Concept of Family Health Care

Concept of Family Health Care Related

Review Concept of Family Health Care related questions and content

A patient admitted yesterday for injuries sustained in a fall while intoxicated believes bugs are crawling on the bed. The patient is anxious, agitated, and diaphoretic. What is the priority nursing diagnosis?

  • A. Ineffective airway clearance
  • B. Ineffective coping
  • C. Ineffective denial
  • D. Risk for injury
Correct Answer: D

Rationale: The correct answer is D: Risk for injury. This is the priority nursing diagnosis because the patient's current state of agitation and anxiety, coupled with the belief of bugs crawling on the bed, poses an immediate risk for self-injury. The patient's altered mental status and intoxication increase the likelihood of accidental harm.

Explanation for other choices:
A: Ineffective airway clearance - While this is always a critical concern, the patient's current presentation does not indicate any immediate threat to the airway.
B: Ineffective coping - While the patient may be experiencing distress, the primary focus should be on addressing the risk of injury given the patient's altered mental status.
C: Ineffective denial - While the patient may be experiencing hallucinations, the primary concern is the risk of injury rather than the patient's denial of the situation.

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You are the Nurse Manager for the trauma unit. Which of these staff comments or statements do not indicate the need for you to provide an educational activity relating to confidentiality and information security?

  • A. “A computer in the hallway was left unattended and a client's medical record was visible to me.”
  • B. “I j ust saw a nursing student looking at the medical record for a client that they are NOT caring for during this clinical experience.”
  • C. “As I was walking past the nursing station, I saw a dietician reading the progress notes written by members of the laboratory department in addition to other dieticians' progress notes.”
  • D. “I refused the nursing supervisor's request to share my electronic password for the new nurse on the unit.”
Correct Answer: D

Rationale: These scenarios highlight breaches in confidentiality and security.

Diverse cultural beliefs can result in dramatically varied perceptions of wellness, disease, and the treatment of disease. In order to best address these variations when planning nursing care, the nurse and client initially:

  • A. Agree to respect each other's beliefs and values.
  • B. Discuss what the client believes is the cause of his or her illness.
  • C. Agree that treatment planning will include family members when possible.
  • D. Discuss the incorporation of both traditional nursing practice and culturally based practices.
Correct Answer: B

Rationale: The correct answer is B: Discuss what the client believes is the cause of his or her illness. This is the best initial step to address cultural variations in perceptions of wellness and disease because it allows the nurse to understand the client's perspective and tailor care accordingly. By exploring the client's beliefs, the nurse can identify any cultural factors that may impact treatment decisions.

A: Agree to respect each other's beliefs and values - While important, this is a broader concept and may not directly address the specific cultural beliefs influencing the client's health views.

C: Agree that treatment planning will include family members when possible - Involving family members is valuable but may not directly address the immediate need to understand the client's beliefs about illness.

D: Discuss the incorporation of both traditional nursing practice and culturally based practices - This is important but may be premature without first understanding the client's specific beliefs about illness.

The theorist associated with zone of proximal development is

  • A. Jean Piaget
  • B. Erik Erikson
  • C. Lev Vygotsky
  • D. John Dewey
Correct Answer: C

Rationale: Vygotsky's zone of proximal development defines learning potential with guidance.

Which assessment findings support a nurse’s suspicion that a patient has been using inhalants?

  • A. Perforated nasal septum and hypertension
  • B. Drowsiness, euphoria, and constipation
  • C. Pinpoint pupils and respiratory rate of 12 breaths per minute
  • D. Confusion, mouth ulcers, and ataxia
Correct Answer: D

Rationale: The correct answer is D because confusion, mouth ulcers, and ataxia are common assessment findings in individuals who have been using inhalants. Confusion and ataxia are neurological symptoms associated with inhalant use, while mouth ulcers can result from the toxic effects of inhalants on oral mucosa. These findings indicate central nervous system depression and potential damage from inhalant exposure.

Choices A, B, and C are incorrect because they do not align with typical assessment findings of inhalant use. Perforated nasal septum and hypertension (A) are more commonly associated with chronic cocaine use. Drowsiness, euphoria, and constipation (B) are symptoms of opioid use. Pinpoint pupils and respiratory rate of 12 breaths per minute (C) are indicative of opioid overdose, not inhalant use.

How many mLs will you administer to the client after you use 3.3 mL of normal saline to reconstitute a medication that will yield 12 mg per mL and the doctor's order is as follows. Doctor's order: 25 mg of medication BID

  • A. 1.9 mL
  • B. 2.0 mL
  • C. 2.5 mL
  • D. 2.1 mL
Correct Answer: D

Rationale: 25 mg / 12 mg/mL = 2.083 mL, rounded to 2.1 mL (D) per dose.

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