Foundations for Population Health in Community/Public Health Nursing 6th Edition by Stanhope and La

TEST BANK Foundations for Population Health in Community/Public Health Nursing 6th Edition by Marcia Stanhope and Jeanette Lancaster

TABLE OF CONTENTS: Chapter 01: Public Health Nursing and Population Chapter 02: The History of Public Health and Public Chapter 03: US and Global Health Care Chapter 04: Government, the Law, and Policy Chapter 05: Economics of US Health Care Chapter 06: Ethics in Public and Community Health Chapter 07: Culture of Populations Chapter 08: Environmental Health Chapter 09: Evidence-Based Practice Chapter 10: Epidemiological Applications Chapter 11: Infectious Disease Prevention and Treatment Chapter 12: Communicable and Infection Disease Chapter 13: Community Assessment and Chapter 14: Health Education in the Community Chapter 15: Case Management

Chapter 16: Disaster Management Chapter 17: Public Health Surveillance and Outbreak Chapter 18: Program Management Chapter 19: Healthcare Improvement in the Chapter 20: Family Development, Family Nursing Chapter 21: Family Health Risks Chapter 22: Health Risks Across the Life Span Chapter 23: Health Equity and Care of Vulnerable Chapter 24: Rural Health and Migrant Health Chapter 25: Poverty, Homelessness, Teen Pregnancy, Chapter 26: Alcohol, Tobacco, and Other Drug Problems Chapter 27: Violence and Human Abuse Chapter 28: Nursing Practice at the Local, State, and Nation Chapter 29: The Faith Community Nurse Chapter 30: The Nurse in Public Health, Home Health, Chapter 31: The Nurse in the Schools Chapter 32: The Nurse in Occupational Health

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Chapter 01: Public Health Nursing and Population Health Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which statement best describes community-based nursing? a. A practice in which care is provided for individuals and families. b. Providing care with a focus on the group’s needs. c. Giving care with a focus on the aggregate’s needs. d. A value system in which all clients receive optimal care.

ANS: A

By definition, community-based nursing is a setting-specific practice in which care is provided for “sick” individuals and families where they live, work, and attend school. The emphasis is on acute and chronic care and the provision of comprehensive, coordinated, and continuous care. These nurses may be generalists or specialists in maternal-infant, pediatric, adult, or psychiatric mental health nursing. Community-based nursing emphasizes acute and chronic care to individuals and families, rather than focusing on groups, aggregates, or systems.

2. Which statement best describes the goal of community-oriented nursing? a. Providing care to individuals and families b. Providing care to manage acute or chronic conditions c. Giving direct care to ill individuals within their family setting d. To preserve, protect, promote, or maintain health and prevent disease ANS: D

By definition, community-oriented nursing has the goal of preserving, protecting, or maintaining health and preventing disease to promote the quality of life. All nurses may focus on individuals and families, give direct care to ill persons within their family setting, and help manage acute or chronic conditions. These definitions are not specific to community-oriented nursing.

3. Which of the following is the primary focus of public health nursing? a. Families and groups b. Illness-oriented care c. Individuals within the family unit d. Health care of communities and populations ANS: D

In public health nursing, the primary focus is on the health care of communities and populations rather than on individuals, groups, and families. The goal is to prevent disease and preserve, promote, restore, and protect health for the community and the population within it. Community-based nurses deal primarily with illness-oriented care of individuals and families across the life span. The aim is to manage acute and chronic health conditions in the community, and the focus of practice is on individual or family-centered illness care.

4. Which of the following is responsible for the dramatic increase in life expectancy during the 20th century? a. Technology increases in the field of medical laboratory research b. Advances in surgical techniques and procedures c. Sanitation and other population-based prevention programs d. Use of antibiotics to fight infections ANS: C

There has to be indisputable evidence collected over time that public health policies and programs were primarily responsible for increasing the average life span from 47 in 1900 to 78.6 years in 2017, an increase of approximately 60% in just over a century plus through improvements in (1) sanitation, (2) clean water supplies, (3) making workplaces safer, (4) improving food and drug safety, (5) immunizing children, and (6) improving nutrition, hygiene, and housing. Although people are excited when a new drug is discovered that cures a disease or when a new way to transplant organs is perfected, it is important to know about the significant gains in the health of populations that have come largely from public health accomplishments.

5. A nurse is developing a plan to decrease the number of premature deaths in the community. Which of the following interventions

would most likely be implemented by the nurse?

Provide free health care to all citizens To increase the number of individuals with access to effective health care benefits Lower the cost of health care to the American population To lessen the governmental burden of providing health care to Americans

a. b. c. d.

ANS: B

The central feature in the Patient Protection and Affordable Care Act (ACA) of 2010 are the mechanisms to increase the number of people with health insurance. The care provided is not necessarily free. While the cost of health care and the burden it places on the American government are serious concerns, they are not the primary focus of ACA.

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6. What is the basic assumption stated by Healthy People 2010 as it relates to public health efforts? a. Health disparities among any groups are morally and legally wrong. b. Health care is the most important priority in government planning and funding. c. The health of individuals cannot be separated from the health of the community. d. The government is responsible for lengthening the life span of Americans.

ANS: C

The major premise of Healthy People 2010 was that the health of the individual cannot be entirely separate from the health of the larger community. Public health practice focuses on the community as a whole, and the effect of the community’s health status (resources) on the health of individuals, families, and groups. The goal is to prevent disease and disability and promote and protect the health of the community as a whole. Public health can be described as what society collectively does to ensure that conditions exist in which people can be healthy. The basic assumptions of public health do not judge the morality of health disparities. The focus is on prevention of illness not on spending more on illness care. Additionally, individual responsibility for making healthy choices is the directive for lengthening life span not the role of the government.

7. Which of the following actions would most likely be performed by a public health nurse? a. Asking community leaders what interventions should be chosen b. Assessing the community and deciding on appropriate interventions c. Using data from the main health care institutions in the community to determine

needed health services d. Working with community groups to create policies to improve the environment ANS: D

Although the public health nurse might engage in any of the tasks listed, he or she works primarily with members of the community to carry out core public health functions, including assessment of the population as a whole and engaging in promoting health and improving the environment. The interventions of asking community leaders which interventions should be chosen, assessing the community and deciding on appropriate interventions, and using data from health care institutions do not demonstrate the engagement of the community when making decisions about what the community actually wants and needs.

8. Which public health nurse most clearly fulfills the responsibilities of this role? a. The nurse who met with several groups to discuss community recreation issues b. The nurse who spent the day attending meetings of various health agencies c. The nurse who talked to several people about their particular health concerns d. The nurse who watched the city council meeting on local cable television ANS: B

Any of these descriptions might represent a nurse communicating, cooperating, or collaborating with community residents or groups about health concerns. A major challenge for the future is the need for public health nursing specialists to be more aggressive in working collaboratively with various groups in the community as well as professional colleagues in institutional settings to deal with barriers to health. However, the nurse who spent the day attending meetings of various health agencies is the most representative, because in public health, concerns are addressed from a broader perspective. In public health, broad concerns of the community should be addressed. Concerns are broader than recreation, individual concerns are not as important as aggregate priorities, and watching television (a one-way form of communication) is less effective than interacting with others.

9. Which of the following best defines aggregate? a. A large group of persons b. A collection of individuals and families c. A collection of people who share one or more characteristics d. Another name for demographic group ANS: C

An aggregate is defined a collection of people who share one or more personal or environmental characteristics. Members of a community can be defined in terms of either geography (e.g., a county, a group of counties, or a state) or a special interest (e.g., children attending a particular school). These members make up a population. The term population may be used interchangeably with the term aggregate. A large group of persons, a collection of individuals and families, and another name for demographic group are not accurate definitions of the term aggregate.

10. Which question asked by a novice nurse would be the most reflective of an understanding of the role of a public health nurse? a. “Which groups are at the greatest risk for problems?” b. “Which patients should I see first as I begin my day?” c. “With which physicians will I be most closely collaborating?” d. “With which nursing assistants will I partner the most?”

ANS: A

Asking which groups are at greatest risk reflects a community-oriented perspective. The incorrect responses reflect a focus on individuals rather than a community-oriented perspective.

11. Making sure that essential community-oriented health services are available defines which of the core public health functions? a. Policy development b. Assessment c. Assurance d. Scientific knowledge-based care ANS: C

Assurance includes making sure that essential community-oriented health services are available in the community. The definition does not fit the terms assessment, policy development. Scientific knowledge-based care is not a core function of public health.

Assessment is systematic data collection on the population, monitoring the population’s health status, and making information available about the health of the community. Policy development refers to efforts to develop policies that support the health of the population, including using a scientific knowledge base to make policy decisions.

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12. When talking to a women’s group at the senior citizens’ center, the nurse reminded them that the only way the center would be able

to afford to provide transportation services for them would be for them to continue to write letters to their local city council representatives requesting funding for such a service. What was the nurse trying to accomplish through this action? a. Ensure that the women did not expect the nurse to solve their problem. b. Demonstrate that the nurse understood the women’s concerns and needs. c. Express empathy, support, and concern. d. Help the women engage in political action.

ANS: D

Public health nurses engage themselves and others in policy development and encourage and assist persons to communicate their needs to those with the power to take action. The nurse is demonstrating the role of advocate through this action, it goes beyond merely understanding the women’s concern, and instead mobilizes them to take action. This action does not demonstrate the nurse showing empathy rather the nurse is empowering these women.

13. The public health nurse has a clear vision of what needs to be done and where to begin to improve the health of the community.

Why would the nurse spend time meeting with community groups to discuss the most important task to be addressed first? a. To increase the group’s self-esteem b. To maintain communication links with the groups c. To make the groups feel good about their contribution d. To work with the groups, not for the groups ANS: D

Historically, health care providers have been accused of providing care for or to people without actually involving the recipients in the decisions. Public health nursing is a “with the people”—not a “to the people” or “for the people”—approach to planning. There is an imperative to work with members of the community to carry out core public health functions. The purpose of meeting with community groups is not to increase their self-esteem or make them feel good about their contribution, rather it is to allow them to act for themselves to solve the problems they are facing. The first task of working with the group should occur before addressing maintaining communication links.

14. The nurse often has to make resource allocation decisions. Which of the following best describes the criterion the nurse should use

in such cases? a. The specific moral or ethical principle related to the situation b. The cheapest, most economical approach c. The most rational probable outcome d. The needs of the aggregate rather than a few individuals ANS: D

The dominant needs of the population outweigh the expressed needs of one or a few people. All of the choices represent components of a decision that the nurse might consider in determining the needs of the aggregate.

15. Which of the following actions best represents public health nursing? a. Assessing the effectiveness of the high school health clinic b. Caring for clients in their home following their outpatient surgeries c. Providing care to children and their families at the school clinic d. Administering follow-up care for pediatric clients at an outpatient clinic ANS: A

A public health or population-focused approach would look at the entire group of children being served to determine whether available services are effective in achieving the goal of improving the health of the school population. Caring for clients and their families focuses on individuals and families and not on the entire population. Public health focuses on care of populations.

16. Two nurses plan to walk under a huge downtown bridge where various homeless persons live. Why would the nurses go to such an

unsafe area? a. To assess the needs of the homeless who live there b. To demonstrate their courage and commitment c. To distribute some of their own surplus clothes to those who can use them d. To share with various churches and other charities what is needed ANS: A

In most nursing practices, the client seeks out and requests assistance. In public health nursing, the nurse often reaches out to those who might benefit from a service or intervention, beginning with assessment of needs. The other answers reflect responses where the nurse is trying to give assistance to this population that may or may not be helpful or welcomed.

MULTIPLE RESPONSE 1. Which of the following variables have led to a stronger commitment to population-focused services? (Select all that apply.) a. Economic turmoil and demand for high-technology care b. Emergence of new or drug-resistant infectious diseases c. Emphasis on overall health care needs rather than only on acute care treatment d. Threat of bioterrorism ANS: B, C, D

As overall health needs become the focus of care in the United States, a stronger commitment to population-focused services is emerging. Threats of bioterrorism, anthrax scares, and the emergence of modern-day epidemics have drawn attention to population-focused safety and services. Economic turmoil and demand for high-technology care have not contributed to a stronger commitment to population-focused services, rather it has occurred as overall health needs have become the focus of care.

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2. Which of the following actions demonstrate effective public health nursing practice in the community? (Select all that apply.) a. Epidemiologic investigations examine the environment for health hazards. b. New services are organized where particular vulnerable populations live. c. Partnerships are established with community coalitions. d. Staff members at the public health agency continue to increase in number. e. Staffing walk in clinics for low income families ANS: A, B, C

Evidence that public health nurses are practicing effectively in the community would include organizing services where people live, work, play, and learn; working in partnerships and with coalitions; and participating in epidemiologic studies. Neither increasing the number of staff nor acting as staff in the delivery of acute and/or chronic care has a relationship to the effectiveness of public health nursing practice.

3. Why are nurses increasingly providing care in clients’ homes rather than in hospitals? (Select all that apply.) a. Home care is less expensive. b. It is much more efficient to give care in the home. c. Nurses prefer to give home care with individual attention. d. People prefer to receive care in their homes rather than in hospitals.

ANS: A, D

An increasing number of clients are receiving care in the home because it is less expensive and clients prefer to receive care in familiar and comfortable settings. It is not more efficient nor more convenient, since travel time has to be considered. Nurses differ as to their preferred employment setting.

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Chapter 02: The History of Public Health and Public and Community Health Nursing Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse is considering applying for a position as a public health nurse. Which of the following would be a reason this position

would be appealing? a. Its autonomy and independence b. Its focus on acute care and immediately visible outcomes c. Its collaboration with other health care professionals d. Its flexibility and higher wages ANS: A

Public health nursing is known for its autonomy and independence. In many instances, there are limited other health care professionals and staff with whom to interact. In-patient acute care nurses focus on acute care with outcomes known fairly quickly.

Acute care nurses collaborate frequently with other health care professionals. Depending on the position there may be more flexibility, but typically public health nurses do not receive higher wages.

2. The Elizabethan Poor Law of 1601 is similar to which current law? a. Welfare b. Food stamps c. Medicaid d. Medicare ANS: C

The Elizabethan Poor Law guaranteed medical care for poor, blind, and “lame” individuals. This minimal care was generally provided in almshouses supported by local government similar to Medicaid assistance. Welfare and food stamps do not provide for medical care. Medicare provides medical care to primarily the elderly population.

3. How did the Industrial Revolution result in previous caregiving approaches, such as care by families, friends, and neighbors,

becoming inadequate? a. Economic and political wars resulted in frequent death and injuries. b. Incredible plagues consistently and constantly swept the European continent. c. Migration and urbanization resulted in increased demand for care. d. Caregivers could easily find other employment, so they demanded to be paid.

ANS: C

Care became inadequate because of the social changes in Europe, with great advances in transportation, communication, and other technologies. The increased mobility led to migration and urbanization, which in turn led to increased need for care. The Industrial Revolution was a time of great advances in technology, transportation, and communication, not a time of economic and political unrest or a time where incredible plagues occurred in Europe. Caregivers during this time period were typically poorly educated and untrained, so there was not an issue related to wages or employment.

