Chapter 16 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 16

Question 1

Type: MCSA

The nurse is providing care within the total care context. What should the nurse consider when using this care approach?

1. The individualism of the client

2. Principles applicable to the client at this moment

3. Principles general to all clients of the same age and condition

4. The persons self-identity

Correct Answer: 3

Rationale 1: In the individualized care context, the nurse becomes acquainted with the client as an individual, referring to the total care principles and using those principles that apply to this person at this time.

Rationale 2: In the individualized care context, the nurse becomes acquainted with the client as an individual, referring to the total care principles and using those principles that apply to this person at this time.

Rationale 3: In the total care context, the nurse considers all the principles and areas that apply when taking care of any client of that age and condition.

Rationale 4: The persons self-identity is part of the individual health dimension of any one client.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Explain the relationship of individuality and holism to nursing practice.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 244

Question 2

Type: MCSA

The nurse is practicing the concept of holism with a client. Which action is the nurse most likely making?

1. Considering how the loss of a clients job will affect the regulation of the clients diabetes

2. Making sure to do complete teaching regarding pharmacological interventions

3. Following physician treatments on schedule

4. Prioritizing the needs of the client assigned according to Maslows hierarchy

Correct Answer: 1

Rationale 1: The concept of holism emphasizes that nurses must keep the whole person in mind and strives to understand how one area of concern relates to the whole person. In this situation, the stress from a job loss will affect the persons chronic condition. The nurse must also consider the relationship of the individual to the external environment and to others.

Rationale 2: This option is only focused on the physiology of the persons condition.

Rationale 3: This option is only focused on the physiology of the persons condition.

Rationale 4: This option is only focused on the physiology of the persons condition.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum,

across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain the relationship of individuality and holism to nursing practice.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 244

Question 3

Type: MCSA

Psychologic homeostasis is maintained by a variety of mechanisms. Which client should the nurse identify as being the most likely candidate to obtain psychologic homeostasis?

1. A child who is used to getting ready for school alone

2. A teenager whose circle of friends includes single parents of the same age

3. An elderly person who has just moved to a long-term care facility

4. A young adult who is in a long-term relationship

Correct Answer: 4

Rationale 1: Psychologic homeostasis is acquired or learned through the experience of living and interacting with others. Individuals can develop psychologic homeostasis if they are in a stable physical environment where they feel safe and secure. A child who is alone while getting ready for school may not feel safe and secure.

Rationale 2: Individuals also need a stable psychologic environment from infancy onward so that feelings of love and trust develop, a social environment that includes adults who are healthy role models, and a life experience that provides satisfaction. Having friends of the same age who are parents may eliminate healthy adult role models for the teenager.

Rationale 3: Individuals also need a stable psychologic environment from infancy onward so that feelings of love and trust develop, a social environment that includes adults who are healthy role models, and a life experience that provides satisfaction. Moving into a long-term care facility can be a huge adjustment for some people, which may affect feelings of safety and security.

Rationale 4: Individuals also need a stable psychologic environment from infancy onward so that feelings of love and trust develop, a social environment that includes adults who are healthy role models, and a life experience that provides satisfaction. A young adult who has a relationship that lasts is the one option that would fit most of these mechanisms.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List four main characteristics of homeostatic mechanisms.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 246

Question 4

Type: MCSA

A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslows human needs theory, at which level should the nurse recognize that the client is struggling?

1. Physiological

2. Safety and security

3. Love and belonging

4. Self-esteem

Correct Answer: 4

Rationale 1: Physiological needs include air, food, water, rest, and sleep.

Rationale 2: Safety and security needs are those things, both psychological and physiological, that help the person feel safe.

Rationale 3: Love and belonging needs include giving and receiving affection, attaining a place in a group, and maintaining the feeling of belonging.

Rationale 4: Self-esteem and esteem from others includes feelings of independence, competence, self-respect, recognition, respect, and

appreciation. Self-hatred and disgust is opposite of what one would expect in the self-esteem level of Maslows model.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify Maslows characteristics of the self-actualized person.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 247

Question 5

Type: MCSA

A client is hospitalized with numerous acute health problems. According to Maslows basic needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client?

1. Risk for Injury related to unsteady gait

2. Altered Nutrition, Less Than Body Requirements related to inability to absorb nutrients

3. Self-Care Deficit related to weakness and debilitation

4. Powerlessness related to chronic disease state

Correct Answer: 2

Rationale 1: Risk for Injury would be the lowerpriority need.

