" phase Explanation: When children are first told they are adopted, they may exhibit "honeymoon behavior" or may try to behave perfectly for fear of being given away again. After this honeymoon period, children may deliberately test their parents to see whether, despite bad behavior such as disobeying a house rule or even shoplifting, the parents will still keep them. When young children have to go to the hospital, they may be terribly afraid they are now being returned to the hospital to be "given back." Parents of an adopted child may need additional help in preparing the child for the hospital experience and also should be encouraged to stay with the child in the hospital as much as possible to reduce this type of postadoption fear. "Kill them with kindness" is not a phase of adoptive children.
The nurse knows that the emancipated minor is considered to have the legal capacity of an adult and may make his or her own health care decisions. Which child would potentially be considered an emancipated minor? A minor who puts his or her medical decisions in writing A minor with financial independence who is living with his parents A minor who is pregnant A child older than 13 years of age who asks for emancipation
A minor who is pregnant Explanation: Emancipation may be considered in any of the following situations, depending on the state's laws: membership in a branch of the armed services, marriage, court-determined emancipation, financial independence and living apart from parents, college attendance, pregnancy, mother younger than 18 years of age, and a runaway.
After an initial cultural assessment, the nurse has determined that a family's time orientation is focused on the present and the past. Which breastfeeding goal will the nurse develop for this family? The parent will be exclusively breastfeeding by the time they leave the hospital. The parent will be breastfeeding when the infant is 1 year old. The parent will be exclusively breastfeeding when the infant is 6 months old. After the hour with the lactation consultant, the infant will establish a good latch.
After the hour with the lactation consultant, the infant will establish a good latch. Explanation: Understanding a family's cultural perception is important when providing care. Good communication will provide a good understanding of client perceptions. Past and present time orientation may make it difficult for a family to focus on a long-term goal. Therefore, the shortest goal is best for this family, which in this case is demonstrating a good latch in 1 hour. This goal is also pertinent to the foundation of breastfeeding.
After an initial cultural assessment, the nurse has determined that a family's time orientation is focused on the present and the past. Which breastfeeding goal will the nurse develop for this family? The parent will be exclusively breastfeeding when the infant is 6 months old. The parent will be exclusively breastfeeding by the time they leave the hospital. After the hour with the lactation consultant, the infant will establish a good latch. The parent will be breastfeeding when the infant is 1 year old.
After the hour with the lactation consultant, the infant will establish a good latch. Explanation: Understanding a family's cultural perception is important when providing care. Good communication will provide a good understanding of client perceptions. Past and present time orientation may make it difficult for a family to focus on a long-term goal. Therefore, the shortest goal is best for this family, which in this case is demonstrating a good latch in 1 hour. This goal is also pertinent to the foundation of breastfeeding.
The nurse is reviewing the medical records of several infants. Which infant is at highest risk for death according to the infant mortality rate in the United States? An infant born at a low birth weight An infant born to adolescent parents An infant born at 38 weeks' gestation An infant born to a 43-year-old mother
An infant born at a low birth weight Explanation: Infant mortality in the United States is associated with low birth weight, prematurity, and congenital abnormalities, among other concerns. An infant born to young or older parents, or at 38 weeks' gestation, would not be considered low birth weight or premature nor considered to be at higher risk for congenital abnormalities.
A pregnant client and partner from a nondominant culture arrive at the facility. The client is in admitted in active labor. The client's partner tells the nurse, "I am going to work, so call me when the baby is born." Which response by the nurse demonstrates respect for the partner's culture? Insist that the partner stay during labor because the client will need their support. Ask if the partner knows that they can stay with the client during labor. Tell the partner that all partners now stay during labor. Tell the partner they are missing out on the opportunity of a lifetime by leaving.
Ask if the partner knows that they can stay with the client during labor. Explanation: When implementing care, the nurse needs to avoid forcing cultural values onto others. The nurse needs to appreciate that such values are ingrained and usually very difficult to change. The nurse also does not know the family's cultural value of work and should not assume that the newborn's birth is more important than work in that family's culture. The responses that "tell" or "insist" that the partner stay to support the client do not respect the family's culture.
The nurse is caring for an 8-year-old client admitted to the hospital for an appendectomy. The client is an immigrant newly arrived in the country. How can the nurse determine the best foods to provide in the postoperative diet? Ask the family and child about preferred foods. Request the family members bring foods from home. Ensure that a pediatric diet is ordered. Follow the postoperative dietary prescription.
Ask the family and child about preferred foods. Explanation: Clients from different cultures may have different food preferences. The nurse should first ask the client and family about preferred foods and diet. Then the nurse can determine what foods are available that align with both preferences and postoperative orders. Family members may bring foods from home if desired, but this should not be required. The standard pediatric diet or what is prescribed may not align with the family and child's dietary preferences.