4. A colonist is working in the public health sector in early colonial America. Which of the following activities would have likely

been completed? a. Establishing schools of nursing b. Developing vaccines to administer to large numbers of people c. Collecting vital statistics and improving sanitation d. Developing public housing and almshouses ANS: C

Collecting vital statistics and improving sanitation are examples of activities from the early colonial America. Establishing schools of nursing, developing vaccines to administer to large numbers of people, and developing public housing and almshouses all happened after the colonial period.

5. Why did American citizens become interested in establishing government-sponsored boards of health? a. They were afraid of infectious diseases such as yellow fever. b. The government could force the poverty-stricken to accept care. c. Such boards could tax and thereby ensure adequate funds to pay for care. d. Such a system would allow for accurate records of births and deaths.

ANS: A

Threat of disease, especially yellow fever, led to public interest in establishing government-sponsored, or official, boards of health.

The threat of disease was the impetus for creation of the boards of establishing boards of health. The primary interest of the boards of health was to provide public health services for the entire population and not only those who were poverty-stricken. The primary purpose of the boards of health was not to collect accurate vital statistics or receive tax dollars rather its purpose w as to ensure the health of the population.

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6. A nurse was employed by the Marine Hospital Service in 1800. Which of the following interventions would the nurse most likely

have implemented? a. Setting policy on quarantine legislation for immigrants b. Establishing hospital-based programs to care for the sick at home c. Identifying and improving environmental conditions d. Providing health care for merchant seamen ANS: D

Providing health care to seamen was an early effort by the federal government to improve public health. The purpose of the Marine Hospital Service was to secure its maritime trade and seacoast cities. Quarantine legislation was enacted by legislation during this time period, but the nurse would not have been responsible for setting these policies. Nursing care for clients in the home began in the first half of the 1800s through a variety of agencies including the Ladies’ Benevolent Society of Charleston South Carolina.

Identifying and improving environmental conditions was a focus of the public boards of health, not necessarily specifically a role of the nurse.

7. What was the outcome of the Shattuck Report? a. Efforts to control alcohol and drug abuse, as well as tobacco use, were initiated. b. Environmental sanitation efforts became an immediate priority. c. Guidelines for modern public health organizations were eventually developed. d. Local and state governments established boards of health after its publication.

ANS: C

It took 19 years for the first of Shattuck’s recommendations to be implemented, but his report was the first effort to create a modern public health organization. This report called for broad changes to improve the public’s health to take place; however, these changes did not happen immediately after publication. They took 19 years to be implemented in the first state of Massachusetts. The report included establishment of a state health department and local health boards in every town, sanitary surveys, and food, drug, and communicable disease control, but none of these changes happened quickly.

8. Which nurse is famous for creating public health nursing in the United States? a. Florence Nightingale b. Frances Root c. Lillian Wald d. Mrs. Solomon Loeb ANS: C

Lillian Wald established the Henry Street Settlement and later emerged as the established leader of public health nursing during its early decades. Mrs. Solomon Loeb was a wealthy layperson who assisted Mary Brewster in the establishment of the Henry Street Nurses Settlement. Francis Root was the first trained nurse in the United States who was salaried as a visiting nurse. Florence Nightingale had many accomplishments, but none of these occurred in the United States.

9. Which of the following would have been the focus of a school nurse in the early 20th century? a. Investigating causes of absenteeism b. Teaching school as well as being a nurse c. Promoting nursing as an autonomous practice d. Providing medical treatment to enable children to return to school ANS: A

Early school nursing focused on investigating causes of absenteeism. Providing medical treatment was the responsibility of physicians. School nurses did not teach in the schools nor were they part of an autonomous practice during this time period.

10. A nurse is reviewing the original work of the National Organization for Public Health Nursing. Which accomplishments of today

were started within this organization? a. Requiring that public health nurses have a baccalaureate degree in nursing b. Standardizing public health nursing education c. Developing public health nursing competencies d. Opening the Henry Street Settlement ANS: B

The National Organization for Public Health Nursing sought to improve the educational and services standards of public health nursing. The Henry Street Settlement was already in existence and was opened by Lillian Wald and Mary Brewster. The baccalaureate degree in nursing was not developed yet. Public health nursing competencies were developed by the Quad Council.

11. Why were nurses so unprepared for public health nursing in the early 20th century? a. Public health nursing had not yet been created as a field. b. No one would teach the nurses how to engage in public health activities. c. Nightingale’s textbook did not include content on public health nursing. d. Nurses were educated in diploma schools, which emphasized care of hospital

clients.

ANS: D

Nursing school courses taught in diploma schools of nursing emphasized hospital care of patients; thus, nurses were unprepared for home visiting. The specialty of public health nursing practice was developed in the early 1800s. There was not a lack of teachers for this activity, rather the focus of nursing care was in the acute care setting and not in the community. Nightingale did not have a published textbook.

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12. A nurse is considering joining the American Public Health Association (APHA). What information about this organization should

be considered when making this decision? a. APHA focuses on the public health concerns of the medical profession. b. APHA represents concerns of nursing specialty practices. c. APHA provides a national forum for nurses to discuss their public health concerns. d. APHA focuses on providing health promotion education to the public.

ANS: C

APHA was formed to facilitate interprofessional efforts and promote the “practical application of public hygiene.” The Public Health Nursing Section within APHA provides nurses with a national forum to discuss their concerns and strategies within the larger context of the major public health organization. It also serves as a focus of leadership and policy development for community/public health nursing. The focus of public health concerns of the APHA is broader than only the medical profession.

The APHA focuses on concerns of public health nurses, not all nursing specialty practice. The APHA focuses on practical application of public hygiene, which is broader than only health promotion education.

13. Why did the Metropolitan Life Insurance Company establish and retain for several years the first community nursing health

program for policyholders? a. Creating such a service was the morally correct thing to do b. Employing nurses directly was less expensive than paying taxes to the city for the same purpose c. Having the company’s nurses make home visits increased worker morale d. Public health nurses visits led to fewer policyholder deaths and lowers company costs ANS: D

Metropolitan Life saw an average decline of 7% in the mortality rate of policyholders and almost a 20% decline in the deaths of children under the age of 3 years. The insurance company attributed this improvement and the associated reduced costs to the work of visiting nurses. There was limited funding in the early 20th century to extending nursing services in the community; thus, home visiting was a very expensive service to provide. Although Metropolitan Life Insurance Company may have increased worker morale that was not the primary reason for continuation of the program.

14. Which client would have been most likely to receive care from the Frontier Nursing Service? a. An injured soldier b. A homebound, elderly male c. A woman in labor d. A child with a broken femur ANS: C

The Frontier Nursing Service nurses were trained in nursing, public health, and midwifery and provided care to rural and inaccessible areas, which led to reduced mortality. Care for soldiers, elderly, and children was not the focus of the care provided by the Frontier Nursing Service.

15. A public health nurse is determining what type of programming should be developed for the community. Which of the following is

the most crucial factor that will influence program development? a. Comprehensive assessment and planning done in the community b. Documented needs of the local community c. Federal funding for priority diseases or groups d. Nursing staff’s expertise and skills ANS: C

Programs are designed to fit funding priorities; thus, the areas supported by Congress determine the categories in which most effort is focused locally. A need in the community may be identified through community assessment, planning, and looking at needs in the community; however, without funding there will not be a way to create necessary programming. The expertise of the staff should not be the determining factor when deciding on programming in the community.

16. A nursing student during World War II would likely join which group? a. The US Public Health Service b. The Marine Nurse Corps c. The Frontier Nursing Service d. The Cadet Nurse Corps ANS: D

The Bolton Act of 1943 established the Cadet Nurse Corps during World War II, which increased enrollment in schools of nursing at undergraduate and graduate levels. The U.S. Public Health Service began to use nurses during World War I to establish a public health nursing program for military outposts. The Marine Hospital Service was established well before World War II in 1798. The Frontier Nursing Service was established by Mary Breckinridge in 1925 and provided health care to the rural and often inaccessible populations in the Appalachian region of southeastern Kentucky.

17. A public health nurse is compiling information about how to promote early detection of breast cancer in women. Which document

would most likely provide useful information about this topic? a. The Future of Public Health b. Healthy People 2020 c. Patient Protection and Affordable Care Act d. Scope and Standards of Public Health Nursing Practice ANS: B

The Healthy People 2020 documents propose a national strategy to significantly improve the health of Americans by preventing or delaying the onset of major chronic illnesses, injuries, and infectious diseases. The disarray resulting from reduced political support, financing, and effectiveness is described in The Future of Public Health. The Scope and Standards of Public Health Nursing Practice describes the processes of assessment, analysis, and planning that are carried out by the public health nurse. The Patient Protection and Affordable Care Act improved access to health insurance for Americans.

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18. A public health nurse is involved in health care reform. Which of the following best explains why the nurse is involved in these

efforts? a. To promote the nursing profession b. To increase funding for public health nursing c. To address the concerns of nurses d. To help improve health care access ANS: D

Public health nurses have been involved in health care reform for several years. An emphasis of reform is that health promotion and disease prevention appear to yield reduction in costs and illness/injury incidence while increasing years of healthy lif e. Health care reform has a larger scope than only the profession of nursing and public health nursing. It addresses the concerns of nurses as well as many other health care professions.

MULTIPLE RESPONSE 1. How did Florence Nightingale help bring about community health nursing? (Select all that apply.) a. She convinced socially prominent wealthy women to volunteer to give care. b. She focused on all soldiers and their environment. c. She interacted with each individual person, assessing his or her needs and acting

to meet those needs. d. She kept careful records on what was done and what were the results.

ANS: B, D

Nightingale progressively improved the soldiers’ health using a population-based approach that improved both environmental conditions and nursing care. Using simple epidemiology measures, she documented a decreased mortality rate to demonstrate the outcomes. While Nightingale was part of a wealthy family, the role of nurses during this time period was typically fulfilled by poor women. The focus of Nightingale’s care was to identify health care needs and interventions that influenced the health of the entire population, not individuals.

2. A nurse working with Mary Breckinridge would have likely assisted in what activity? (Select all that apply.) a. Establishing the Henry Street Settlement b. Developing health programs geared toward improving the health care of the rural

populations c. Blazing a nursing trail through the Rockies, providing nursing care to miners and

their families d. Ensuring positive outcomes for pregnancies among women in the Appalachian region ANS: B, D

Mary Breckinridge developed health programs geared toward improving the health care of the rural and often inaccessible populations in the Appalachian regions of the Southern Kentucky. Breckinridge introduced the first nurse-midwives into the United States when she deployed FNS nurses trained in nursing, public health, and midwifery. Their efforts led to reduced pregnancy complications and maternal mortality, and to one-third fewer stillbirths and infant deaths in an area of 700 square miles. Lillian Wald established the Henry Street Settlement. Mary Breckinridge developed health programs geared toward improving the health care of the rural and often inaccessible populations in the Appalachian regions of southern Kentucky, not the Rockies.

3. How did nursing education change in the 1950s? (Select all that apply.) a. Baccalaureate nursing programs typically included public health nursing b. c. d. e.

concepts.

Diploma schools of nursing continued to expand their student numbers.

Junior and community colleges began offering nursing programs.

Nurses were strongly encouraged to have a scientific basis for their practice.

Post diploma training was initiated nationwide.

ANS: A, C

In the 1950s, public health nursing became a required part of most baccalaureate nursing education programs. In 1952, nursing education programs began in junior and community colleges. Associate degree programs began to expand their enrollments, not diploma schools. The need for evidence-based practice continues to grow but was not a change in the 1950s. In 1914 Mary Adelaide Nutting, working with the Henry Street Settlement, began the first course for post-diploma school training in public health nursing at Teachers College in New York City.

4. How did health care and its delivery change during the 1980s? (Select all that apply.) a. Funding to public health increased as funding for acute hospital care decreased. b. Laws began to be passed that discouraged the use of alcohol, drugs, and tobacco. c. Nurse practitioners were increasingly used to provide care. d. Public health programs suffered reduced political support, financing, and

effectiveness.

ANS: B, C, D

During the 1980s funding began to shift to meet the costs of acute hospital care, medical procedures, and institutional long-term care. The use of health maintenance organizations was encouraged, and the use of nurse practitioners increased. Consumer and professional advocacy groups urged the passage of laws to prohibit unhealthy practices such as smoking and driving under the influence of alcohol. By the late 1980s, public health had declined in political support, financing, and effectiveness.

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Chapter 03: US and Global Health Care Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A public health agency is planning to implement the electronic health record. (Which is a benefit of this choice? a. Facilitation of interprofessional care b. Improved client compliance with medical regimens c. Cost savings to the agency d. Compliance with JCAHO standards ANS: A

The electronic medical record facilitates interprofessional care in chronic disease management and coordination of referrals; 24-hour availability of records with downloaded laboratory results and up-to-date assessments; incorporation of protocol reminders for prevention, screening, and management of chronic disease; improvement of quality measurement and monitoring; increased client safety; and decline in medication errors. There is no evidence that an electronic health record improves client compliance with medical regimens. Electronic health records can increase costs to an agency. JCAHO does not accredit public health agencies.

2. Which statement best describes the cost of health care in the United States? a. Health care costs are kept low, and the indicators of health are among the best

worldwide. b. Health care costs are low which has resulted in poor health outcomes. c. Health care costs are the highest in the world, but the indicators of health are not the best worldwide. d. Health care costs and indicators of health are the highest in the world.

ANS: C

Health care costs in the United States are the highest in the world and comprise the greatest percentage of the gross domestic product, the indicators of what constitutes good health do not document that Americans are really getting their money’s worth.

Health care costs are not low in comparison to the rest of the world. The health outcomes in the United States are poor in comparison to other countries who spend less money on health care.

3. A nurse is explaining the health care system in the United States to a group of health care providers visiting from South America.

How would the nurse best describe the current health care system? a. “It is a logical, rational approach to meeting expressed needs while still trying to control costs.” b. “It is a centralized system that provides care in hospitals.” c. “It is divided primarily into two components: private health care and public health care.” d. “It is the best in the world with outstanding research and high-technology care available to all.”

ANS: C

Health care in the United States consists of a private or personal care system and a public health system, with overlap between the two. The United States health care system is one of the most expensive systems in the world that does not do a good job at controlling costs. Care is provided through an enormous range of facilities and providers, including hospitals, physicians’ and dentists’ offices, nursing homes, mental health facilities, ambulatory care centers, and freestanding clinics. Although there is great research and high-technology care in the United States, the health care outcomes of the country do not reflect this. Health care disparities exist among multiple populations making this system not available to all.

4. Which statement best describes ideal primary health care? a. Based on a multidisciplinary group of health care providers that work as a team b. Essential care available to all community members, which encourages

self-management Focused on health promotion and disease prevention for everyone enrolled in the health center d. Local efforts to meet the Declaration of Alma Ata principles c.

ANS: B

Primary health care is generally defined as essential care made universally accessible to individuals, families, and the community.