Rationale 2: In needs theories, human needs are ranked on an ascending scale according to how essential the needs are for survival. Physiologic needs are those such as air, food, water, shelter, rest, sleep, activity, and temperature maintenance, which are all crucial for survival. Nutritional deficits would fall into this level and take priority over the others listed.

Rationale 3: Self-Care Deficit would fall in the fourth levelself-esteem needs.

Rationale 4: Powerlessness is part of the need to develop ones maximum potential. It falls into the fifth and highest level of self-actualization.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify Maslows characteristics of the self-actualized person.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 247


Question 6

Type: MCSA

The nurse is using Kalishs adaptation of Maslows hierarchy of needs when planning client care. Which client should the nurse identify as exhibiting a level of Kalishs adaptation?

1. Has a homosexual encounter for the first time

2. Has a need to participate in school sports and be on the team

3. Strives to become the CEO of a company

4. Is sleep deprived because of musculoskeletal discomfort

Correct Answer: 1

Rationale 1: Richard Kalish added a sixth level to Maslows five levels and referred to it as stimulation needs. This level includes sexual activity, exploration, manipulation, and novelty.

Rationale 2: A client who wants to be on the team is exhibiting characteristics of love and belonging needs; mentioned in Maslows original five-level hierarchy.

Rationale 3: Striving to be in charge of a company is part of self-actualization, mentioned in Maslows original five-level hierarchy.

Rationale 4: Sleep is one of the basic physiological needs mentioned in Maslows original five-level hierarchy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify Maslows characteristics of the self-actualized person.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 247

Question 7

Type: MCSA

A nurse is delivering a workshop regarding health promotion to a group of elderly clients. In describing Healthy People 2010, which goal should the nurse emphasize for this group?

1. Eliminating health disparities

2. Believing that individual health is closely related to community health

3. Increasing quality and years of life

4. Developing partnerships between individual and community health

Correct Answer: 3

Rationale 1: The second goal of Healthy People 2010 is to eliminate health disparities, which reflects the diversity of the entire population, not just the elderly.

Rationale 2: The foundation for this document is the belief that individual health is closely linked to community health, and the reverse, but this applies to the entire population, not just the elderly.

Rationale 3: Healthy People 2010 has four main goals. The first is to increase quality and years of healthy life, which applies to the clients who will be the focus of this workshop.

Rationale 4: The foundation for this document is the belief that individual health is closely linked to community health, and the reverse. In order to bring this about, partnerships are important to improve the health of individuals and communities, but this applies to the entire population, not just the elderly.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe the vision, mission, and goals of Healthy People 2020 to help improve the health of a community.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 248

Question 8

Type: MCSA

A client comes to the clinic seeking information regarding smoking cessation classes and ways to improve respiratory function. This

client is modeling which behavior?

1. Health promotion

2. Health protection

3. Tertiary prevention

4. Primary prevention

Correct Answer: 2

Rationale 1: Health promotion is behavior motivated by the desire to increase well-being and actualize human health potential.

Rationale 2: Health protection or illness prevention is behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness. Expressing a desire to quit smoking would be modeling this behavior. The information we are given does not tell us if the client has pathology or not, but the client certainly has been exposed to a health hazard.

Rationale 3: Tertiary prevention focuses on restoration and rehabilitationit is not a behavior.

Rationale 4: Primary prevention focuses on health promotionit is not a behavior.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Differentiate health promotion from health protection or illness prevention.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 249

Question 9

Type: MCMA

A community health nurse wants to provide health promotion classes through the local hospital. Which topics should the nurse include in this endeavor?

Standard Text: Select all that apply.

1. Time management

2. Healthy eating habits

3. Exercise after stroke

4. Bicycle safety for children

5. Performing self-examination of the breasts

Correct Answer: 1, 2, 4

Rationale 1: Health promotion activities include those items that increase well-being and overall health.

Rationale 2: Health promotion activities include those items that increase well-being and overall health.

Rationale 3: Teaching about exercise following a stroke focuses on rehabilitation, not health promotion.

Rationale 4: Health promotion activities include those items that increase well-being and overall health.

Rationale 5: Performing self-examination of the breasts is a health protection activity.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Identify various types and sites of health promotion programs.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 248

Question 10

Type: MCSA

A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior-specific cognitions?