The nurse is caring for an 8-year-old client admitted to the hospital for an appendectomy. The client is an immigrant newly arrived in the country. How can the nurse determine the best foods to provide in the postoperative diet? Ensure that a pediatric diet is ordered. Request the family members bring foods from home. Follow the postoperative dietary prescription. Ask the family and child about preferred foods.
Ask the family and child about preferred foods. Explanation: Clients from different cultures may have different food preferences. The nurse should first ask the client and family about preferred foods and diet. Then the nurse can determine what foods are available that align with both preferences and postoperative orders. Family members may bring foods from home if desired, but this should not be required. The standard pediatric diet or what is prescribed may not align with the family and child's dietary preferences.
A nurse who specializes in maternal and child health care performs many varied functions in diverse settings over the course of a year. Which action would be outside the nurse's scope of practice? Read a recent journal article on breastfeeding and its benefits for new mothers. Assist in the treatment and recovery of a woman with ovarian cancer. Provide preconceptual health care to a client. Discuss methods of alleviating morning sickness with a client in her first trimester.
Assist in the treatment and recovery of a woman with ovarian cancer. Explanation: The primary goal of both maternal and child health nursing can be stated simply as the promotion and maintenance of optimal family health to ensure cycles of optimal childbearing and childrearing. Assisting in the treatment and recovery of a woman with ovarian cancer is the least likely function of a nurse specializing in this type of nursing. Preconceptual care, care of a woman during her first trimester, and reading journal articles regarding breastfeeding are all within the scope of practice of maternal and child health nursing.
A healthy client without a primary care provider is exploring the options available for a health care provider to assist with her pregnancy. Which health care provider can the nurse point out as a best option? Certified nurse midwife Lay midwife Clinical nurse specialist (CNS) Women's health nurse practitioner (NP)
Certified nurse midwife Explanation: A certified nurse midwife is a nurse with advanced practice training in the care of women, specific to pregnancy and birth. A women's health NP would not be able to deliver the infant. A CNS is an advanced practice role but not specific to the care of pregnancy women. The lay midwife has no formal education.
A nurse is reviewing a labor plan with a client who has been admitted to the labor and birth unit. The client states that she has been drinking a significant amount of herbal teas lately to help with uterine contractions. Which is the priority action by the nurse? Ask about other complementary and alternative therapies. Ask the client when she last ate or drank anything. Prepare the client for a fetal nonstress test. Determine the type of herbal teas recently consumed.
Determine the type of herbal teas recently consumed. Explanation: Certain herbal teas can be used during pregnancy, and most are made with flower or berries that are safe for both mother and fetus. To determine if the herbal tea is safe or has had any effect on the status of the birth, it is important for the nurse to find out what type of tea the client has been consuming and in what quantities.
When providing family-centered care for a new mother and infant, which is the appropriate action by the nurse? Have the infant stay in the nursery. Oversee care provided by the mother. Limit interactions by other family members. Encourage rooming-in to develop bonding.
Encourage rooming-in to develop bonding. Explanation: The nurse should encourage rooming-in of the infant with the mother to develop bonding and provide physical and emotional care. This increases comfort level while nursing staff is available to monitor and provide guidance and assistance; it also promotes a healthy family unit.
Which nursing intervention would best demonstrate evidence-based practice in maternal-child health care? Decentralizing care to allow clients to be closer to home Placing adults and children with similar diseases on the same unit Minimizing parental interaction with preterm infants Family-centered pediatric care
Family-centered pediatric care Explanation: Evidence-based practice has become the standard that nurses are to strive for in caring for their clients. By involving the family in caring for ill children, the child and the family are better served and have improved outcomes. Parental interaction is encouraged for preterm infants to foster bonding. Children and adults need to be separated on inpatient units to ensure that the caregivers have a clear understanding of each client's needs, since children are not small adults. Centralized care has proved to be most beneficial to client outcomes by providing resources and specialists in one location.
A nursing student is preparing a presentation illustrating the Human Genome Project. Which function will the student point out as being the primary focus? Genetic testing in adults Treatment of gene mutations Detection of genetic mutations in children Identification of human genes and functions
Identification of human genes and functions Explanation: The Human Genome Project was founded in 1990 and its primary purpose was to identify and label all human genes and their functions. Information from the HGP may eventually be used in genetic testing, the detection of mutations or variations in children, and gene therapy.
The nurse is preparing to reduce a young parent's anxiety about a child needing hospitalization. Which action should the nurse prioritize? Schedule time to address the parent's concerns. Let the parent know you will relay any messages she has for the doctor. Include the parent in the medical decision-making. Tell the parent about the tests being performed.