Health care is made available to them with their full participation and is provided at a cost that the community and country can afford. Public health is described as organized and multidisciplinary efforts aimed at preventing disease and promoting health, not primary care. Primary care provides for the integration of health promotion, disease prevention, with curative and rehabilitative services. The Declaration of Alma Ata was aimed at a world-wide, not local goal, to attain a level of health that permitted all citizens of the world to live socially and economically productive lives.

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5. How does managed care (MC) attempt to control costs of care? a. By encouraging families to use the point of service list of individual practice

associates b. By requiring families to choose a care provider from the MC network and not allowing access to other services without their provider’s permission c. By moving Medicaid-eligible families onto state Medicare enrollment d. By refusing permission for families to use urgent care or emergency department services ANS: B

Managed care is a system in which care is delivered by a specific network of providers. Each provider serves as a gatekeeper who controls access to other providers and services. Cost is reduced because members cannot use specialists or seek hospital or other care without permission from their primary-care providers. Thus, those enrolled in Medicaid managed care have restrictions that help keep costs down for government (and for taxpayers). Managed care provides care through a specific network of providers who agree to comply with the care approaches established through a case management approach, not through a point of service list of individual practice associates. Medicaid and Medicare programs are not interchangeable, these programs serve different populations. Managed care does not refuse permission for certain services such as urgent care or emergency department, rather a case management approach is used to control costs.

6. An 80-year-old woman comes to the community health care facility with a large bag of medications. She tells the nurse she can no

longer afford these medications because her only income is Social Security. Which statement is the best response by the nurse? a. “Let’s go through these medications and see which ones we can delete.” b. “You can get these medicines at this clinic for free.” c. “Let’s see if we can get some help from Medicare to help you pay for these medications.” d. “These medications are important. Do your best to pay for them.”

ANS: C

This elderly patient probably is eligible for benefits through Medicare Part D. Medicare Part D has been added to Medicare to help cover the cost of prescriptions. The role of the nurse would not be to delete medications for the patient or to tell the patient to figure it out on her own. Because of the age of the patient, the nurse should see if options exist under the Medicare system before looking into receiving the medications for free as there may be other barriers which limit the abilities to get these medications at a discounted cost.

7. A nurse is determining which health care services must be offered at a local public health clinic. Which factor is most important for

the nurse to consider? a. Data available from the most recent community assessment b. Suggestions from community members about what is needed c. Recommendations from Healthy People 2020 d. Services mandated by the state government ANS: D

At the local level, health departments provide care that is mandated by state and federal regulations. Data available from the most recent community assessment, suggestions from community members about need, and recommendations from Healthy People 2020 could all be used. However, funding for these types of programs may not be available. The services that are mandated by the state government will be funded and allow the clinic to be able to provide these services.

8. A public health nurse is working with a low-income population in Massachusetts. Which of the following assumptions can the

nurse make about this population? a. They have difficulty accessing health care due to a shortage of primary-care providers. b. They most likely receive health insurance through Medicare. c. They are unable to access health care due to the implementation of the Affordable Care Act. d. They have access to affordable health care insurance.

ANS: D

Massachusetts began an experiment in health reform in 2006. Two years after health reform legislation became effective, only 2.6% were uninsured, the lowest percentage ever recorded in any state. The shortage of primary care providers is not significantly different in Massachusetts than in other areas of the country. Low-income populations are eligible for Medicaid services, not Medicare. The program in Massachusetts became a model for the Affordable Care Act. 9. A public health nurse is working with a client who does not have health insurance. Where will the nurse most likely direct the

client to in order to receive care? a. Managed care b. Community health center c. Emergency department d. Physician office ANS: B

There is a safety net for the uninsured or underinsured. These are the federally funded community health centers which provide a broad range of health and social services, using nurse practitioners and RNs, physician assistants, physicians, social workers, and dentists. Community health centers serve primarily in medically underserved areas which can be rural or urban as well as people of all ages, races, and ethnicities, with or without health insurance. Managed care is a system in which care is delivered by a specific network of providers who agree to comply with the care approach, not a place to refer a client without health insurance. Emergency departments and physician offices are not the best place for an individual without health insurance to receive care. Both are expensive and do not provide the necessary resources for the individual to possibly receive health insurance.

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10. Which of the following best describes why local, state, and federal governmental agencies have started to cooperate and collaborate

more closely in the last few years? a. Increased administrative pressures to demonstrate outcomes b. Increased focus on emergency preparedness and response c. Increased taxpayers’ complaints and general unhappiness d. Increased pressure to decrease overlap in services ANS: B

Since the tragedy of September 11, 2001, health departments have increasingly focused on emergency preparedness and response. In case of an emergency event, state and local health departments in the affected area will be expected to collect data and accurately report the situation, to respond appropriately to any type of emergency, and to ensure the safety of the residents of the immediate area, while protecting those just outside the danger zone. This goal—to enable public health agencies to anticipate, pre pare for, recognize, and respond to terrorist threats or natural disasters—has required an unprecedented level of interstate and f ederal-local planning and cooperation among these agencies. Demonstrating outcomes and decreasing overlap of services are both important factors to consider; however, this is not the reason why increased collaboration has occurred. There has not been an increase in taxpayer complaints or unhappiness that has caused these changes to occur.

11. Minority nurses represented about 30.1 percent of the RN population. What is this an example of? a. Projection b. Disparity c. Racism d. A sentinel event ANS: B

Disparities are racial or ethnic differences in the quality of health care or representation of a faction of the population, not based on access or clinical needs, preferences, or appropriateness of an intervention. Projection is an estimate or forecast of a future situation based on current trends. Racism is a prejudice that exists against someone of a different race based on the belief that one’s own race is superior. A sentinel event is an unanticipated event in health care that results in death or serious injury to the pa tient.

MULTIPLE RESPONSE 1. A public health agency is in the process of obtaining accreditation. Which of the following best describes why the agency would

want to achieve accreditation? (Select all that apply.) a. To improve health programming and services b. To improve community relationships c. To improve performance and quality d. To improve management e. To decrease cost of health care ANS: B, C, D

The purpose of accreditation for public health departments is to assist and identify quality health department performance and quality, and it develops leadership, improve management, and improve community relationships. Neither the improvement of health care programming and services nor minimizing health care costs is a reason why a public health agency would want to achieve accreditation.

2. What do demographic figures suggest about the ways in which the population of the United States is changing? (Select all that

apply.) a. Foreign-born immigrant population is increasing. b. Hispanics are the largest minority group population. c. Leading causes of death are from infectious diseases. d. Mortality for both genders in all age groups declined. e. Unintentional injuries are among the top 10 causes of death.

ANS: A, B, D, E

The nation’s foreign-born population is growing, and it is projected that from now until 2050 the largest population growth will be due to immigrants and their children. Although African Americans used to be the largest minority group, Hispanics now have that distinction. The population of the United States continues to increase, and mortality for both genders from all age groups has declined. The leading causes of death have changed from infectious diseases to chronic and degenerative diseases with unintentional injuries being among the top 10.

3. Which of the following statements is accurate descriptions of current social and economic trends in the United States? (Select all

that apply.) a. Citizens are appreciating the quality of life enjoyed in the United States. b. Enjoying life is not as important as the need to take care of oneself. c. People often spend a considerable amount of their own money on complementary therapies. d. The gap between the richest and poorest is widening. e. The composition of families and living patterns are changing.

ANS: A, C, D, E

Several social trends that influence health care include changing lifestyles, a growing appreciation of the quality of life, the changing composition of families and living patterns, changing household incomes, and a revised definition of quality health care.

People often spend a considerable amount of their own money for these types of therapies because few are covered by insurance. It is obvious that the gap between the richest and poorest is widening because of the percent wage increase in the higher income levels. Americans spend considerable money on health care, nutrition, and fitness, because health is seen as an irreplaceable commodity. To be healthy, people must take care of themselves.

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4. Which of the following provides evidence that the US health care system is in crisis? (Select all that apply.) a. Health insurance is an expensive benefit for employers to provide. b. Incompetent or negligent nurses are an ongoing source of medical errors. c. Long work hours and provider fatigue are a major factor in medical errors. d. More punitive measures must be taken to decrease provider errors. e. Consumers want lower costs and high-quality health care without limits.

ANS: A, C, E

Consumers want lower costs and high-quality health care without limits and with an improved ability to choose providers and services of their choice while employers are typically the purchasers of health care; they want to be able to obtain basic health care plans at reasonable costs for their employees. Many employers have seen their profits diminish as they put more money into providing adequate health care coverage for employees. Nurses working long hours pose a serious threat to patient safety because fatigue slows reaction time, saps energy, and diminishes attention to detail. The Institute of Medicine’s (IOM) report To Err Is Human recommends that we stop blaming and punishing individuals for errors and instead begin identifying and correcting system failures by designing safety into the process of care. The report makes it clear that the majority of medical errors today were not produced by provider negligence, lack of education, or lack of training.

5. A nurse is working at a state health department. Which of the following duties would most likely be completed in this setting?

(Select all that apply.) a. Administering the Medicaid program b. Assessing the health needs of the state’s citizens c. Employing and supervising school health nurses d. Establishing and maintaining child immunization clinics e. Providing education regarding established health codes ANS: A, B, E

State health departments try to prevent and respond to infectious disease outbreaks. They also are responsible for health care financing and administering Medicaid, providing mental health and professional education, establishing health codes, licensing facilities and personnel, and regulating the insurance industry. State health departments also give direct assistance to local health departments in areas such as ongoing assessment of health needs. Employing and supervising school health nurses occur at the local level, and many times within a specific school. Provision of child immunization clinics occurs at the local level.

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Chapter 04: Government, the Law, and Policy Activism Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following best defines the word politics? a. The art of influencing others b. The outcome of governmental policies c. A provision of power for making decisions d. The result of legislative action ANS: A

Politics is the art of influencing others to accept a specific course of action. Political action results in governmental policies and legislation. The result of legislative action typically is done in the form of laws and policies. The provision of power for making decisions is typically assumed by the government.

2. Which of the following activities is completed by the executive branch of the federal government? a. Administration of policy b. Interpretation of policy c. Proposal of policy d. Passage of policy ANS: A

The executive branch administers and regulates policy. The legislative branch proposes policy (as bills) and passes policy (as laws).

The judicial branch interprets laws.

3. A nurse meets with a senator to lobby for passage of a bill to increase funding for interpreter services. With which of the following

branches of the government is the nurse working? a. Constitutional branch of government b. Executive branch of government c. Legislative branch of government d. Judicial branch of government ANS: C

The legislative branch of government is composed of the Senate and the House of Representatives. The legislative branch identifies problems and proposes and then debates, passes, and modifies laws to address those problems. There is not a constitutional branch of the government. The executive branch administers and regulates policy. The judicial branch interprets laws.

4. Which of the following statements best describes why the federal government has become involved in health care? a. The states asked the federal level to become involved. b. Because of rising costs to the states, the federal budget needed to be used to pay

for necessary services.

The Constitution gives the federal government the power to promote the general welfare. d. This step was necessary to standardize care on a national level. c.

ANS: C

One of the first constitutional challenges to a federal law passed by Congress was in the area of health and welfare in 1937. The Supreme Court (judicial branch) reviewed the legislation in question and determined, through interpretation of the Constitution, that such federal governmental action was within the powers of Congress to promote the general welfare. According to Article I, Section 8 of the US Constitution Congress has multiple roles in relation to health care: provide for the general welfare, regulate commerce among the states, raise funds to support the military, and provide spending power. Thus, Congress was within its role to become involved in health care and was not asked to do so by the states or used to standardize care on the national level.

5. A client states to the nurse, “I have heard the Affordable Care Act is supposed to help improve the health care I receive, but so far I

have seen no benefits from this legislation.” Which of the following statements would be the best reply by the nurse? a. “Maybe you have not directly seen the changes; however, several things have changed in health care because of this bill.” b. “It will take years to see any effects from the act because of the delays in implementation of the changes.” c. “This legislation will primarily improve care for the elderly and poor populations, so this is why you may not have seen any benefits.” d. “The way health care operates at the federal and state levels has changed, so most individuals will not see any direct impact.”

ANS: A

It is possible that unless one has been in a situation where changes have been made, that one may not realize any of the effects of this law. The goal of the Affordable Care Act was to improve the health of the nation and access care. Several changes to health care have already been made because of this legislation, and more changes will continue in the future. Multiple provisions of the act will affect individuals and families.

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6. What was the significance of the 1979 Surgeon General’s report? a. It planned the goals and priorities for the entire Veterans Administration medical

system. b. It vastly increased funding for health promotion activities. c. It identified the use of tobacco as a cause of lung cancer. d. It created national goals for promoting health and preventing disease.

ANS: D

The 1979 Surgeon General’s report began a focus on preventing disease and promoting health for all Americans. It was a national effort with all levels of government, as well as other interested parties, involved. The 1979 report did not plan goals and priorities for the Veterans Administration medical system; rather it looked at health of all Americans. There was no funding associated with the report. It addressed prevention of disease and promotion of health for multiple diseases, not just lung cancer.

7. A nurse is advocating for the public health department to increase the number of public health nurses that it employs. Which of the

following factors should the nurse emphasize? a. Providing disease investigation training b. Providing research opportunities c. Providing leadership experiences d. Providing salaries commensurate with responsibilities ANS: D

Through the input of the Division of Nursing’s National Advisory Council for Nursing Education and Practice (NACNEP), the Division of Nursing sets policy for nursing nationally. A few of the factors indicated by the NACNEP that need to be in place to support the public health nurse role are competitive salaries commensurate with responsibilities, experience in health promotion and prevention, long-term trusting relationships in the community, and a commitment to social justice and eliminating health disparities. The Division of Nursing’s National Advisory Council for Nursing Education and Practice (NACNEP) did not emphasize the importance of providing disease investigation training, research opportunities, or leadership experiences.

8. A nurse is determining whether a hospital has the right to require infected patients to be isolated against their will. To which type of

law will the nurse refer? a. Common law b. Constitutional law c. Legislation and regulation d. Judicial law ANS: B

Constitutional law provides the right to intervene in a reasonable manner to protect the health, safety, and welfare of the citizenry.

State power concerning health care is called police power. This power allows states to act to protect the health, safety, and welfare of their citizens. The state must show that it has a compelling interest in taking actions, especially actions that might infringe on individual rights. The state can isolate an individual to prevent an epidemic, even though this infringes on individual rights. The community’s rights are deemed more important than the individual’s rights when there is a threat to the health of the public.

Judicial law, based on court and jury decisions, and the principles of common law (precedent, justice, fairness, respect for an individual’s autonomy, and self-determination) are both used by court’s as the basis to make a decision and do not relate to having the right to isolate a patient. Legislation is law that comes from the legislative branches of the government and regulations are specific statements of law related to defining or implanting individual pieces of legislation. Neither are as important in this case as the constitutional law of the police power of the states in regards to isolation of a patient.