1. Interpersonal influences

2. Perceived benefits of action

3. Situational influences

4. Perceived self-efficacy

Correct Answer: 2

Rationale 1: Interpersonal influences are a persons perceptions concerning the behaviors, beliefs, or attitudes of othersincluding family, peers, and health professionalswho can influence their success.

Rationale 2: Behavior-specific cognitions and affect are considered to be of major motivational significance for acquiring and maintaining health-promoting behaviors. Perceived benefits of action affect the persons plan to participate in health-promoting behaviors and may facilitate continued practice. If this client has prior positive experience with the behavior or observations of others engaged in the behavior, he or she may be motivated to success.

Rationale 3: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of options, demand characteristics, and the aesthetic features of the environment.

Rationale 4: Perceived self-efficacy refers to the conviction that a person can successfully carry out the behavior necessary to achieve a desired outcome.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Identify various types and sites of health promotion programs.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 251

Question 11

Type: MCSA

A client has been working hard in rehabilitation following a traumatic brain injury. She has a weak support system in that her family lives a far distance away and her coworkers are not involved. On which behavior-specific cognitions should the nurse focus to assist this client with success in the rehabilitation program?

1. Situational influences

2. Perceived benefits of action

3. Perceived barriers to action

4. Interpersonal influences

Correct Answer: 4

Rationale 1: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment.

Rationale 2: Perceived benefits of action affect the persons plan to participate in health-promoting behaviors and may facilitate continued practice.

Rationale 3: Perceived barriers to action may be real or imagined and may affect health-promoting behaviors by decreasing the individuals commitment to a plan of action.

Rationale 4: Interpersonal influences are a persons perceptions concerning the behaviors, beliefs, or attitudes of others. Family, peers, and health professionals are sources of interpersonal influences that can affect a persons health-promoting behaviors. Because this particular client does not have a close support system, the nurse will look to other possibilities (i.e., the other health professionals involved in the clients care such as other nurses, therapists, and physicians).

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Identify various types and sites of health promotion programs.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 252

Question 12

Type: MCSA

A client is learning how to manage his asthma. In providing teaching, the nurse stresses the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which health promotion behavior?

1. Competing preferences

2. Competing demands

3. Situational influences

4. Interpersonal influences

Correct Answer: 1

Rationale 1: Competing preferences are behaviors over which an individual has a high level of control and depend on the individuals ability to be self-regulating. In this case, the individual must make a choice to use his peak flow meter every day. Its really his choiceeither he uses it or he doesnt.

Rationale 2: Competing demands are behaviors over which an individual has a low level of control; something unexpected competes with a planned activity.

Rationale 3: Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment.

Rationale 4: Interpersonal influences are a persons perceptions concerning the behaviors, beliefs, or attitudes of others.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Discuss the Health Promotion Model.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 252

Question 13

Type: SEQ

Before helping a client with smoking cessation, the nurse reviews the steps of the change process. In which order should the nurse expect the client to progress through the stages of health change behavior? Arrange the following stages in the correct order:

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Preparation stage

Choice 2. Contemplation stage

Choice 3. Maintenance stage

Choice 4. Precontemplation stage

Choice 5. Termination stage

Choice 6. Action Stage

Correct Answer: 4, 2, 1, 6, 3, 5

Rationale 1: This is the third stage, where the client intends to take action in the immediate future (e.g., within the next month). Some people in this stage may have already started making small behavioral changes, such as buying a self-help book. At this stage, the person makes the final specific plans to accomplish the change.

Rationale 2: This is the second stage, where the client acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future (e.g., next 6 months).

Rationale 3: This is the fifth stage, where the client strives to prevent relapse by integrating newly adopted behaviors into his or her lifestyle. This stage lasts until the person no longer experiences temptation to return to previous unhealthy behaviors. It is estimated that maintenance lasts from 6 months to 5 years.

Rationale 4: This is the first stage, where the client is not contemplating change for at least 6 months.

Rationale 5: This is the sixth and last stage (the ultimate goal), where the individual has complete confidence that the problem is no longer a temptation or threat. It is as if the individual never acquired the habit in the first place or the new behavior has become automatic.