Include the parent in the medical decision-making. Explanation: The family-centered care approach is a researched-based philosophy that promotes family coping with a child needing medical attention. The nurse should collaborate with the family to address the family's needs, as well as the medical care of the child. Including the parent in the process of medical decision-making would be the priority. The other choices (letting the parents know about the tests to be performed; relaying messages; addressing concerns promptly instead of setting aside to discuss all the concerns simultaneously) would be additional ways to include the parents in the process and relay necessary information to be able to make informed decisions.
A nursing instructor is teaching a session investigating infant mortality as a standard measurement of the quality of health care in the country. The instructor determines the session is successful when the students correctly choose which factors as contributing to the high numbers of deaths in the United States? Select all that apply. Preterm births Congenital deformities and chromosomal abnormalities Male gender of infant Maternal complications Maternal age 30 to 34 years
Maternal complications Congenital deformities and chromosomal abnormalities Preterm births Many factors contribute to the high infant mortality rates in the United States. Some of the most common factors are low gestational age and prematurity, congenital deformities and chromosomal abnormalities, and maternal complications such as cervical insufficiency, multiple births, and premature rupture of membranes. Female infants have lower mortality rates than males, and the best outcomes are in mothers who give birth between 30 and 34 years of age.
When integrating the principles of family-centered care, the nurse would include which concept? Families are unable to make informed choices. Parents want nurses to make decisions about their child's treatment. People have taken increased responsibility for their own health. Families require little information to make appropriate decisions.
People have taken increased responsibility for their own health. Explanation: Due to the influence of managed care, the focus on prevention, better education, and technological advances, people have taken increased responsibility for their own health. Parents now want information about their child's illness, to participate in making decisions about treatment, and to accompany their children to all health care situations.
A nurse is conducting a teaching session on sudden infant death syndrome (SIDS) for expectant parents. Which information should the nurse include? Select all that apply. Allow the infant to sleep with a bottle. Co-bedding or sharing a bed creates parental bonding. Sharing a room allows for monitoring of the infant. Maintain neutral temperatures and avoid overheating. Place the infant on his or her back to sleep.
Place the infant on his or her back to sleep. Maintain neutral temperatures and avoid overheating. Sharing a room allows for monitoring of the infant. Sharing of a room allows for monitoring and bonding of the infant as well as ease of feeding. Placing the infant on his or her back to sleep is the recommended sleeping position for all infants until 12 months of age, or until they can change their own position during sleep. Infants are not able to regulate their temperature; therefore, overheating can increase their risk for SIDS. Co-bedding increases the risk for accidental suffocation, and allowing an infant to sleep with a bottle increases risk for aspiration and infection.
A nurse witnesses a peer tell a client, "You are a mother now and you have to do what is best for you baby. You have to breastfeed her!" Which is the best action by the nurse? Fill out an incident report to go in the nurse's personnel file. Approach the client later and provide correct information. Pull the nurse aside and inquire as to the content of the conversation. Immediately interrupt the conversation and reprimand the nurse.
Pull the nurse aside and inquire as to the content of the conversation. Explanation: The nurse overheard just a small portion of the conversation between the client and the peer nurse. The best action would be to inquire as to the content of the conversation and then determine if the peer nurse's comments were appropriate. If the comments were inappropriate, the nurse would then need to fill out an incident report.
The nurse is caring for a pregnant client in a prenatal clinic who states, "I want to view this labor and delivery as a natural process....not like an illness." How will the nurse respond? Refer the client to a midwife in preparation for a birth in a birthing center. Schedule the client for a tour of the women's unit at a large urban hospital. Provide the names of several obstetricians in the local area for consideration. Offer education regarding how to best utilize pharmacologic pain medication during labor.
Refer the client to a midwife in preparation for a birth in a birthing center. Explanation: The nurse recognizes the client is seeking a birth with little intervention. This client would benefit from a consultation with a midwife in preparation for a home birth or in a birthing center birth. An obstetrician would be beneficial for a woman seeking specialized care with more interventions, not less. A tour of the local hospital would be beneficial if the woman was planning a hospital birth with interventions traditionally available at a hospital. Pain control during labor is considered an intervention and would not benefit a woman wanting limited intervention.
An Islamic woman is in active labor and informs the nurse that she is fasting during the day since it is Ramadan. What would the nurse assess for in this woman related to her cultural ritual? Ask the family to bring in traditional foods during the evening hours so the woman can receive some nourishment. Fasting will be able to continue since laboring women are not allowed to eat at this time. Respect this woman's faith, but also assess for dehydration and hypoglycemia. Call the health care provider for a prescription for IV fluids to keep her hydrated as she labors.