9. Who is responsible for determining the scope of practice for registered nurses? a. American Nurses Association b. Federal legislators c. State legislators d. US Department of Health and Human Services ANS: C

Health care practitioners are subject to the laws of the state in which they practice. The state nurse practice acts def ine the practice of professional nursing, identify the scope of nursing practice, set educational qualifications, and determine legal titles. The nurse practice act is governed by legislators in each state. The American Nurses Association, US Department of Health and Human Services, and federal government do not determine the scope of practice for nurses; this responsibility is the role of state governments. The US Department of Health and Human Services is the agency most heavily involved with the health and welfare of US citizens.

10. Which of the following statements by a client indicates a lack of understanding regarding an appropriate reason to sue for

professional negligence? a. “Because the health care workers didn’t turn my mother every 2 hours, she developed bedsores.” b. “I received permanent nerve damage because they would not remove a cast that was too tight.” c. “My daughter wasn’t given a call light, and for a whole shift no one checked on her condition.” d. “They amputated the wrong leg during surgery.”

ANS: C

Professional negligence, or malpractice, is defined as an act (or failure to act) that leads to injury. All of the choices specify an injury, except for “My daughter wasn’t given a call light, and for a whole shift no one checked on her condition,” in which case the care was substandard but no injury resulted. The incorrect responses all specify an injury whereas professional negligence, or malpractice, is defined as an act (or failure to act) that leads to injury.

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11. Which of the following statements best describes the law in relation to clinical practice by nursing students? a. Students are considered certified until licensure is obtained. b. Students are expected to meet the same standard of care as the professional nurse. c. Students are not legally liable for errors because they practice under the license of

their instructor. d. Students have a scope of practice determined by the nurse practice act.

ANS: B

Nursing students need to be aware that the same laws and rules that govern the professional nurse apply to them as well. Students are expected to meet the same standard of care as that met by any licensed nurse practicing under the same or similar circumstances. Although it is true that students cannot practice outside the scope of practice determined by the nurse practice act, they also cannot perform the tasks and responsibilities of the licensed practitioner within the scope of practice until they have received adequate knowledge; therefore, the scope of practice for the student is determined by the instructor, based on the student’s level of education.

12. A nurse wishes to see a bill passed to support funding for the use of interpreters for clients with limited English proficiency. Which

of the following would be the best time for the nurse to request support from the local senator, who is not on the committee that is reviewing this bill? a. When the bill is first assigned to a committee. b. When the bill is discussed and debated within the committee. c. When the bill moves out of committee to be heard by the entire Senate. d. When the bill passes the Senate and moves to the House of Representatives.

ANS: C

Once the bill is passed by committee and moves out of committee to be heard by all senators, it will be important to contact this senator, who will then be in a position to act on it. To contact the senator when the bill is first assigned to the committee or is being discussed and debated within the committee is too early to effectively influence the individual senators. The nurse would not want to wait until after the vote has been taken in the Senate because it would then be too late for the senator to act.

13. The state board of nursing has written new regulations to clarify in a more concrete manner what the nurse practice act allows and

requires. Which of the following effects will this change have on nurses in this state?

None, because they are just helpful guidelines for maximum safety.

None, because they just give specifics that may change over time.

Major, because prudent nurses would follow such regulations.

Major, because these rules and regulations have the effect of law and must be obeyed.

a. b. c. d.

ANS: D

When the legislature passes a law and delegates its oversight to an agency, it gives that agency the power to make regulations.

Because regulations flow from legislation, they have the force of law. Whether prudent or not, nurses are obligated to practice consistent with these regulations. All nurses have the responsibility to follow the changes that are in place by legisla tion. They are laws that must be followed, not guidelines.

14. A bill with the potential to decrease health care services is passed by Congress. Which of the following actions should the nurse

take to influence the bill’s implications? a. Exercise veto power by calling for petitions from health care agencies. b. Contact the regulatory agency and participate in public hearings. c. Call members of congress to request that they rescind the legislation that was passed. d. Discuss the change in services with the administrators at the hospital.

ANS: B

Once a bill is passed and becomes law, it is too late to influence congressional members to change their vote; however, it is not too late to influence the outcome of the vote because the nurse can influence how the law is regulated. An agency typically writes the regulations that control how the law is implemented in more specific detail. Often this process can be just as important as lobbying against a bill because it shapes the final implementation of the law. Health care agencies do not have the ability to veto a bill. After a bill has been passed, it is too late to contact members of congress. Calling the hospital will not change the implications of the bill.

Contact must be made with the regulatory agency in order to influence how the law is regulated.

15. Which of the following agencies has the most influence on the health and welfare of US citizens? a. Agency for Healthcare Research and Quality (AHRQ) b. Centers for Disease Control and Prevention (CDC) c. US Department of Health and Human Services (USDHHS) d. World Health Organization (WHO) ANS: C

As the agency to which most health care legislation is delegated, the USDHHS is the agency most heavily involved with the health and welfare of citizens. The AHRQ and CDC are divisions of the USDHHS. WHO’s policy-making body provides policy options and guides but not laws. In the textbook, only the USDHHS is discussed regarding its responsibility for Medicare and Medicaid through the Centers for Medicare and Medicaid Services (CMS).

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16. Which of the following laws established programs for provision of health services for women and children and supported

community-oriented nursing practice? a. Early Periodic Screening and Developmental Testing (EPSDT) Initiative b. Healthy People 2000 Initiative c. Sheppard-Towner Act d. State Child Health Improvement Act (SCHIP) ANS: C

The Sheppard-Towner Act of 1921 played an important role in the development of public health policy, public health nursing, and social welfare policy. Of particular importance was the fact that it established standards for programs to serve women and children and made nurses available to provide these services in the community setting. Within the Sheppard-Towner Act was a provision to start the EPSDT initiative. SCHIP provides insurance for children and families who cannot otherwise afford health insurance.

Healthy People 2000 focuses on promoting health and preventing disease for all Americans.

MULTIPLE RESPONSE 1. Which of the following describes the significance of the passage of The Public Health Threats and Emergencies Act? (Select all

that apply.) a. It funded ongoing activities of the public health system. b. It led to improved water quality and food safety guidelines. c. It included funding for public health activities. d. It validated that the public health system was prepared for terrorism. e. Expanded the role of Secretary of HHS to include aspects of public health emergencies.

ANS: B, C

The Public Health Threats and Emergencies Act was the first federal law to comprehensively address the public health system’s preparedness for bioterrorism and other infectious disease outbreaks and signaled the beginning of renewed interest in public health as the protector for entire communities. The focus of this law was to address emerging threats to the public’s health and authorize the Secretary of HHS to take appropriate response actions during a public health emergency, including investigations, treatment, and prevention. A focus was the improvement of water quality and food safety. It did not support the ongoing activities of public health.

It did not validate the public health system was prepared for terrorism.

2. Which of the following best describes the importance of the World Health Organization (WHO) to the United States? (Select all

that apply.) a. Provides daily information on disease occurrences. b. Establishes international standards for antibiotics and vaccines. c. Creates international legislation regarding international cooperation. d. Supports national programs to fight disease when asked to do so. e. Monitors for adverse drug reactions.

ANS: A, B, D, E

Some WHO services that benefit all countries (including the United States) are providing day-to-day information service on the occurrence of internationally important diseases; publishing the international list of causes of disease, injury, and death; monitoring adverse reactions to drugs; and establishing international standards for antibiotics and vaccines. Individual countries can request assistance with strengthening the delivery of health services, supporting national programs to fight disease, and training health workers—which the United States does not. WHO can suggest but cannot legislate to individual countries.

3. Which of the following activities is the responsibilities of the Centers for Disease Control and Prevention (CDC)? (Select all that

apply.) a. Conduct research to enhance disease prevention. b. Detect and investigate infectious disease problems. c. Develop public health policies. d. Publish national goals for promoting health and preventing disease. e. Serves as an advocate of public health polices ANS: A, B, C, E

The mission of the CDC is to promote health and quality of life by preventing and controlling disease, injury, and disability. To monitor health, the CDC will detect and investigate health problems, conduct research that will enhance prevention, and develop and advocate sound public health policies and other prevention strategies. The safety and health of the workplace is the specific responsibility of OSHA. The CDC cannot write or pass legislation. The USDHHS published national health goals in Healthy People 2020.

4. A nurse is visiting a state legislator to encourage the legislator to vote for a particular health bill that the state n urses association has

endorsed. Which of the following actions would be most important for the nurse to complete? (Select all that apply.) a. Encourage the legislator or staff to ask relevant questions. b. Be friendly and engage in small talk so that rapport can be established. c. Be aware that legislators are well informed; don’t insult the legislator by stating information that is obvious. d. Have a handout that summarizes all the major points in support of the bill.

ANS: A, D

Legislators might not be well informed about every issue, so they need and want important information. The nurse should allow time for questions or clarifications of information shared and have the material on a handout for the legislator’s convenience. It is also helpful to invite the legislator to attend nursing conferences or meetings where health issues will be discussed. The nurse should not waste time with small talk but briefly present his or her stand, emphasizing other nurses who support the bill, because numbers count. Legislators might not be well informed about every issue, so they need and want important information that the nurse can provide.

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5. A nurse would like to become involved in political action. Which of the following actions would be most appropriate for the nurse

to accomplish this goal? (Select all that apply.) a. Become a member of the state nurses association. b. Be friendly with everyone, whether supportive or not of your ideas. c. Focus on being appointed to the state level committees. d. Focus all your efforts on your specialty practice area and your employment site. e. Volunteer to serve on relevant committees.

ANS: A, B

A nurse wishing to become politically involved should begin by joining the state nurses association, networking with others involved, and volunteering to serve on committees or in offices. Be friendly and network to increase your knowledge beyond your own workplace or specialty and seek opportunities to share expertise with others. Becoming involved locally is a good opportunity to start becoming involved in political action and allows for networking at the local level. Seeking opportunities beyond one’s workplace or specialty area allows the nurse to gain additional knowledge and share expertise in specialty area with oth ers.

6. A nurse is testifying at a committee meeting about a health bill. Which of the following actions should be taken by the nurse?

(Select all that apply.) a. Briefly describe professional education. b. Discuss how the bill affects more than just nurses. c. Include factual data and, if possible, statistical information in visual form. d. Provide written proof of personal and professional qualifications e. Provide information about relevant expertise and related experience.

ANS: A, B, C, E

Language must be simple and carefully chosen to convey information to listeners and to avoid professional jargon. The nurse must share a bit of personal education, experience, and expertise to be seen as a credible source, but written proof of credentials is not necessary unless specifically requested. The testimony must go beyond just nursing’s interest and include accurate, credible data.

The data must be accurate and credible which may not be the case when getting names from the media.

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Chapter 05: Economics of US Health Care Delivery Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse is discussing how health care rationing occurs in the United States. Which of the following would most likely be discussed

as the criterion that is used to ration health care? a. Clinic operating hours b. Ability to pay for services c. Availability of local provider services d. Transportation availability ANS: B

Because there are not enough health care services available to provide desired services to everyone, the focus has been on reducing costs by controlling the use of services. All of the factors listed affect health care access and therefore affect health care rationing (either directly or indirectly). The primary determinant, however, is the ability to pay for services. Without this ability, services are denied; therefore, those without insurance that is accepted by a provider or institution or who do not have the money to pay out of pocket are unable to obtain services regardless of operating hours, transportation issues, or availability.

2. Which of the following must a nurse be knowledgeable about to make decisions regarding the most cost-effective way to allocate

health care resources? a. Insurance resources b. Health care rationing c. Health economics d. Medical technology ANS: C

Economics is the science concerned with the use of resources; health economics is concerned with how scarce resources affect the health care industry. Insurance resources, health care rationing, and medical technology are important components of health economics but by themselves do not provide the broad understanding called for in this question.

3. Which of the following individuals would most likely experience a barrier when accessing health care? a. A 40-year-old female who speaks English as a second language b. A 25-year-old female with co-pay health insurance c. A 50-year-old male with hypertension d. A 30-year-old male who is unemployed ANS: D

Barriers to accessing care include the inability to afford health care, lack of transportation, physical barriers, communication problems, childcare needs, lack of time or information, or refusal of services by providers. The unemployed male is most likely to experience a barrier because of not having a job, which may reduce his access to health insurance and limit his income. Those who speak English as a second language and have health insurance even with co-pay requirements should both find it easier to access health insurance than someone who is unemployed since the inability to afford health care is a primary barrier. Medical diagnoses, such as having hypertension, do not present a barrier to accessing health care.

4. Which person is most likely to be uninsured? a. An 82-year-old woman with chronic medical problems b. A 2-year-old whose mother is on welfare c. A 50-year-old business man who works for a large corporation d. A 24-year-old man who works part-time at a small business ANS: D

Young adults (ages 19 to 25 years) account for a disproportionately large share of the uninsured, largely due to their low incomes. The elderly person would be eligible for Medicare, and the 2-year-old is probably eligible for Medicaid. The man who works at the large corporation probably has health insurance, because most large businesses provide it.

5. Which of the following is most closely correlated with poor health? a. Age and gender (i.e., older males) b. Low socioeconomic status c. Minority race status d. High-risk lifestyle behaviors ANS: B

Poverty is more closely related to health status even when controlling for age, gender, race, education, and lifestyle behaviors. The rate of uninsured remained higher among people with lower incomes and lower among those with higher incomes. Households of three with less than $20,000 annual income are at the highest risk for being uninsured. Socioeconomic status has the closest correlation to health status; thus, age, gender, minority race status, and high-risk lifestyle behaviors do not have the closest correlation.

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6. A pregnant teenager has approached a nurse asking about ways to improve the health outcomes for her and her unborn child. Which

of the following statements would be most appropriate for the nurse to make? a. “Don’t drop out of school.” b. “Sign up for childbirth classes.” c. “Sign up for the WIC program.” d. “Take your prenatal vitamins daily.”

ANS: A

The question specifies the health of both the mother and the child. Socioeconomic conditions improve with education. Because socioeconomic status is inversely related to mortality and morbidity, by becoming better educated, the mother-to-be will be less likely to live a life of poverty and, as a consequence, will enjoy a greater chance of better health for herself and for her child. The priority of the nurse should be to encourage the teenager to stay in school as this choice will provide for the best long-term outcome for the client. Signing up for childbirth classes, the WIC program, and taking prenatal vitamins all address short-term outcomes which are not as important as the future of the teenager raising this child.

7. A nurse is providing care to a child whose parents do not receive health insurance as an employee benefit and who do not have the

financial resources to pay for health care out of pocket. Which of the following resources should the nurse recommend to the family? a. A managed care organization b. An emergency department c. Medicaid d. Medicare ANS: C

Medicaid provides coverage for adults with low income and their children. Managed care is a type of private insurance while Medicare is available to persons aged 65 and older. The emergency department would charge a co-pay for care given to both the child and the parents.

8. Which of the following best explains how the government unintentionally encourages low-income persons to use emergency

departments as their primary care provider? a. A huge amount of paperwork is required when Medicaid clients go to a physician’s office. b. Government regulations require Medicaid clients to use emergency departments when their primary health care provider is unavailable. c. Legally, emergency departments must see clients even if clients can’t pay. d. Physicians’ limited office hours make them unavailable during evenings and weekends.