Rationale 6: This is the fourth stage, where the client actively implements behavioral and cognitive strategies of the action plan to interrupt previous health risk behaviors and adopt new ones. This stage requires the greatest commitment of time and energy.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Explain the stages of health behavior change.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 252

Question 14

Type: MCSA

Several nursing students have been discussing the benefits of joining a study group. They realize the importance of applying nursing knowledge to the clinical area and determine that together they may be more effective in retaining this information than if they continued in their individual settings. Which stage of behavior change are they exemplifying?

1. Termination stage

2. Preparation stage

3. Contemplation stage

4. Action stage

Correct Answer: 3

Rationale 1: The termination stage is the ultimate goal, where the individual has complete confidence that the problem is no longer a temptation or threat.

Rationale 2: The preparation stage occurs when the person undertakes cognitive and behavioral activities that prepare the person for change.

Rationale 3: During the contemplation stage, the person acknowledges the problem, considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future. Discussing benefits of a study group would fall into this stage. They havent started a group nor have they made any preparation toward it; they have merely been talking about it.

Rationale 4: The action stage occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Explain the stages of health behavior change.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 252

Question 15

Type: MCSA

A client with diabetes wants to have better control over her blood sugar levels. She has set a goal that she will have laboratory values that reflect this, and she has been monitoring her blood sugar twice a day for the past month. Along with regular checks, she has kept all appointments with her nutritionist. This client is modeling which stage of health behavior change?

1. Termination stage

2. Maintenance stage

3. Contemplation stage

4. Action stage

Correct Answer: 4

Rationale 1: The termination stage occurs when the individual has complete confidence that the problem is no longer a temptation or a threat.

Rationale 2: The maintenance stage is where the person integrates adopted behavior patterns into his or her lifestyle. This stage lasts until the person no longer has temptation to return to previous unhealthy behaviors.

Rationale 3: In the contemplation stage, the person acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future.

Rationale 4: The action stage occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones. This stage requires the greatest commitment of time and energy and is where the person is actually doing something to change the behavior.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Explain the stages of health behavior change.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 252

Question 16

Type: MCSA

The health nurse of a busy university campus is implementing a health promotion activity by placing posters about proper hand washing in all of the public restrooms on campus. Which type of health promotion program is the nurse implementing?

1. Environmental control

2. Information dissemination

3. Health risk appraisal and wellness assessment

4. Lifestyle and behavior change

Correct Answer: 2

Rationale 1: Environmental control programs have been developed as a result of the continuing increase of contaminants of human origin that have been introduced into the environment.

Rationale 2: Information dissemination is the most basic type of health promotion program. This method makes use of a variety of media to offer information to the public about the risk of a particular lifestyle choice and personal behavior as well as the benefits of changing that behavior.

Rationale 3: Health risk appraisal and wellness assessment programs are used to describe risk factors to people and motivate them to reduce specific risks and develop positive health habits.

Rationale 4: Lifestyle and behavior change programs require participation of the individual and are geared toward enhancing the quality of life and extending the life span.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify various types and sites of health promotion programs.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 253

Question 17

Type: MCSA

The nurse is preparing information packets for incoming college students regarding sexually transmitted disease, drug and alcohol abuse, and the use of stimulants among this age group. In this situation, the nurse has assumed which role?

1. Facilitator

2. Advocate

3. Teacher

4. Coordinator of services

Correct Answer: 3

Rationale 1: A facilitator is involved in the assessment, implementation, and evaluation of health goals.

Rationale 2: The advocate helps implement changes that promote a healthy environment.

Rationale 3: The teaching role focuses on self-care strategies such as enhancing fitness, improving nutrition, managing stress, and enhancing relationships.

Rationale 4: A coordinator helps to guide and reinforce the clients development in effective problem solving and decision making as well as reinforces personal and family health-promoting behaviors.

Global Rationale:

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Discuss the nurses role in health promotion.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Discuss the nurses role in health promotion.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 253

Question 18

Type: MCSA

The nurse suggests that a client make a list of past experiences that have brought joy, peace, and hope into the clients life. What action is the nurse assisting the client to complete?

1. Lifestyle assessment

2. Social support systems review

3. Health beliefs review

4. Spiritual health assessment

Correct Answer: 4

Rationale 1: Lifestyle assessment focuses on the personal lifestyle and habits of the client as they affect health.

Rationale 2: A social support systems review takes into account the social context in which a person lives and works and is important in health promotion. This includes individuals, groups, and interpersonal relationships that provide comfort, assistance, encouragement, and information.