Respect this woman's faith, but also assess for dehydration and hypoglycemia. Explanation: Knowing which religion a family practices can help the nurse locate the correct religious support person if one is needed. It helps in planning care if the nurse knows a woman wants a time set aside daily for private prayer or if she intends to fast, such as during Ramadan. The nurse should respect the woman's faith; however, the nurse should also assess hydration status and for hypoglycemia since she is fasting yet working hard to give birth to the infant. Most women in labor can drink fluids throughout the labor process. Asking the family to supply foods may be appropriate but also may be inappropriate if the woman is the one that cooks for the family. Hydration in the form of IV fluids may be considered inappropriate since the culture is for fasting from fluids and food.
Question 5 of 5 A nurse is assigned four clients for care. The clients are from various cultures. The nurse says, "I don't think people have any differences. I think we are all alike, and so I plan to treat all of my clients equally and with respect." Which response by the charge nurse is appropriate? The charge nurse agrees stating the nurse is being culturally sensitive. The charge nurse disagrees stating cultural blindness has occurred. The charge nurse agrees and states that respect is important. The charge nurse disagrees stating equality is not always achievable.
The charge nurse disagrees stating cultural blindness has occurred. Explanation: The charge nurse is correct to disagree with the nurse's statement. People commit cultural blindness when they do not see or believe there are cultural differences among people. Cultural destructiveness can occur by making everyone fit the same cultural pattern, and excluding those who don't fit. Equality is strived for with cultural sensitivity in understanding and accepting different cultural values, attitudes, and behaviors. Agreeing with the nurse's statement does not represent cultural competence.
A school-aged child with immigrant parents expresses concern to the school nurse about feeling embarrassed over the parents' limited ability to speak the dominant language, noting that classmates are sometimes cruel. After counseling the child, the nurse identifies that which evaluation reflects a positive outcome for this child? The child finds a voice and confronts the children who have been making fun of the parents' heritage. The child sees their differences but no longer feels isolated because of the family's differences. The child tries to blend in with the peer group and tries to avert attention from the parents' culture. The child does not directly confront the teasing classmates about the parents' heritage, and instead talks with a teacher.
The child sees their differences but no longer feels isolated because of the family's differences. Explanation: When a child states that they no longer feel socially isolated because of the family's differences, this is an example of an expected outcome that has been resolved positively. Not directly confronting teasing friends usually does not make the child feel positive. Finding a voice and confronting classmates who make fun of their background is not the ideal way for the child to deal with this situation. Blending in with peers can be beneficial, but not if the child is trying to avert attention from the parents' culture.
A client who does not speak the dominant language becomes upset when the nurse brings in an interpreter, rather than using a family member as the translator. Which would be the best reason for using an official interpreter in this case? Many words have double meanings, challenging the client to try to make sense of what is being communicated. There is no additional cost to the client when a professional interpreter is utilized. The client was unable to pronounce the words the nurse had written down on a sheet of paper. There may be cultural limitations that change how the information is being interpreted by the family.
There may be cultural limitations that change how the information is being interpreted by the family. Explanation: It is unacceptable to have a family member serve as an interpreter. There may be cultural limitations that change how the information the nurse is stating is being interpreted for a parent or partner. Additionally, the medical terminology used in the health care system is best translated by a trained professional interpreter.
A young couple are very excited to learn they are expecting their first child and question the nurse about which test they need to discover its gender. Which procedure will best provide this information to the couple? Ultrasound HGP Amniocentesis Chorionic villus sampling
Ultrasound Explanation: Ultrasound is a visual method for assessing the fetus in the uterus and will provide information about the gender. Amniocentesis and chorionic villus sampling provide the entire genetic code of the fetus. HGP refers to the Human Genome Project, which can provide information regarding gene mutations and variations.
A nurse teaches a couple how to administer medication to their infant. Neither of the parents speaks the dominant language proficiently. The parents have a 10-year-old child at the appointment who appears to speak the dominant language fluently. Which would be the best course of action for the nurse? Wait for an interpreter to arrive to relay the instructions. Suggest that the parents contact their local pharmacy. Write the instructions down in the dominant language for the family. Have the 10-year-old child interpret the instructions for the parents.
Wait for an interpreter to arrive to relay the instructions. Explanation: Waiting for an interpreter to arrive to relay the instructions would be the best course of action, because it would ensure that the parents fully understand the instructions. As a general rule, it is unfair to ask children to interpret for their parents, because this can place a child in situations that require adult judgment and knowledge. In some cultures, it might be unacceptable for a younger person to serve as an interpreter for an older person or for a subservient woman to interpret for a dominant man, because this shifts authority. In many instances, written communication is even more problematic than oral communication as many people can speak a second language but cannot write or read it. Referring the parents to a pharmacy would not be appropriate, because they may not know how to contact a pharmacy and, even if they do, they will likely encounter the same language barrier again.