ANS: C

People on Medicaid frequently have no primary care provider and may not be able to pay for their care. Although physicians can choose clients based on their ability to pay, emergency departments are required by law to evaluate every client regardless of ability to pay. Emergency department co-payments are modest and are frequently waived if the client is unable to pay. Thus, low out-of-pocket costs provide incentives for Medicaid clients and the uninsured to use emergency departments for primary care services. Limited physician office hours over the weekend does make it difficult for low-income persons to access care through a primary care provider; however, this is not influenced by a government decision. The government does not require Medicaid clients to use the emergency department when their primary care provider is unavailable, rather the policies of the emergency department to see all clients regardless of ability to pay may inadvertently encourage them to use this service. The paperwork at a physician’s office that needs to be completed by a Medicaid client is not any different than any other client receiving care at the office.

9. Which of the four main factors that affect health, is the most important? a. Environment b. Human biology c. Lifestyle choices d. Health care system ANS: C

Personal biology and behavior (or lifestyle), environmental factors and policies (including physical, social, health, cultural, and economic environments), social networks, living and working conditions, and the health care system—medical services are said to have the least effect. Behavior and lifestyle have been shown to have the greatest effect on longevity, with the environment and biology accounting for the greatest effect on the development of all illnesses.

10. A nurse is trying to maximize the quality of life of clients while reducing health care costs. Which of the following actions would

most likely be completed by the nurse? a. Assisting in cast application for a client who was injured in a skateboard incident b. Irrigating the eyes of a client splashed with chemicals c. Restoring a normal cardiac rhythm following cardiopulmonary resuscitation of a client with a heart condition d. Teaching a high school boy about sexually transmitted infections and proper condom application ANS: D

Education is primary health care prevention. A proactive investment in disease prevention and health promotion targeted at improving health behaviors and lifestyle has the potential to improve health status and reduce health care costs. Assisting in a cast application, irrigating a client’s eyes, and restoring a normal cardiac rhythm are all tertiary prevention methods as a condition has already occurred and the nurse is focusing on restoring health. In order to maximize quality while reducing health care costs, the nurse should focus on primary prevention strategies.

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11. Which of the following caused health care providers to begin to focus on individual infections and trauma in the 1900s in the

United States? a. Education of health care providers moved into universities. b. People finally had enough money to pay for medical care. c. The improved outcomes of hospital care were recognized. d. Advances were made in sewage disposal, and water and milk quality.

ANS: D

Environmental conditions influencing health began to improve with major advances in water purity, sanitary sewage disposal, milk quality, and urban housing quality. The health problems of this era were no longer mass epidemics but individual acute infections or traumatic episodes. The education of health care providers did move into universities during this time period; however, this is not the reason why there was an increased focus on infections and trauma. Health care was paid for primarily by individuals during this time period so there was not an increase in the amount of money available to pay for health care. The outcomes of hospital care improved because of the advances that were being made in technology, not because health care providers were focusing more on infections and trauma.

12. Which of the following accurately describes a challenge that will be faced by health care providers in the 21st century? a. Lack of available space to provide care for clients in hospitals b. Emergence of new and old communicable and infectious diseases c. New guidelines for chronic disease management d. Increased use of technology leading to a decreased need for health care workers ANS: B

In the 21st century, the emergence of new and the reemergence of old communicable and infectious diseases are occurring as well as larger foodborne disease outbreaks and acts of terrorism. Care for clients continues to move out of the hospital setting and into the community. Chronic disease management will be a challenge for health care providers; however, new guidelines should ease the care provided for these diseases and wouldn’t be seen as a challenge. The use of technology will continue to increase, but the need for health care workers will not be decreasing. New health care careers will emerge because of the changes in technology.

13. Which of the following demographic factors is expected to have the greatest influence on national health care spending? a. The aging population b. Use of diagnosis-related groups to determine reimbursement c. Insurance reform d. An increasing number of people without health insurance ANS: A

The aging population is expected to affect health services more than any other demographic factor. The majority of older adults rely on publicly funded programs. As the Baby Boom generation ages and retires, federal expenses for Social Security and health care will increase. The use of diagnosis-related groups to determine reimbursement started in 1983 and is not expected to have a great influence on national health care spending at this time. Insurance reform is not a demographic factor. Due to the Affordable Care Act, the number of people without health insurance is decreasing.

14. Which of the following groups pays the largest amount for health care in the United States today? a. Consumers b. Federal and state government c. Insurance companies and other third-party payers d. Hospitals and health care providers ANS: B

Combined state and federal governments paid the most for health care in 2018. Health care financing has evolved from a time when the most money was expended by consumers, then to a system financed by third-party payers such as insurance companies, and finally, to today, when state and federal government payments (primarily through Medicare and Medicaid) pay more than private insurance companies or consumers. From 1960 to 2018, the percentage of third-party public insurance payments increased and the percent of out-of-pocket payments declined.

15. Which of the following services would be covered under Medicare Part A? a. Blood draw to assess PT/INR b. Physical therapy visit c. Stay in skilled nursing facility d. Transportation by an ambulance ANS: C

Medicare Part A covers hospital care, home care, and skilled nursing care. Medicare Part B covers “medically necessary” services, such as health care provider services, outpatient care, home health, and other medical services such as diagnostic services and physiotherapy.

16. A Medicare recipient has elected to pay a monthly premium for Medicare that will cover expenses such as durable medical

equipment. Which of the following best describes this part of Medicare? a. Part A b. Part B c. Part C d. Part D ANS: B

Medicare Part B is a supplemental (voluntary) program; it provides coverage for services that are not covered by Part A, such as laboratory services, ambulance transportation, prostheses, durable medical equipment, and some supplies. Medicare Part A covers hospital care, home care, and skilled nursing care. Medicare Part C plans are coordinated care plans that include health maintenance organizations, private fee-for-service plans, and medical savings accounts. Medicare Part D provides prescription drug coverage.

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17. Which of the following criterion is now used for deciding the amount of the reimbursement before care is provided? a. A proportion of actual cost arbitrarily decided by the Medicare panel b. The federal budget constraints for the current fiscal year c. Hospital and health care provider feedback and political persuasion d. Prospective payment scale based on the medical diagnosis ANS: D

As a result of rising health costs, Congress passed a law in 1983 that mandated an end to cost-plus reimbursement and instituted a prospective payment system (PPS) for inpatient hospital services to shift the cost incentives away from the providing of more care and toward more efficient services. The basis for prospective reimbursement is the 468 diagnosis-related groups (DRGs). There is not a Medicare panel that determines the actual cost of services. Payments are determined in advance based on DRGs and are not determined by the budget of the federal government. Hospital and health care provider feedback do not influence the prospective reimbursement; rather, the third-party payer establishes the amount of money that will be paid for the delivery of a particular service before offering the services to the client.

18. Which of the following payment systems tries to keep clients healthy through education and health promotion, with the goal of

reducing the need for professional health care intervention and therefore also lowering cost? a. Managed care plan b. Fee-for-service payment c. Prospective reimbursement d. Retrospective reimbursement ANS: A

The concept of managed care is that costly care could be reduced if consumers had access to education and health promotion.

Fee-for-service payment encourages more services to be given. Reimbursement, whether prospective or retrospective, is based on the same criteria, but managed care integrates the financing and the delivery of health care.

19. Which of the following terms describes when a nurse practitioner receives a set monthly payment to take care of a group of clients

regardless of the services needed and provided? a. Capitation b. Fee for service c. Rationing d. Retrospective reimbursement ANS: A

In payment by capitation, practitioners are paid a set amount to provide care to a given client or group of clients for a set period of time. In the fee-for-service payment system, which is like the retrospective reimbursement, the practitioner determines the costs of providing a service, delivers the service to a client, submits a bill for the delivered service to a third-party payer, and is paid by the third-party payer. Rationing implies reduced access to care and potential decreases in the acceptable quality of service s offered.

20. A client expresses concern that health care coverage based on capitation may have negative side effects. Which of the following

would most likely be a consequence of capitation? a. Coercing clients to attend health promotion education classes b. Encouraging clients to seek care elsewhere c. Increasing the number of interventions to maximize payment d. Neglecting to order certain tests or treatment to minimize cost to the provider ANS: D

In capitated arrangements, physicians and other practitioners are paid a set amount to provide care to a given client for a set period of time and amount of money. Thus, neglecting to order certain tests or treatment would be a way for the provider to maximize the amount of money received to provide care to members of this group. In a capitated arrangement, the provider would most likely not increase the number of interventions used or coerce clients to attend health promotion classes as both of these strategies would cost the provider more money, and the provider will be receiving a set amount of money to provide care for a given client for a set period of time. It is unlikely that the provider would encourage clients to seek care elsewhere; rather the provider would be conscientious about the number of tests and treatments that are ordered in order to try to contain costs.

21. When did medicine in the United States make a shift away from the treatment of acute infection to care of chronic illnesses? a. Between 1890 and 1920 b. Between1920 and 1940 c. Between 1940 and 1960 d. Between 1945 and 1984 ANS: D

The later part of the 20th Century (1945-1984) ushered in a shift away from acute infectious health problems of previous stages toward chronic health problems such as heart disease, cancer, and stroke.

22. A nurse is implementing a primary prevention strategy focusing on economics within the community. Which of the following

interventions is the nurse most likely completing? a. Applying for a grant to establish a daycare center to serve dependent older adult clients living with working families b. Persuading legislators to pass a bill offering health care financial aid to families at risk c. Screening cocaine addicts for financial assistance eligibility for drug treatment d. Referring clients with renal failure to apply for Medicare ANS: B

Primary prevention occurs before an illness or condition develops. Of the options provided, only persuading legislators to pass a bill offering health care financial aid to families at risk addresses initiating interventions before an illness occurs. Applying for a grant and referring clients with renal failure both demonstrate the use of tertiary prevention as the illness or conditi on has already developed. Screening cocaine addicts displays the use of secondary prevention as a screening technique is being used to identify the problem as soon as possible.

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MULTIPLE RESPONSE 1. In which of the following situations would the federal government provide money through tax relief for private enterprise? (Select

all that apply.) a. A business pays for part of health insurance premiums for its employees. b. A business purchases gifts for its employees to award them for their service. c. An employer provides health screenings. d. An employer requests reimbursement for employee transportation costs. e. An employer offers immunizations to all eligible employees.

ANS: A, C, E

Businesses can pay for disease prevention and health promotion services for employees (and sometimes their families) in the form of immunizations, health screenings, and counseling. The business can then deduct these costs as a business expense, which reduces the amount the business owes the government in taxes on their profits. Similarly, when businesses subsidize health insurance for their employees—and families—this is also a business expense, which decreases the amount the business would otherwise pay in taxes. Thus, the government indirectly provides the money, but the business, a part of the private sector, decides how it is used. A business purchasing gifts for its employees and an employer requesting reimbursement for employee transportation costs do not result in tax relief for the business. Rather, the business providing health insurance and health promotion/disease prevention services allows the amount of taxes that the business owes to the government to be reduced.

2. Which of the following best explains why clients who have Medicaid have poor health outcomes? (Select all that apply.) a. Clients may have preexisting conditions not covered by insurance. b. Many physicians won’t accept Medicaid clients. c. Medicaid won’t pay for certain medical interventions. d. Medicaid recipients are noncompliant with their health care providers’

recommendations. e. There is a general hesitancy among those eligible to seek health care.

ANS: A, B, C

The primary reasons for delay, difficulty, or failure to access care include inability to afford health care and a variety of insurance-related reasons, including the insurer not approving, covering, or paying for care; the client having preexist ing conditions; and physicians refusing to accept the insurance plan. Practical problems such as lack of childcare, transportation, long waiting periods, and communication issues also interfere. Noncompliance is not a primary reason why Medicaid clients have poor outcomes. There is no research to confirm that Medicaid recipients are reluctant to seek medical care. Rather there are usually other compounding factors that interfere with the client following the regimen or accessing other needed health care services which result in the poor health outcomes.

3. A nurse would like to help members of the community focus on receiving primary preventive health care services. Which of the

following interventions should be implemented by the nurse? (Select all that apply.) a. Publicize data on success of health promotion efforts. b. Lobby for decreased reimbursement for secondary and tertiary care services. c. Establish standards for appropriate screenings at specific intervals. d. Encourage members of the military service to engage in appropriate healthy lifestyle behaviors. e. Provide transparency to the public regarding service costs and savings.

ANS: A, E

Reasons given for the lack of emphasis on prevention in clinical practice and lack of financial investment in prevention include provider uncertainty about which clients should receive services and at what intervals, lack of information about preventive services, negative attitudes about the importance of preventive care, lack of time for delivery of preventive services, delayed or absent feedback regarding success of preventive measures, less reimbursement for these services than for curative services, lack of organization to deliver preventive services, and lack of use of services by the poor and elderly. Considering how health care dollars are spent in the United States, it would not be reasonable to lobby for decreased funding for secondary and tertiary services, as this would result in less care available for individuals. Requiring people to change their lifestyle would be illegal.

4. Which of the following are some major differences in health care today, as compared with the first half of the 20th century? (Select

all that apply.) a. Consumers are influenced by advertising for specific health care agents or procedures. b. The emphasis is on the continued expansion of health care facilities, especially acute care hospitals. c. Education and specialization of personnel have increased. d. The need to create new ways to pay for health care is a central focus. e. Hospital stays are much shorter.

ANS: A, C, E

Since the 1980s, the United States has been in a period of limited resources, with an emphasis on containing costs, restricting growth in the health care industry, and reorganizing care delivery. Results have included shorter hospital stays and sub stitution of one set of personnel (such as nurse practitioners) for another set (physicians). Such trends are made more challenging by increased direct marketing to consumers. Also with increased knowledge has come increased education and specialization. Shorter hospital stays continue to occur so there is a focus on expanding care in the community, not in acute care hospitals. Containment of costs is a major focus; however, creation of new payment methods has not been part of this conversation.

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Chapter 06: Ethics in Public and Community Health Nursing Practice Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following is generally considered to be nursing’s first code of ethics? a. Nightingale Pledge b. Code for Professional Nurses c. Code of Ethics for Nurses d. Principles of the Ethical Practice of Public Health ANS: A

The Nightingale Pledge is generally considered to be nursing’s first code of ethics. After the Nightingale Pledge, the Code for Professional Nurses was formally adopted by the ANA House of Delegates in 1950. It was amended and revised five more times, until, in 2001 the ANA House of Delegates adopted the Code of Ethics for Nurses with Interpretive Statements. The Principles of the Ethical Practice of Public Health was approved in 2002.

2. A nurse didn’t know what to do when faced with a particular ethical dilemma because an option that would have a good outcome

didn’t seem possible. The nurse decided to talk to the agency supervisor and decide what action to take. Which of the following best describes the nurse’s actions? a. Appropriate, because the supervisor is responsible for the nurse’s choices. b. Intelligent, because the supervisor has access to resource persons (clergy, physicians, administrators) who might know of options the nurse hadn’t considered. c. Justified, because this provides an opportunity to discuss the issue but the nurse maintains responsibility for the decision. d. Wise, because the supervisor would be more knowledgeable concerning agency priorities and traditional practices.