Rationale 3: A health beliefs review is a clarification of those beliefs that determine how a person maintains control of his or her own health status.

Rationale 4: Spiritual health is the ability to develop ones spiritual nature to its fullest potential, including the discovery of how to experience love, joy, peace, and fulfillment. An assessment of spiritual well-being is a part of evaluating the persons overall health.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 18. Develop an awareness of patients as well as healthcare professionals spiritual beliefs and values and how those beliefs and values impact health care

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11. Describe components of health assessment that pertain to health promotion.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 255

Question 19

Type: MCSA

A client has received a high score on the Life-Change Index. For which part of the clients assessment should the nurse use this information?

1. Life stress review

2. Social support systems review

3. Lifestyle assessment

4. Health beliefs review

Correct Answer: 1

Rationale 1: The Life-Change Index is a tool that assigns numerical values to life events and is a way to identify clients in stress. Studies have shown that high levels of stress are associated with an increased possibility of illness in an individual.

Rationale 2: A social support systems review takes into account the social context in which a person lives and works.

Rationale 3: A lifestyle assessment focuses on the personal lifestyle habits of the client as they affect health.

Rationale 4: A health beliefs review provides information about how much clients believe they can influence or control health through personal behaviors.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 11. Describe components of health assessment that pertain to health promotion.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 256

Question 20

Type: MCSA

The client is a high school student who is also a single parent. She is attending parenting classes while studying full time and living in an apartment with her child. The student also meets twice a week with a teen peer group and participates in a nutrition program through the county. Which is the most appropriate diagnosis for this client?

1. Risk for Situational Low Self-Esteem

2. High Risk for Caregiver Role Strain

3. Readiness for Enhanced Coping

4. Readiness for Enhanced Nutrition

Correct Answer: 3

Rationale 1: The information given in the scenario does not indicate that the client is experiencing problems with low self-esteem.

Rationale 2: The information given in the scenario does not indicate that the client is experiencing problems with caregiver role strain.

Rationale 3: Wellness diagnoses describe the human responses to levels of wellness in an individual. In this situation, even though the client is young and single, she is making every effort to be well in her situation. Attending parenting classes, meeting with peers, and learning about nutrition all point to a person who has a positive outlook but requires teaching.

Rationale 4: The client is doing much more than just learning about nutrition. She is learning how to cope and be well in her life and the life of her child.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 12. Discuss nursing diagnosing, planning, implementing, and evaluating as they relate to health promotion.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 256

Question 21

Type: MCSA

The nurse educator provides developmental testing for kindergarten through thirdgrade students. Which level of prevention is the nurse performing?

1. Primary

2. Secondary

3. Tertiary

4. Community

Correct Answer: 2

Rationale 1: Primary prevention is true health promotion and precedes disease or dysfunction.

Rationale 2: Secondary prevention emphasizes early detection of disease and health maintenance for individuals experiencing health problems. This would include providing assessment of the growth and development of children.

Rationale 3: Tertiary prevention begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible.

Rationale 4: Community health is a broad category that includes many facets. It is not a level of prevention.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Discuss the Health Promotion Model.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 249

Question 22

Type: MCSA

A client has had a severe brain injury and has been in a rehabilitation hospital for several months. Recently, the client developed pneumonia and is currently on intravenous antibiotic therapy. Which level of prevention should the nurse use to address the health problem of pneumonia?

1. Primary

2. Secondary

3. Tertiary

4. Acute

Correct Answer: 2

Rationale 1: Primary prevention is true health promotion and provides specific interventions against disease.

Rationale 2: Secondary prevention emphasizes early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems. Because the pneumonia is a current health problem, interventions focused on that would be considered secondary prevention.

Rationale 3: All cares related to rehabilitation following the brain injury would be tertiary prevention. Tertiary prevention focuses on rehabilitating individuals to an optimum level of functioning.

Rationale 4: Acute care is a part of health care, but not one of the levels of prevention.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Discuss the Health Promotion Model.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 249

Question 23

Type: MCSA

A nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. When planning health promotion strategies, what factor should the nurse take into consideration?

1. Rest and exercise

2. Adjusting to physiologic changes and limitations

3. High obesity percentages

4. Safety promotion and injury prevention

Correct Answer: 2

Rationale 1: Rest and exercise are life span considerations of children.

Rationale 2: In the elderly population, health promotion and illness prevention are important, but the focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing strengths continues to be of prime importance in maintaining optimal function and quality of life.