A 15-year-old client has just given birth and states that she does not want her infant to receive any newborn vaccines. What is the appropriate action for the nurse to take? Call the primary care provider. Withhold the vaccines. Ask the grandparents for permission. Administer the newborn vaccines.
Withhold the vaccines. Explanation: The client would frequently be considered emancipated and therefore legally able to make legal decisions regarding the health care of the infant. The nurse should withhold the vaccines but inquire as to the reason for no vaccination.
A nurse is struggling to communicate with a young man who does not speak English proficiently. He emigrated to the United States from Mexico several years ago. Finally, an interpreter arrives, and the nurse is able to communicate effectively with the client. At the end of the visit, after the client has left, the nurse says to the interpreter, "I think everyone who comes to this country should learn to speak English, don't you?" The nurse's question reveals that she expects what of ethnic minorities? acculturation ethnocentrism assimilation stereotyping
assimilation Explanation: Cultural assimilation means people blend into the general population or adopt the values of the dominant culture. This is what the nurse in the scenario appears to expect of ethnic minorities in the United States. The other answers do not accurately describe the nurse's expectations. Acculturation refers to the loss of ethnic traditions because of disuse. Stereotyping is expecting a person to act in a characteristic way without regard to his or her individual traits. Ethnocentrism is a belief that one's own culture is superior to all others.
A couple has recently been divorced. The couple has joint custody of their 15-year-old daughter. The nurse recognizes that the daughter is now at a 50% greater risk for: experiencing upper respiratory infections. being the victim of abuse. being exposed to violence on television. beginning smoking or drinking alcohol.
beginning smoking or drinking alcohol. Explanation: Findings have revealed that adolescents living in shared physical custody had higher rates of health risk behaviors, such as beginning smoking or drinking alcohol, compared with adolescents from two-parent families (60% and 50% higher). Children with parents who are both employed would be more likely to be exposed to violence on television if they are at home alone or to experience upper respiratory infections if in day care. Although incidence of child maltreatment remains high, there is no correlation between joint custody and a 50% increase in risk for abuse.
A nurse is conducting a presentation for a group of pregnant women about appropriate health promotion strategies to address issues related to infant mortality. Which strategy would the nurse encourage to reduce the infant's risk for infection after birth? newborn development support groups folic acid supplementation breastfeeding sleeping on the back
breastfeeding Explanation: After birth, other health promotion strategies can significantly improve an infant's health and chances of survival. Breastfeeding has been shown to reduce rates of infection in infants and to improve long-term health. Emphasizing the importance of placing an infant on his or her back to sleep will reduce the incidence of SIDS. Newborn development support groups will help provide education about normal child development and child rearing. Folic acid supplementation is used during pregnancy to prevent neural tube defects.
As part of the nurse's prenatal checklist when working with an expectant mother, the nurse mentions the potentially harmful effects of the mother drinking alcohol during pregnancy. Both the mother-to-be and her spouse look offended and say, "We are Sikhs! Alcohol is prohibited in our religion." The nurse responds, "I apologize—I am afraid I do not know much about your religion, although I would like to learn more. Are there any resources you could refer me to?" Which behavior is the nurse exhibiting? cultural awareness prejudice ethnocentrism cultural humility
cultural humility Explanation: Cultural humility is a lifelong process of self-reflection and self-critique that begins not with an assessment of a client's beliefs, but rather an assessment of one's own. The nurse exhibits cultural humility in this scenario by being willing to learn more about another culture. The nurse does not exhibit cultural awareness, as the nurse was not already aware that Sikhs do not drink alcohol. However, the nurse is also not exhibiting prejudice, which is a preconceived judgment of a group of people, nor ethnocentrism, which is believing that one's own culture is superior to all others.
As part of the nurse's prenatal checklist when working with an expectant mother, the nurse mentions the potentially harmful effects of the mother drinking alcohol during pregnancy. Both the mother-to-be and her spouse look offended and say, "We are Sikhs! Alcohol is prohibited in our religion." The nurse responds, "I apologize—I am afraid I do not know much about your religion, although I would like to learn more. Are there any resources you could refer me to?" Which behavior is the nurse exhibiting? ethnocentrism cultural awareness cultural humility prejudice
cultural humility Explanation: Cultural humility is a lifelong process of self-reflection and self-critique that begins not with an assessment of a client's beliefs, but rather an assessment of one's own. The nurse exhibits cultural humility in this scenario by being willing to learn more about another culture. The nurse does not exhibit cultural awareness, as the nurse was not already aware that Sikhs do not drink alcohol. However, the nurse is also not exhibiting prejudice, which is a preconceived judgment of a group of people, nor ethnocentrism, which is believing that one's own culture is superior to all others.