ANS: C

Ethically, each nurse is responsible for his or her own decisions and cannot avoid ethical accountability by relying on obedience to a supervisor or any external rule or policy. The supervisor is not responsible for the nurse’s choices, the nurse must maintain responsibility for his/her own decisions. The nurse should have access to the same resources as the supervisor and should have similar knowledge as the supervisor.

3. Which of the following is the first and most crucial step in a generic ethical decision-making process? a. Assess the context or environment in which the decision must be made. b. Consider the various ethical principles or theories. c. Identify the ethical issues and dilemmas. d. Make a decision and act on it.

ANS: C

The first step in the ethical decision-making framework is to identify the ethical issue or dilemma. After the first step of identifying the ethical concern, the following steps are: (2) place the ethical issue or dilemma within a meaningful context, (3) obtain all relevant facts, (4) reformulate ethical issues or dilemmas, if needed, (5) consider appropriate approaches to action or options, (6) make the decision and take action, and (7) evaluate the decision and action.

4. A nurse is asked to meet with a family who recently immigrated from Botswana (Africa). After the physician tells the husband the

wife’s diagnosis of breast cancer, the family thanks the physician and starts to leave. Ethically, which of the following is the nurse’s most important action? a. Emphasizing that the family must set up a surgical appointment for the wife immediately b. Assessing the family’s current living situation, including insurance and other assets c. Educating the family concerning the usual treatment and the prognosis of breast cancer d. Interviewing the family concerning their perspective of the threat to the family’s well-being ANS: D

The United States is a multicultural nation with diverse ethnic groups and diverse values. Before any intervention can be made, the health care professionals must understand the family’s cultural, psychological, social, communal, and environmental contexts, because these contexts affect the way issues are formulated and decisions are made. Consequently, it is crucial to interview the family to determine their understanding of the situation before deciding what, if any, intervention must be made. In many cultures, the family, rather than the individual, is the unit of primary concern. Setting up a surgical appointment immediately would not be an appropriate action for the nurse to take as this would be a premature action for anyone who has just been told that she has cancer. Assessing the family’s current living situation would not be the first concern of the nurse; the first concern should focus on the family’s well-being. After assessing the family’s well-being, the next action of the nurse may be to educate the family about the treatment and prognosis of breast cancer.

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5. The nurse learns that a family has declined an elective medical intervention for a health care problem because paying for the care

would drastically reduce the family’s resources and ability to meet the needs of other family members. Ethically, which of the following actions should be taken by the nurse? a. Appreciate that the family has made the decision that it feels is best and take no further action if it is clear the family has made an informed choice. b. Stress that each individual in society has a right to health care and the family will have to create some way to raise funds for the needed treatment. c. Talk to the media to see whether a campaign to raise funds for the family can be created. d. Try to convince the agency to give the care for free, even if it means economic stress for the agency, because the medical need is obvious.

ANS: A

According to Callahan, although the nurse may attempt moral persuasion to change the family’s values, in the absence of immediate and grievous harm, no ethical requirement exists to interfere with the family’s values. Because there is no immediate or grievous harm, it is not in the best interest of the nurse to interfere with the family’s decision. Thus, the other answers are not an appropriate action for the nurse to take.

6. Some nurses are debating about the appropriate action to take in relation to a particular family. The father is ill, and the other

family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “It is a wife’s responsibility to care for an ill husband.” Which of the following ethical approaches is being used by this nurse? a. Consequentialism b. Communitarianism c. Deontological ethics d. Principlism ANS: C

The nurse is focusing on duty, which is a deontological approach based on the moral obligation to engage in certain actions. The nurse is focusing on duty, which is a deontological approach based on the moral obligation to engage in certain actions. Based upon this understanding, none of the other options correctly describes the nurse’s statement.

7. Some nurses are debating about the appropriate action to take in relation to a particular family. One member of the family is ill, and

the other family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “The whole family is being affected and will fall apart if they don’t focus on their family’s needs first before anything else.”

Which of the following ethical approaches is being used by this nurse? a. Communitarianism b. Deontology c. Principlism d. Utilitarianism ANS: D

By focusing on the whole family, not individual members, and the consequences or outcomes for the whole family during this time of stress, the nurse is taking a utilitarian approach. Principlism relies on these ethical principles to guide decision- making.

Communitarianism is similar to virtue ethics and looks at the relationship and responsibility between the individual and the community. The ethical approach of deontology describes adhering to moral rules or duty rather than to the consequences of the actions.

8. Some nurses are debating about the appropriate action to take in relation to a particular family. One member of the family is ill, and

the other family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “But it doesn’t have to be an either/or situation. Perhaps each family member could take a turn calling in sick just 2 or 3 days. That way they could all take a turn at helping and yet not upset their employers. Wouldn’t that be fair?” Which of the following ethical approaches is being used by this nurse? a. Communitarianism b. Deontology c. Principlism d. Utilitarianism ANS: C

The nurse is focusing on ethical principles—in this case, beneficence (do good for the ill family member), nonmaleficence (do no harm, even to the employer), and justice (everyone takes a turn and shares equally). Communitarianism is similar to virtue ethics and looks at the relationship and responsibility between the individual and the community. The ethical approach of deontology describes adhering to moral rules or duty rather than to the consequences of the actions. Utilitarianism is a consequentialist ethical theory associated with outcomes or consequences in determining which choice to make.

9. Some nurses are debating about the appropriate action to take in relation to a particular family. One member of the family is ill, and

the other family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “It’s not up to us; it’s the family’s decision. They know what is best for them.” Which of the following ethical approaches is being used by this nurse? a. Communitarianism b. Deontology c. Principlism d. Utilitarianism ANS: C

The nurse is using an ethical principle, namely autonomy, in which each person or group can choose those actions that fulfill its values and goals. Therefore, the nurse is using Principlism—that is, basic principles are the basis of the nurse’s actions.

Communitarianism is similar to virtue ethics and looks at the relationship and responsibility between the individual and the community. The ethical approach of deontology describes adhering to moral rules or duty rather than to the consequences of the actions. Utilitarianism is a consequentialist ethical theory associated with outcomes or consequences in determining which choice to make.

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10. Which of the following is the dominant issue in ethical debate around an issue such as continuing or withdrawing treatment in acute

health care? a. Doing what is best for the community b. Doing what is best for the family c. Obeying legal mandates d. Upholding ethical principles ANS: D

In acute care settings with a single localized issue, the primary ethical principles are usually applied, with patient a utonomy being the dominant or most crucial principle. Upholding ethical principles should be the first consideration before obeying legal mandates or doing what is best for the community or family.

11. The staff cannot reach an agreement on what is the right thing to do in relation to a specific patient. Which of the following

approaches should the nurse use in personally deciding what is right? a. Do whatever will not get the nurse in trouble with employer. b. Do whatever is supported by an ethical expert, such as the hospital chaplain. c. Do whatever the nurse would recommend to anyone in a similar situation. d. Do whatever the nurse supervisor would feel comfortable reporting to administration.

ANS: C

One of the rules in deontological decision-making is to determine whether the proposed actions can be generalized so that all persons in similar situations are treated similarly. In the same way, Principlism suggests the nurse examine the context and make the decision that can be morally justified within that context. In order to apply the deontological ethics decision process, the nurse must first determine the moral rules that serve as standards by which individuals can perform their moral obligations, examine their own personal motives, and then determine whether the proposed actions can be generalized. Doing whatever will not get the nurse in trouble, whatever is supported by an ethical expert, or whatever the nurse supervisor feels comfortable with is not an appropriate way to make an ethical decision.

12. A man entered the emergency department bleeding profusely and screaming, “I’ve got to see a doctor right now! I’ve got a right to

see a doctor! I’m hurt. You have to take care of me!” Which of the following premises would ethically justify such a demand for immediate attention? a. All hospitals receive federal money and all capable employed adults pay taxes, so all adults have a right to what their tax money has purchased. b. Saving an individual’s life improves society and upholds tradition. c. Our society believes that all persons should be treated equally and that basic needs, such as not dying if death can be avoided, should be met. d. The man has a property right to his own body, and the government is responsible to ensure that property rights are protected.

ANS: C

The ethical theory of egalitarianism suggests that everyone is entitled to equal rights, equal treatment, and an equal share of the goods of society—and that the government’s role is to ensure this happens, at least on a basic level. Therefore, the man has a right to emergency care. Hospital funding and use of taxpayer money does not demonstrate the use of an ethical principle. Saving an individual’s life may or may not improve society. There is not an ethical principle that states that the man has a property right to his own body.

13. From an ethical standpoint, what is the problem with the belief that everyone should receive his or her fair share, that life should

always be fair, and that everyone should make his or her own decisions? a. With this belief, the needs of society as a whole are ignored. b. Insufficient resources exist to give everyone a fair share. c. This belief leads to a propensity for some people to like to be taken care of. d. Some people think they deserve more than others.

ANS: A

All principles of justice focus on the individual, which ignores the needs of society as a whole. The rights of an individual may conflict with the rights of the community as a whole. It is recognized that distribution should be based on what needs and deserves there is considerable disagreement that exists when considering what these terms mean in the context of fairness.

14. A health care provider refuses to order pain medication for a drug addict who has been severely injured in a car accident. When

reminded by nurses that pain medication has not been ordered, the provider merely replies that the patient’s suffering from the pain of his injuries will build character and that the addicted patient needs to get off drugs. Which of the following ethical theories is being using (or misusing)? a. Consequentialism b. Communitarianism c. Deontological ethics d. Virtue ethics ANS: D

Virtue ethics emphasizes practical reasoning applied to character development. Although such action by a care provider is paternalistic and unethical on many grounds, the physician may truly be concerned with enabling the injured addict to learn from his experience and possibly develop into a drug-free person. Communitarianism is similar to virtue ethics and looks at the relationship and responsibility between the individual and the community. When decisions are based on outcomes or consequences, it is known as consequentialism. The ethical approach of deontology describes adhering to moral rules or duty rather than to the consequences of the actions.

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15. Which of the following is considered the most important goal in nursing today? a. Adapting to technological advances such as electronic medical records b. Demonstrating caring as the basis of nursing practice c. Distinguishing nursing care from medical care d. Seeking evidence-based outcomes to demonstrate nursing’s contribution to care ANS: B

Since the mid-1980s, nurses have written about caring as the essence of nursing and as the ethical and moral ideal of nursing practice. Caring is part of the core values of public health nursing and addresses the importance of the fiduciary relationship between the patient and the care provider. The primary goal of nursing is not to adapt to technological advances, distinguish nursing from medical care, or seek evidence-based outcomes; rather, the goal of nursing is to implement caring which has been the moral ideal of nursing for many years.

16. With which of the following ethical approaches are Gilligan and Noddings associated? a. Distributive justice approach b. Feminine ethic c. Principlism approach d. Virtue ethics ANS: B

Gilligan and Noddings are associated with the approach known as the feminine ethic, which focuses on the morality of responsibility in relationships that emphasize connection and caring as a moral imperative. Distributive justice (fair distribution of the benefits and burdens of society), Principlism (relying on ethical principles for decision- making), and virtue ethics (seeking to enable persons to flourish as human beings) were not developed by Gilligan and Noddings.

17. How are ethics and public policies similar? a. Both are abstract principles that often differ in actual practice. b. Both are best achieved by persons in high political office who can effect change. c. Both strive for the public good. d. Both use general principles in making decisions.

ANS: C

An important goal of both policy and ethics is to achieve the public good, and both are involved in good citizenship. Ethics involves the application of specific principles when making decisions. There is nothing that supports that ethics and public policies are better achieved by those in high political office.

18. A new nurse states to a nursing colleague, “But why do I have to be involved in politics? I just want to be the very best clinical

nurse I can.” Which of the following would be the best response from the nursing colleague? a. “As long as you pay your membership fee to the American Nurses Association, you have participated in the profession’s political endeavors.” b. “Political action is the way you try to fulfill your ethical responsibilities to clients.” c. “You’re absolutely right; if you are good clinically, you have fulfilled your obligation.” d. “When you’ve completed your clinical orientation, then you’ll have time to be involved in politics.”

ANS: B

To be a good clinical nurse, the nurse needs resources and supportive policies that can be obtained only through political action to ensure those very resources and policies. Many clients are members of vulnerable groups who have often previously lacked access to quality care at an affordable cost. The American Nurses Association Code of Ethics for Nurses emphasizes political action as the mechanism to affect social justice and reform regarding homelessness, violence, and stigmatization. Nurses need to be involved in the political process in more ways than only being a dues paying member to the American Nurses Association. Clinical practice is not the same as political involvement; political involvement is necessary to achieve the advocacy role of the nurse. Nurses must make a conscious effort to be involved in political action.

19. Which of the following would confirm that the nurse’s advocacy has been truly successful or effective? a. Audiences agree with the nurse who is serving as advocate. b. Legislators discuss appropriate legislation to better allocate resources. c. People verbalize that the disenfranchised should be better treated. d. Systematic social changes are made to improve quality of life.

ANS: D

Advocacy is the application of information and resources to effect systematic changes that shape the way people in a community live to reduce death and disability and improve quality of life in the community. Only when systematic social changes are made to improve quality of life can advocacy be considered truly effective. Systematic change encompasses the complete role of the nurse as an advocate. Audiences do not necessarily have to agree with the nurse who is serving as advocate as different populations may have different views than the nurse. Advocacy goes beyond only working with legislators to allocate resources. Serving those who are disenfranchised is only one part of the advocacy role.

20. How can nurses know whether they have been effective in assessing the community and planning and implementing appropriate

interventions? a. Ask community leaders for their opinion of the interventions. b. Examine the morbidity and mortality rate of the community. c. Reassess the community to determine whether obvious needs have been met. d. Systematically survey community residents regarding their perception.

ANS: B

The end products of appropriate advocacy are decreased morbidity and mortality. In other words if advocacy has been effective, public health problems will be decreased. Effectiveness cannot be assessed accurately by asking community leaders for their opinions, reassessing the community, or surveying community members regarding their perception; data must be collected to determine results.

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21. How can ethics be applied to public health nursing practice? a. Ethics and actual nursing practice are not related. b. Knowing ethics allows nurse to recognize the source of most problems. c. Ethics is constantly involved in nurses’ clinical decisions. d. Although ethics is important, political and legal responsibilities are more

important in practice.

ANS: C

Ethical problems in public health nursing include inequities in power, unacceptable practices, inequitable resource allo cation, conflict between ethics and law, and inadequate systems support for nursing. Therefore, ethics permeates every aspect of public health nursing as nurses attempt to meet the needs of the community. Ethical principles are applied in nursing practice on a regular basis and assist with problem-solving. The use of ethics does not allow the nurse to recognize the source of most problems. The used of ethics is more important than political and legal responsibilities in practice.