Rationale 3: In the elderly population, health promotion and illness prevention are important, but the focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing strengths continues to be of prime importance in maintaining optimal function and quality of life. Rest and exercise and high obesity percentages are life span considerations of children.

Rationale 4: Safety promotion and injury prevention are life span considerations for adolescents.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Discuss the Health Promotion Model.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 250

Question 24

Type: MCSA

A nurse is working with various cultures while implementing health promotion activities for the community center. Bringing the minister of the church into the planning stage of these activities would be sensitive to which cultural groups?

1. Latino American

2. Asian American

3. Native American

4. African American

Correct Answer: 4

Rationale 1: Latino Americans view the family as being a major social support system.

Rationale 2: Asian Americans view the family as being a major social support system.

Rationale 3: Native American people live in social networks that foster mutual assistance and support.

Rationale 4: In the African American community, the family and church have been major providers of social support.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 12. Discuss nursing diagnosing, planning, implementing, and evaluating as they relate to health promotion.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 253

Question 25

Type: MCMA

The nurse is reviewing the characteristics of homeostatic mechanisms prior to assessing a client. Which characteristics should the nurse keep in mind during this assessment?

Standard Text: Select all that apply.

1. They are self-regulating.

2. They are compensatory.

3. They are regulated by negative feedback systems.

4. They can require several feedback mechanisms to correct only one physiologic imbalance.

5. They are related to a closed system.

Correct Answer: 1, 2, 3, 4

Rationale 1: Homeostatic mechanisms are self-regulating.

Rationale 2: Homeostatic mechanisms are compensatory.

Rationale 3: Homeostatic mechanisms are regulated by negative feedback systems.

Rationale 4: Homeostatic mechanisms can require several feedback mechanisms to correct a physiologic imbalance.

Rationale 5: Homeostatic mechanisms are not related to a closed system.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List four main characteristics of homeostatic mechanisms.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 245

Question 26

Type: MCMA

The nurse is an advocate for health promotion activities. Which nursing actions demonstrate this nurses advocacy?

Standard Text: Select all that apply.

1. Participating in a community-focused 5-mile run.

2. Attending the local high schools football games.

3. Providing an educational program to senior citizens on blood pressurecontrol strategies.

4. Attending a community meeting that is promoting the creating of a walking path in the city park.

5. Encouraging an anxious client to practice relaxation techniques.

Correct Answer: 1, 3, 4, 5

Rationale 1: The nurses role in health promotion includes modeling healthy lifestyle behaviors and attitudes.

Rationale 2: This is not an example of active role modeling.

Rationale 3: The nurses role in health promotion includes assisting clients, families, and communities to develop and choose health-promoting options.

Rationale 4: The nurses role in health promotion includes advocating in the community for changes that promote a healthy environment.

Rationale 5: The nurses role in health promotion includes teaching clients self-care strategies to enhance fitness, improve nutrition, manage stress, and enhance relationships.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 10. Discuss the nurses role in health promotion.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 249

Question 27

Type: MCMA

The nurse is reviewing information collected while providing client care. Which findings should the nurse identify as being a homeostatic mechanism?

Standard Text: Select all that apply.

1. The clients heart rate increases when walking up a flight of stairs.

2. The client shivers when core body temperature drops.

3. A childs bone growth occurs in spurts.

4. Decreased secretion of insulin occurs when food is not ingested.

5. Lactation occurs in a pregnant woman.

Correct Answer: 1, 2, 4

Rationale 1: Homeostatic mechanisms have characteristics that include self-regulation, such as automatically increased respiratory rates.

Rationale 2: Homeostatic mechanisms have characteristics that include compensatory actions, such as shivering to create body heat.

Rationale 3: This is not an example of a homeostatic mechanism; they are self-regulation, compensation, negative feedback, and utilization of multiple mechanisms to correct a physiological imbalance.

Rationale 4: Homeostatic mechanisms have characteristics that include regulation by negative feedback systems.

Rationale 5: This is not an example of a homeostatic mechanism; they are self-regulation, compensation, negative feedback, and utilization of multiple mechanisms to correct a physiological imbalance.

Global Rationale:

Page Reference:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: VII. 5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List four main characteristics of homeostatic mechanisms.

MNL Learning Outcome: 1.3.1. Use appropriate strategies to promote health.

Page Number: 245

 

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