The nurse cares for a pregnant woman who is lactose intolerant. What food item will the nurse recommend to ensure the client's calcium needs are met? kidney beans dark green vegetables cranberry juice Greek yogurt
dark green vegetables Explanation: When counseling during pregnancy, the nurse should not advise a woman who is lactose intolerant to drink milk or to eat products such as cheese or Greek yogurt. She can obtain adequate calcium through supplements or other foods high in calcium such as dark green vegetables. Other products such as seafood, orange juice (not cranberry), and legumes contain or can be fortified with calcium as well. Kidney beans are a good source of protein.
The nurse is assessing a family in which the parents are going through a divorce. There are three siblings in the family: a 4-year-old girl, a 10-year-old boy, and a 15-year-old girl. Which of the following is an important framework for the nurse to use when assessing the response of each child to the divorce? life cycle developmental stages family systems crisis intervention
developmental stages Explanation: Assessing each child individually from the perspective of his or her developmental stage allows for the planning of interventions suitable to each child. Each of the other three frameworks addresses family dynamics rather than the specific needs of the children.
The nurse is providing education to the parents of a school-aged child. Which information would the nurse include in the teaching plan? teaching about the signs and symptoms of sexually transmitted infections information about and encouragement to avoid the dangers of distracted driving verbal directions regarding gates at the top and bottom of the stairs discussion of the importance of proper use and fit of a helmet for bike riding
discussion of the importance of proper use and fit of a helmet for bike riding Explanation: The school-aged child is involved in many outside activities, including bike riding. Safety discussions should include the need for wearing a helmet when bike riding as well as the proper fit. Distracted driving and sexually transmitted infections would be appropriate for the adolescent client. Gates on the stairs would be appropriate for the infant and toddler age groups.
A laboring client, 2 cm dilated and 50% effaced, is screaming in pain. The nurse caring for this client recognizes this woman's response to pain should be documented using which label? lack of pain control high pain tolerance inappropriate response to pain low pain threshold
low pain threshold Explanation: A person's response to pain is both individually and culturally determined. The pain threshold is the point at which the individual reports a stimulus is painful. Pain tolerance is the point at which an individual withdraws from a stimulus. Lack of pain control and inappropriate response to pain reflects the nurse's individual bias.
The community health nurse is assessing a new client who reports having recently moved to the area and living with an aunt and her parents. The nurse determines this client resides in which type of family structure? immediate extended communal blended
extended Explanation: The extended family is an immediate family with other family members in the same house. The immediate family is composed of an individual's smallest family unit (commonly parents and their children), all of whom share a common household. Members of a communal family share responsibility for homemaking and child rearing; all children are the collective responsibility of adult members. In a blended family, both partners in the marriage bring children from a previous marriage into the household.
A nurse is concerned about a 14-year-old girl under her care because she has recently learned of an outbreak of sexually transmitted infections at the girl's high school. The nurse asks the girl's parents whether they would be willing to let the nurse discuss it with their daughter in private, along with contraception options. The mother quickly interrupts the nurse and says, "Absolutely not. We will discuss that with her ourselves." Which role is the mother playing in this situation? health manager problem-solver financial manager gatekeeper
gatekeeper Explanation: The mother is playing the role of the gatekeeper, or the person who allows information into and out of the family. She is not solving a problem, managing her daughter's health, or managing the family's finances in this situation.
A nurse is discussing calcium with a client who is lactose intolerant. Which foods will the nurse include when selecting the client's dinner? baked potato with butter and sour cream fruit and yogurt parfait green leafy salad hot dog and bun
green leafy salad Explanation: The nurse should counsel this client to consider what the food choices contain in order to decide if milk or milk products are present. Milk products should not be recommended to a client who has an intolerance to lactose. A green leafy salad is high in calcium and contains no milk or milk products, so it is the best choice. Sour cream and yogurt both contain milk products. Processed meats, such as deli meat and hot dogs, also contain dairy as well as some breads and buns.
A nurse is discussing calcium with a client who is lactose intolerant. Which foods will the nurse include when selecting the client's dinner? green leafy salad fruit and yogurt parfait baked potato with butter and sour cream hot dog and bun
green leafy salad Explanation: The nurse should counsel this client to consider what the food choices contain in order to decide if milk or milk products are present. Milk products should not be recommended to a client who has an intolerance to lactose. A green leafy salad is high in calcium and contains no milk or milk products, so it is the best choice. Sour cream and yogurt both contain milk products. Processed meats, such as deli meat and hot dogs, also contain dairy as well as some breads and buns.