MULTIPLE RESPONSE 1. Three nurses disagree over the appropriate treatment for a woman who is an excellent candidate for hospice care. The first nurse

believes that deciding on care rather than cure is the woman’s decision and no one else can decide for her. The second nurse says that it is the responsibility of the health care team to do good for the woman, and if the physician thinks there is still a possibility of cure, then the nurses should do everything they can to implement the treatment plan. The third nurse states that it isn’t fair for the family members to expend all their resources on the woman, who is probably going to die anyway. Which of the following conclusions can be drawn from this dispute? (Select all that apply.) a. Ethical principles can conflict with one another. b. The nurses are each using different ethical approaches. c. The first nurse is correct because autonomy demands that the woman decide for herself. d. There is no single accepted approach for resolving such disagreements.

ANS: A, B, D

One of the criticisms of using ethical principles is that they can conflict with one another in any given situation. No rule exists for helping resolve such conflicts. Each nurse can apply different ethical principles to reach their own ethical decision. Because there is no one rule to assist with solving an ethical conflict, and ultimately no one right answer, there is not a correct decision that can be made.

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Chapter 07: Culture of Populations in Communities Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following best describes most Americans’ attitude toward immigrants? a. Ambivalence, because there are no clear solutions about how to address their

needs. b. Strongly negative, because immigrants take jobs that native-born Americans could have instead. c. Strongly positive, because immigrants bring useful job skills and often join previous family members already in the United States. d. Strong opposition to further immigration, because of the increasing population in the United States.

ANS: A

Most Americans are ambivalent about immigration, recognizing both the positive and negative aspects involved and realizing that it is a complex issue that has no clear solutions. Because Americans are ambivalent, there is neither a strong negative nor a positive attitude toward immigrants. However, many times immigrants do enter the United States because they have useful job skills or family ties. They are more likely to be low-income workers who work in low-wage, blue-collar jobs and industries.

2. Earlier in the week, a nurse carefully taught a patient from a different culture exactly how much medication to take and emphasized

the importance of taking the correct amount. However, the patient is back in the hospital today with symptoms of an overdose although the patient denies taking more than the label indicated. Which of the following is the most likely explanation? a. The patient was taking more mediation in the hope of getting well faster. b. The patient was also taking folk medicines that had many of the same effects and perhaps some of the same ingredients as the prescribed medication. c. The patient truly did not understand and thought the dose being taken was correct. d. The patient had a unique response to the medication and should have a smaller dose ordered.

ANS: B

For fear of disapproval, a person may not tell the nurse that he or she is using folk medicine as well as Western medication. The two medicines may have cumulative effects that could be dangerous to the client. Nurses who lack cultural knowledge may develop feelings of inadequacy and helplessness because they are often unable to effectively help their clients. It is unlikely that the patient was taking too much medication, taking the incorrect dose, or having a unique reaction to the medication. Rather the nurse should first interview the patient about use of folk medicine which may interact with the prescribed medication regimen.

3. A nurse wishes to develop cultural competence. Which of the following actions should the nurse take first? a. Complete a survey of all the various ethnicities represented in the nurse’s

community. b. Consider how the nurse’s own personal beliefs and decisions are reflective of his or her culture. c. Invite a family from another culture to join the nurse for an event. d. Study the beliefs and traditions of persons living in other cultures.

ANS: B

Cultural awareness requires self-examination and an in-depth exploration of one’s own beliefs and values as they influence behavior. Cultural awareness is the first element in the model of cultural competence. Following the development of cultural awareness, the next step is cultural knowledge in which information about organizational elements of diverse cultures and ethnic groups is collected. The next stage of the model, cultural skill, occurs with the effective integration of cultural awareness and cultural knowledge to obtain relevant cultural data and meet the needs of culturally diverse clients. The fourth construct essential to this model is cultural encounter, which is the process that permits nurses to seek opportunities to engage in cross-cultural interactions with clients of diverse cultures to modify existing beliefs about a specific cultural group.

4. A nurse is caring for a client of another culture. Which of the following actions would be the most appropriate for the nurse to take? a. Alter personal nonverbal behaviors to reflect the cultural norms of the client. b. Keep all behaviors culturally neutral to avoid misinterpretation. c. Rely on friendly gestures to communicate caring for the client. d. Avoid any pretense of prejudice by treating the client in the same way as any

other client.

ANS: A

Cultural competence in nursing includes adoption of culturally congruent behaviors. Culturally skillful nurses use appropriate touch during conversation, modify the physical distance between themselves and others, and use strategies to avoid cultural misunderstandings while meeting mutually agreed-upon goals. Nurses who strive to be culturally competent are expected to respect other cultures and value diversity. These behaviors tend to provide more responsive care. Nurses should be knowledgeable of other cultures and communicate with the client based on cultural norms. Culturally skillful nurses understand the unique difference among individuals within a given culture and work with those individuals to learn more about their culture and provide culturally sensitive care.

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5. A male nurse had a habit of sitting with the lower part of one leg resting over the knee of his opposite leg when collecting a client’s

history. He stopped doing this around specific clients after being told that they were offended when he exposed the sole of his foot (shoe) to their face. Which of the following was exhibited by the nurse when he changed his behavior? a. Cultural accommodation b. Cultural imposition c. Cultural re-patterning d. Cultural skill ANS: D

Cultural skill is the effective integration of cultural knowledge and awareness to meet client needs—in this case, the clients need to not be offended by having the bottom of the nurse’s foot or shoe in view of the client’s face. The nurse using cultural skill makes sure that nonverbal communication techniques take into consideration the client’s use of body language and space. Cultural accommodation involves negotiation with clients to include aspects of their folk practices with the traditional health care system to implement essential treatment plans. Cultural imposition is the process of imposing one’s values on others. Cultural re-patterning is working with clients to make changes in their health practices if cultural behaviors are harmful or decrease their well-being.

6. The nurse practitioner (NP) discovered that an immigrant client is not taking the penicillin prescribed because his illn ess is “hot”

and he believes that penicillin, a “hot” medicine, will not provide balance. Which of the following terms best describes the action taken by the NP when the client’s prescription is changed to a different yet equally effective antibiotic? a. Cultural awareness b. Cultural brokering c. Cultural knowledge d. Cultural skill ANS: C

Cultural knowledge is information about organizational elements of diverse cultures and ethnic groups; emphasis is on learning about the client’s worldview from an emic (native) perspective. Cultural skill involves the provision of care that is beneficial, safe, and satisfying to the client. The medication change allows the client to retain his cultural beliefs and also satisfies the nurse practitioner’s need to prescribe an effective antibiotic. Cultural awareness is the self-examination and in-depth explor ation of one’s own biases, stereotypes, and prejudices that influence behavior. Cultural brokering is advocating, mediating, negotiating, and intervening between the client’s culture and the biomedical health care culture on behalf of clients.

7. An immigrant who takes metamizole (banned in the United States) for pain may experience life-threatening agranulocytosis. Which

of the following actions would be taken by a nurse who employs cultural re-patterning? a. Complete a cultural assessment to identify any other dangerous medications that the client may be taking. b. Put this into perspective by considering that many drugs used in the United States cause agranulocytosis. c. Explain the harmful effects of metamizole and recommend an alternative medication for pain. d. Recognize that taking metamizole is common among persons living in Mexico and accept this as a cultural tradition.

ANS: C

Cultural re-patterning means that the nurse works with clients to help them reorder, change, or modify their cultural practices when the practice is harmful to them. Completing a cultural assessment involves learning more about the client’s culture but does not address the need to consider changing or modifying cultural practices. In order to complete cultural re-patterning, the nurse has to take an action to resolve this potential problem.

8. A health care worker tells a nurse, “It does no good to try to teach those Medicaid clients about nutrition because they will just eat

what they want to no matter how much we teach them.” Which of the following is being demonstrated by this statement? a. Cultural imposition b. Ethnocentrism c. Racism d. Stereotyping ANS: D

Stereotyping occurs when someone attributes certain beliefs and behaviors about a group to an individual without giving adequate attention to individual differences. In this instance, the health care worker makes the assumption that clients with low incomes are not educable. The health care worker is guilty of making another assumption as well: noncompliance among other Medicaid clients the worker has known may have been related to an inability to afford nutritious food. Cultural imposition is the belief in one’s own superiority, or ethnocentrism, and is the act of imposing one’s values on others. Ethnocentrism is a type of cultural prejudice at the population level which involves the belief that one’s own group determines the standards for behavior by which all other groups should be judged. Racism refers to the belief that persons who are born into a particular group are inferior in intelligence, morals, beauty, or self-worth.

9. An American nurse says, “I’m not going to change the way I practice nursing based on where the client is from because research

shows that Western health care technology and research is best.” Which of the following is being demonstrated by the nurse’s statement? a. Ethnocentrism b. Prejudice c. Racism d. Stereotyping ANS: A

Ethnocentrism, a type of cultural prejudice at the cultural population level, is the belief that one’s own group determines the standards for behavior by which all other groups are to be judged. For example, some American nurses and providers may think, “The way we do it is the only right way to provide this care.” Prejudice refers to having a deeply held reaction, often negative, about another group or person. Racism refers to the belief that persons who are born into a particular group are inferior in intelligence, morals, beauty, or self-worth. Stereotyping occurs when attributing certain beliefs and behaviors about a group to an individual without giving adequate attention to individual differences.

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10. A nurse states, “The best way to treat a client from another country is to care for them the same way we would want to be cared for.

After all, we are all humans with the same wants and needs.” What does this statement reflect in relation to culture? a. Awareness b. Blindness c. Knowledge d. Preservation ANS: B

Cultural blindness is the tendency to ignore differences between cultures and to act as if they do not exist. People from different cultures may have different expectations, wants, and needs. Cultural awareness is the self-examination and in-depth exploration of one’s own biases, stereotypes, and prejudices that influence behavior. Cultural knowledge is information about organizational elements of diverse cultures and ethnic groups; emphasis is on learning about the client’s worldview from an emic (native) perspective. Cultural preservation means that the nurse supports and facilitates the use of scientifically supported cultural practices from a person’s culture along with those from the biomedical health care system.

11. A Spanish-speaking family comes to the public health department. No one in the family speaks English, and nobody at the health

department speaks Spanish. Which of the following actions should be taken by the nurse? a. Attempt communication using an English-Spanish phrase book. b. Call the local hospital and arrange a referral. c. Emphatically state, “No hablo Español” (I don’t speak Spanish). d. Obtain an interpreter to translate.

ANS: D

Communication with the client or family is required for a careful assessment. When nurses do not speak or understand the client’s language, they should obtain an interpreter. The nurse must use strategies that will allow effective communication with the client.

The client has the right to receive effective care, to judge whether the care was appropriate, and to follow up with appropriate action if the expected care was not received. The nurse must contact an interpreter in order to provide the best care for the client—attempting communication using a book, stating that he or she does not speak English, and arranging for a referral do not address the priority action of finding an interpreter.

12. A nurse who is explaining to an immigrant client why it is important to take medication states, “The medication takes a couple of

weeks to be effective, but then you should feel better.” When the client is next seen, no medication has been purchased. Which of the following is the most likely explanation? a. The nurse emphasized that eventually the client would feel better, but the client needed to feel better immediately so didn’t bother with the drug. b. The medication required a trip to the pharmacy, and the client just hadn’t had time to obtain the drug yet. c. The medication was too expensive for the client’s family. d. The client really hadn’t understood why the medication was important.

ANS: A

If we look closely at what the nurse stated, there may have been a cultural disconnect based on time perception. Many nurses are future oriented, whereas many families may place greater value on quality of life and view present time as being more important.

When nurses discuss health promotion and disease prevention strategies with persons from a present orientation, they should focus on the immediate benefits these clients would gain rather than emphasizing future outcomes. The cultural disconnect of time should be the immediate concern of the nurse. It is possible that the client did not have the necessary resource or did not understand the importance of the medication, but the nurse should first investigate the potential cultural disconnect.

13. A client is crying softly and saying, “What did I do to deserve this punishment, Lord?” Which of the following responses by the

nurse would be the most appropriate? a. “God doesn’t punish people. You’re sick just because of bad luck.” b. “I can call the hospital chaplain to help you talk about these feelings.” c. “What can I do to be helpful to you right now?” d. “Would you like to confess your sins and repent so this illness will go away?”

ANS: C

Some clients may view their illness as punishment for misdeeds and may have difficulty accepting care from nurses who do not share their beliefs. Because the nurse may not be a member of the client’s religious faith group, an open-ended response showing caring is the most appropriate statement. The most therapeutic response from the nurse is an open-ended question. This allows the client to share information and not feel like his or her actions are being judged by the nurse. Also, this allows the nurse to not give advice or offer false information to the client.

14. A patient who identifies as Buddhist enters the hospital for diagnostic testing just before lunch time. The nurse tells the aide to give

a meal tray to the new patient, because no tests will be done until later that evening. The aide gives the patient a meal of Salisbury steak, bread, green beans, and potatoes with brown gravy. The patient eats nothing but a slice of bread and the green beans. Which of the following considerations was omitted by the nurse? a. The patient should not be served any food until a primary care provider’s order is obtained. b. The patient’s Buddhist faith probably requires a vegetarian diet. c. The patient may be too frightened about the tests to want to eat very much. d. The patient may have diabetes or be allergic to some foods.

ANS: B

Although it is always wise to check with a patient before sending in food, the meal given to this patient was offensive. Most Buddhists are vegetarians and don’t eat meat. The nurse should be aware of the cultural considerations that should be made for Buddhist patients. The nurse should ask the client about dietary restrictions before ordering a meal for the client so that these considerations can be made. The nature of the test determines the fasting requirements; no order is needed. Whether the client is diabetic or allergic to some foods should be determined upon admission.

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15. At a local hospital, the postpartum care policy requires that nurses observe the mother during infant care to assess the mother’s

ability to care for the new baby and to promote bonding. A new mother expresses concern that in her country, all infant care is provided by other family members so that the mother can rest and recover. Which of the following actions would be taken by a culturally competent nurse? a. Allow family members to provide the newborn’s care and assess the mother’s knowledge of child care through discussion. b. Reinforce the importance of bonding and that all good mothers gladly assume these responsibilities. c. Explain that the process of postpartum recovery does not require this much rest and require that she provide infant care. d. State that she must abide by hospital policy because documentation of the mother’s ability to give the infant care is required for discharge.

ANS: A

Culturally competent nursing care focuses on the specific patient, reflects the patient’s individual beliefs and values, and is provided with sensitivity. The nurse should accept the cultural norms and behaviors of this client and her family. Thus, the nurse should provide culturally competent care and comply with the client’s desire. This should take priority over any judgments the nurse could make about this client or hospital documentation related to infant care by the mother. This respect of culture makes the other options incorrect.