A nurse is working as part of a larger community group to develop programs to address current barriers to health care being experienced by women. The community is in the city with a large population of low-income families. On which factor should the group focus their efforts to address a main barrier to access to care? health insurance language transportation low health literacy
health insurance Explanation: Although transportation, language and culture, and low health literacy are barriers to health care, health insurance is a major factor affecting access to health care. The existence of financial barriers is one of the most important factors that limits access to care. Many families do not have health insurance so they cannot afford to see health care providers for maintenance and prevention services. Many do not have enough health insurance to cover services they need or cannot pay for services.
A nurse is teaching women the importance of good nutrition and taking prenatal vitamins if they are planning pregnancy. Which measure is the nurse performing? health promotion health rehabilitation health maintenance health restoration
health promotion Explanation: Health promotion means educating clients to be aware of good health through teaching and role modeling. Health maintenance means intervening to maintain health when risk of illness is present. Health restoration is promptly diagnosing and treating illness using interventions that will return clients to wellness most rapidly. Health rehabilitation means preventing further complications from an illness, bringing an ill client back to an optimal state of wellness, or helping a client to accept inevitable death.
A 58-year-old woman comes to the clinic for a routine evaluation. When reviewing the woman's health history, which finding(s) would lead the nurse to suspect that the woman is at risk for heart disease? Select all that apply. menopause at age 50 years recent loss of 10 lb (4.5 kg) over 6 months hemoglobin A1c levels at 6% (0.06) history of polycystic ovary syndrome history of gestational hypertension
history of polycystic ovary syndrome history of gestational hypertension menopause at age 50 years Causes of heart disease for women may include: menopause (associated with a significant rise in coronary events); history of preeclampsia; diabetes, high cholesterol levels, and left ventricular hypertrophy; smoking, including secondhand smoke (which have a greater effect on women due to smaller body size); gestational hypertension; polycystic ovary syndrome; blood vessel inflammation and repeated episodes of weight loss and gain (increased coronary morbidity and mortality). An A1c level of 6% (0.06) is considered within normal parameters. Repeated episodes of weight loss and gain, not a single weight loss episode, would be a risk factor.
What is the effect of low birth weights in babies born in the United States? higher costs of care higher states of obesity in adulthood fewer deliveries in hospitals increased infant mortality rates
increased infant mortality rates Explanation: Many factors may be associated with high infant mortality rates and poor health. Low birth weight and late or nonexistent prenatal care are the main factors in the poor rankings in infant mortality.
An expectant mother has arranged for her massage therapist to provide gentle hand, arm, and neck massage for the client while she is in labor in the hospital. Which trend in today's health care environment is most related to this arrangement? initiating more holistic care reduction of health care costs through the utilization of nonlicensed care providers meeting the work needs of pregnant and breastfeeding women increasing use of alternative treatment modalities
increasing use of alternative treatment modalities Explanation: There is a growing tendency for families to use alternative forms of therapy, such as acupuncture or therapeutic touch, in addition to (or instead of) traditional health care measures. Nurses have an increasing obligation to be aware of complementary or alternative therapies such as these as they have the potential to either enhance or detract from the effectiveness of traditional therapy. The other answers do not pertain to the arrangement the client has made to have her massage therapist present at her labor.
During a home visit from a "Parents as Teachers" leader, the leader notes the mom is enforcing "time-out" when the preschool child breaks a rule. The mother is responsible for establishing rules and work assignments based on the child's age. When documenting the family assessment visit, the leader would identify the mother as fulfilling which family role? problem solver allocation of resources maintenance of order socialization of family members
maintenance of order Explanation: Maintenance of order includes establishing family values, establishing rules about expected family responsibilities and roles, and enforcing common regulations for family members, such as using "time-out" for toddlers. In healthy families, members know the family rules and respect and follow them; in dysfunctional families, the nurse may see a flagrant disregard of rules. Socialization of family members includes being certain that children feel part of the family and are learning appropriate ways to interact with people outside the family, such as teachers, neighbors, or police. It means the family has an open communication system among family members and community members. Allocation of resources involves determining which family needs will be met and their order of priority, including material goods as well as affection and space. In healthy families, there is justification, consistency, and fairness in the distribution. In many families, resources are limited (e.g., no one has new shoes). The problem solver does just what the title implies, looking at problems and helping come to solutions.
During a visit with a new family, the nurse assesses one of their children. The nurse asks about current immunization status and how often the child visits the family health care provider. The nurse also asks the child about experiences with activities outside the home. The nurse reviews the importance of safety like wearing helmets. Given this data, what age group of child would one anticipate this nurse is assessing? preschool school-age adolescent toddler
school-age Explanation: When working with the family of a school-age child, the nurse should focus the assessment on: promoting children's health through immunizations, dental care, and routine health assessments; promoting child safety related to home and automobiles; encouraging socialization experiences outside the home such as sports participation, music lessons, or hobbies; and encouraging a meaningful school experience to make learning a lifetime concern.
The nurse is caring for a client with brown skin color and makes a judgment about the client's background prior to meeting the client. Which consequence of a nurse equating the client's skin color and other features with culture is most concerning? stereotyping, which impacts care developing transcultural sensitivity generalizing care, being the same for all a lack of individuality
stereotyping, which impacts care Explanation: Although ethnic and racial groups overlap, nurses must not equate skin color and other physical features with culture. Doing so may lead to erroneous assumptions that all people with certain physical attributes essentially share the same culture and ethnicity. Such an attitude leads to stereotyping, which impacts the care received from the nurse. A lack of individuality takes away the personalization of care to the specific client. Generalization acknowledges common trends in a group and recognizes that more information is required. Equating clients' skin color and other physical features with culture does not help develop cultural competence and transcultural sensitivity.
A female-to-male (FTM) transgender individual who has undergone breast surgery wants to become a parent. During the teaching session, which instruction is essential for the client to understand to achieve the goal of pregnancy? feeling confident in selecting a supportive health care provider discussing how to deal with leakage of milk from nipples stopping current testosterone hormone therapy discussing safety concerns if victimization occurs during pregnancy
stopping current testosterone hormone therapy Explanation: To sustain a successful pregnancy, it is essential to stop testosterone hormone therapy to carry the pregnancy. The cessation of testosterone and the changes that occur with pregnancy can cause huge shifts in an individual's mental well-being and can lead to increased gender dysphoria. FTM transgender individuals may also find it difficult to obtain an understanding health care provider, one whom they can trust and who can care for the specific needs related to pregnancy, gender dysphoria, and lactation. Though important, this ultimately does not achieve the goal of pregnancy. Breast surgery involves removal of the breasts as part of the transitioning; therefore, there will be no leakage of milk with pregnancy. Transgender women face victimization at twice the rate that cisgender women do; however, there is no indication that this is a problem in this scenario.
A couple is arguing and bickering all the time. This couple has not told the children yet that they are planning to get a divorce. When the couple discusses this with the school nurse, the nurse shares that at this early phase, children likely experience what type of feelings? act out their feelings by crying and screaming at their parents to "Stop!" take blame for their parents quarreling and try to behave better tell their friends that their parents are always "mad" at them make up false stories, pretending they are "one big happy family"
take blame for their parents quarreling and try to behave better Explanation: The most appropriate answer is taking blame for their parents quarreling. The first phase is apt to be an antagonistic time as parents realize they are no longer compatible, marked by quarreling, hurt feelings, and whispered conversations. This phase can be particularly upsetting for children because they usually have not been told what is happening as yet. They may assume the quarreling is their fault (i.e., if they had behaved better, this would not be happening). They may act out (depending on age of child). Sometimes children share their feelings with the school nurse or teaching and they may use the word "mad" when describing the fighting in the home. Sensitive children may make up imaginary families that are happy.
A nurse working at a child health clinic is involved in primary prevention activities. Which activity will the nurse perform in this role? reviewing laboratory test results assisting with physical therapy exercises after knee surgery performing hearing screenings teaching about healthy food choices
teaching about healthy food choices Explanation: Primary prevention involves health-promoting activities to prevent the development of illness or injury, such as teaching about healthy food choices. This level of prevention includes giving information regarding safety, diet, rest, exercise, and disease prevention through immunizations and emphasizes the nursing roles of the educator and client advocate. Secondary prevention focuses on health screening activities that aid in early diagnosis and encourage prompt treatment before long-term negative effects arise, such as hearing screenings and reviewing laboratory test results. Tertiary prevention involves health-promoting activities that focus on rehabilitation, such as physical therapy exercises after surgery, and providing information to prevent further injury or illness.
A nurse is working as part of a community group to develop programs to lower risks to the health status of children and adolescents. Which issue will the group identify as the priority for program development? learning disorders communicable diseases unintentional (accidental) injuries inadequate health insurance
unintentional (accidental) injuries Explanation: Although inadequate health insurance, communicable diseases, and learning disorders are issues related to the health of children and adolescents, today, the largest risk to all children and adolescents is unintentional (accidental) injury, frequently the result of motor vehicle accidents.