16. For a bedridden Muslim patient, the nurse rearranges the room and moves the bed so that it faces toward Mecca for the patient’s

daily prayers. Which of the following is the nurse demonstrating through these actions? a. Accommodation b. Awareness c. Brokering d. Imposition ANS: A

Cultural accommodation involves including aspects of the patient’s religious beliefs and/or folk practices in the traditional health care system to implement essential treatment plans. For this patient, daily prayer in the tradition of Islam is important—from the patient’s perspective, possibly more important than medical treatment. Cultural awareness is the self-examination and in-depth exploration of one’s own biases, stereotypes, and prejudices that influence behavior. Cultural brokering is advocating, mediating, negotiating, and intervening between the client’s culture and the biomedical health care culture on behalf of clients. Cultural imposition is the belief in one’s own superiority, or ethnocentrism, and is the act of imposing one’s values on others.

17. A nurse gives detailed information on how to apply for Medicaid to a new mother who moved to the United States from Russia

about 10 years ago. The nurse’s next client is an African-American mother of newborn twins who worked until the children were born. The nurse knows the woman is eligible to maintain her insurance after her employment was lost and does not discuss insurance options at all. Which of the following errors is being made by the nurse? a. Covert intentional prejudice b. Covert unintentional prejudice c. Overt intentional prejudice d. Overt unintentional prejudice ANS: C

The nurse may have assumed that the African-American mother knew the available resources and could negotiate for assistance on her own and that the immigrant Russian woman had no experience negotiating government programs and thus needed the nurse to advocate for her and inform her of the programs available to her. The nurse, not knowing the health-seeking behaviors of either client, stereotyped both women and intentionally used her informational power to help one client while denying assistance to the other client. Covert prejudice involves subtle or passive acts of prejudice. This can occur intentionally or unintention ally. In this case, the actions of the nurse were intentional, which means it was an overt behavior. Overt prejudice includes any action that intends to give unequal treatment to an individual or group. Given the scenario, it appears that the action of the nurse was intentional, not unintentional.

18. A 40-year-old Bosnian, Muslim woman who does not speak English presents to a community health center in obvious pain. She

requests a female health care provider. Through physical gestures, the woman indicates that the pain is originating in either the pelvic or genital region. Which of the following interpreters would be the most appropriate in this situation? a. A Bosnian male who is certified as a medical interpreter b. A female from the client’s community c. A female who does not know the client d. The client’s 20-year-old daughter ANS: C

Although having experience in medical interpretation is important, in many cultures it is inappropriate to have a male interpreter for females. This client has specifically requested a female provider; therefore, one might anticipate that the client will not be as forthcoming with a male interpreter. Regardless of certification and ability, the interpreter cannot interpret information the client may withhold because she feels it inappropriate to discuss private matters in front of a male. This client may also feel it inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or if they involve infidelity). Additionally, to avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community as the client.

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19. When teaching a nutrition class to a student group with a large Latino population, the school nurse incorporates foods such as salsa

and other healthy dishes familiar to students into the presentation. Which of the following best describes the action taken by the nurse? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Both primary and secondary preventions ANS: A

Primary prevention involves activities such as health teaching to prevent a problem from occurring. Secondary prevention occurs when a nurse completes screenings. Tertiary prevention occurs after a problem has occurred and aims to restore the client to the highest level of functioning as possible.

MULTIPLE RESPONSE 1. An undocumented immigrant comes to a primary care provider’s office to receive care. Which of the following services can the

client receive? (Select all that apply.) a. Treatment for tuberculosis b. Treatment for type 2 diabetes c. Immunization for polio d. Physical examination e. Sutures for a laceration ANS: A, C, E

Undocumented immigrants or illegal aliens are individuals who have crossed a border into the United States illegally or whose legal permission to stay in the United States has expired. They are eligible only for emergency medical services, immunizations, treatment for the symptoms of communicable diseases, and access to school lunches. Undocumented immigrants are not eligible to receive treatment for chronic diseases such as type 2 diabetes or physical examinations.

2. A nurse recognizes that although a patient speaks English, the patient is from a culture with which the nurse is unfamiliar.

Therefore, a cultural assessment should be attempted. Which of the following questions should the nurse ask? (Select all that apply.) a. “Can you tell me where your family is from?” b. “Do you practice a particular religious faith?” c. “What other countries have you lived in?” d. “Is there anything special we need to know about your food preferences?” e. “What do you think is causing your health problem?”

ANS: A, B, D, E

In a general cultural assessment, nurses ask clients about their ethnic background, language, education, religious affiliation, dietary practices, family relationships, hospital experiences, occupation and socioeconomic status, cultural beliefs, and language. Nurses want to also ask about the client’s perception of the health issue and what caused it and how it should be treated as well as the results they expect from the care they get. Such basic data help nurses understand the client from the client’s point of view and recognize what is unique about the person, thus avoiding stereotyping. Knowing the other countries that the client has lived in may be helpful; however, necessary information about the client’s culture should be able to be collected through broad questions about the client’s culture.

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Chapter 08: Environmental Health Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse wants to have a better understanding of the physiological effects of selected chemicals. Which of the following individuals

would provide the most useful information to the nurse? a. Chemist b. Epidemiologist c. Pharmacist d. Toxicologist ANS: D

Toxicology is the basic science that studies the health effects associated with chemical exposures. A chemist, epidemiologist, or pharmacist would probably be able to provide some information, but the toxicologist would most likely provide information related to physiological processes.

2. A nurse wants to find information about environmental threats that are present in the community. Which of the following would be

the best source of data for the nurse? a. Cumulative Index of Nursing and Allied Health (CINAHL) database b. National Library of Medicine c. State health department d. Closest local library ANS: B

Technology helps us understand environmental threats. The National Library of Medicine (NLM) databases are user-friendly and accessible on the Internet. The NLM website provides access to medical databases such as PubMed and GratefulMed, which can be searched for possible environmental linkages to illnesses using key terms. The CINAHL database provides access to literature related to nursing and allied health journals and would not be as comprehensive as the National Library of Medicine. It would be difficult to access information easily through the health department. The information that is available at the local library would be dependent on the community in which one lived.

3. A nurse is assessing potential environmental health risks in the community. Which of the following would be the first step that the

nurse should take? a. Conduct health risk assessments of randomly selected individuals. b. Perform a windshield survey. c. Review facility permits and consumer confidence reports. d. Survey community members.

ANS: B

Conducting a windshield survey is a useful first step to understanding potential environmental health risks. This provides firsthand information about the community and areas of concern that must be investigated. Conducting health risk assessments of randomly selected individuals or surveying community members does not give the nurse a good assessment of potential environmental health risks of the entire community. Reviewing facility permits and consumer confidence reports would not provide enough information to assess the environment of a community.

4. A community citizen reports to the public health nurse that the city water in one neighborhood has had an unusual taste for the past

few months. Which of the following actions should the nurse take first? a. Check the most recent consumer confidence report. b. Consult the Centers for Disease Control and Prevention. c. Notify the Environmental Protection Agency (EPA). d. Place a call to the poison control center.

ANS: A

The consumer confidence report (also known as the right-to-know report) reports the condition of drinking water. Because this is only one citizen, whose sense of taste may be affected by many conditions, it would not be appropriate to overreact by calling in governmental agencies or poison control first. Even so, in case one needed to contact an authority, it would be appropriate to start with local governmental agencies such as the city water department rather than federal agencies.

5. A nurse who works at the local hospital asks a public health nurse what might be causing her hands to become very sore and

sensitive. Which of the following statements would be the most appropriate response by the public health nurse? a. “Ask the staff in employee health if there have been any other complaints.” b. “Call the local health department about any recent problems at the hospital.” c. “Check the material safety data sheet on any chemicals you have used recently.” d. “See the nurse’s health care provider for a complete work-up.”

ANS: C

Employees have the right to know about hazardous chemicals with which they work. Employers must maintain a list of all hazardous chemicals used on the premises, along with a material safety data sheet that addresses health risks related to these chemicals, as well as information about safe use and handling. After checking the material safety data sheets, the next steps would be to connect with a health care provider which could include staff in employee health, a local health department, or one’s own health care provider. The first step should be to determine what exposure occurred.

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6. Which of the following statements about children and environmental hazards is correct? a. The prevalence of autism is directly related to the increase in environmental

toxins. b. Children are more susceptible to environmental toxins because of their smaller size. c. The incidence of asthma among children has been decreasing. d. Children are more susceptible to cancer if they have a family history of the disease.

ANS: B

Because of the smaller size of children, they are exposed to higher doses of pesticide residues in the foods they eat and drink.

Infants and young children drink more fluids per body weight than adults, and this increases the dose of contaminants in their drinking water, milk (hormones and antibiotics), and juices (particularly pesticides). Only a small percentage of childhood cancers are associated with heredity. However, exposure to ionizing radiation increases the risk of childhood leukemia and possibly other cancers. All of the causes of autism spectrum disorder are not currently known. Environmental factors are thought to be a possible cause, as are biologic and genetic factors. Asthma is common among children, and the strongest risk factors are genetic factors and inhaled substances and particles that provoke an allergic reaction or irritate the airways. Indoor air quality is a grow ing concern because of the alarming rise in the incidence of asthma in the United States, particularly among children.

7. Which of the following actions represents the use of secondary prevention to reduce environmental health risks? a. Collecting blood specimens from preschool children to check for lead levels b. Meeting with local government officials to request that the city clean up a

hazardous vacant lot c. Referring a child with toxic lead levels to a neurologist d. Teaching parents of a 2-year-old about the dangers of lead-based paint in older

homes ANS: A

Secondary prevention refers to actions such as surveillance and screening, which are undertaken so that problems may be detected at early stages. Meeting with local government officials to request that the city clean up a hazardous vacant lot and referring child with toxic lead levels to a neurologist are examples of tertiary prevention as the problem already exists. Education to avoid exposure is part of primary prevention which relates to teaching parents about the dangers of lead-based paint in older homes.

8. An occupational health nurse at a local factory is using primary prevention strategies to reduce the environmental health risks

among the employees. Which of the following activities would the nurse most likely implement? a. Checking radiation detectors to monitor for unsafe levels of radiation exposure b. Irrigating the eyes of an employee who has had a chemical splash to the face c. Teaching new employees who will work outdoors about the signs and symptoms of heat-related illness d. Using spirometry to rule out obstructive or restrictive lung disease for workers who will be wearing mask respirators ANS: C

Education is a primary preventive strategy. When examining the sources of environmental health risks in communities and planning intervention strategies, it is important to apply the basic principles of disease prevention. Checking radiatio n detectors and using spirometry are both examples of screening for potential exposure which is part of secondary prevention. Irrigating the eyes of an employee who had a chemical splash to the face addresses tertiary prevention as a problem has already occurred.

9. A nurse wants to help keep the community environment safe. Which of the following is the most appropriate action for the nurse to

take? a. Conserve water by bathing less often. b. Downsize to a smaller living space. c. Reduce, reuse, and recycle. d. Replace all his or her appliances with new energy-efficient ones.

ANS: C

All persons can engage in minimizing their impact on the environment by reducing, reusing, and recycling the individual products they currently consume. Although it would be nice to replace all appliances for energy-efficient newer models, most people can’t afford that—furthermore, it is an environmental issue to discard the used models. Similarly, downsizing to a smaller living space could help the environment, because the nurse would use less energy, but again, not everyone can afford all the expenses involved in moving.

10. Which of the following best describes the purpose of local health departments making unannounced inspections of local

restaurants? a. To enforce local laws and regulations b. To ensure compliance c. To provide oversight to potential exposure d. To monitor employee safety ANS: B

Ensuring compliance refers to the process of making certain that permitting requirements are met. Although this activity may be seen as a type of monitoring, the question asks for the purpose, which is to ensure compliance. Enforcement involves penalties such as fines or facility closure.

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11. A city has announced its plans to build a city dump near a community of poor and predominantly African-American citizens.

Which of the following principles would the nurse be using when vocalizing opposition for this plan? a. Environmental justice b. Environmental epidemiology c. Tertiary prevention d. Risk communication ANS: A

Environmental justice is the goal of campaigns seeking to improve the unequal burden of environmental risks borne by impoverished and minority communities. The Environmental Justice Act would be used in support of the nurse’s position.

Environmental epidemiology is concerned with the discovery of environmental exposures that contribute or protect against disease or illness which is not accomplished by the nurse vocalizing opposition to the plan. Vocalizing opposition to the plan would not be a tertiary prevention strategy as the nurse is addressing a problem that does not yet exist. Risk communication includes general principles of good communication (right information, to the right people, at the right time). In this scenario, the nurse is vocalizing opposition, not communicating risks.

12. A nurse is completing a basic health assessment. Which of the following questions should be asked by an environmentally aware

nurse? a. “Is anyone else in your family having these symptoms?” b. “How many people live in your home?” c. “What jobs have you held the longest?” d. “Where did you live 10 years ago?”

ANS: C

An exposure history should identify current and past exposures, have a preliminary goal of reducing or eliminating current exposures, and have a long-term goal of reducing adverse health effects. The “I PREPARE” mnemonic consigns the important questions to categories that can be easily remembered. Asking about previous employment helps to answer the “P” of past work.

The other questions do not address the topics identified in the “I PREPARE” mnemonic (investigate potential exposures, present work, residence, environmental concerns, past work, activities, referrals, and resources, and educate).

13. A high school student considering a job in the restaurant industry after graduation asks a nurse about workplace safety issues.

Which of the following acts would the nurse most likely discuss with the student? a. Chemical Safety Information, Site Security, and Fuels Regulatory Act b. Comprehensive Environmental Response, Compensation, and Liability Act c. Food Quality Protection Act d. Occupational Safety and Health Act ANS: D

The Occupational Safety and Health Act (OSHA) was passed to ensure worker and workplace safety in all employment settings, including restaurants. The Chemical Safety Information, Site Security, and Fuels Regulatory Act, Comprehensive Environmental Response, Compensation, and Liability Act, and Food Quality Protection Act may contribute to safety but do not have the full oversight of OSHA. 14. The nurse is examining blood lead levels in school-age children 1 year after a community-wide education intervention. Which of

the following phases of the nursing process is being implemented? a. Assessment b. Diagnosis c. Intervention d. Evaluation ANS: D

In this instance, the nurse is evaluating the results of the intervention to determine whether goals were reached. Assessment would have been done earlier in the process because this was needed to determine that a problem existed and that interventions were needed. Diagnosis occurs when the disease and environmental factors are related to the diagnosis. When intervention is used, the nurse coordinates medical, nursing, and public health actions to meet the client’s needs.

15. A nurse practitioner has established a mobile clinic to vaccinate adults against influenza. Which of the following phases of the

nursing process is being implemented? a. Assessment b. Planning c. Intervention d. Evaluation ANS: C

Giving immunizations is an intervention that will increase the number of people who will be vaccinated. Intervention includes coordinating medical, nursing, and public health actions to meet the client’s needs. Assessment would have been done earlier in the process because this was needed to determine that a problem existed and that interventions were needed. Planning occurs when the nurse looks at community policy and laws as methods to facilitate the care needs for the client. When criteria that includes the immediate and long-term responses of the client as well as the recidivism of the problem for the client are examined, it is part of the evaluation phase.

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MULTIPLE RESPONSE 1. A public health nurse is assisting the community in dealing with the effects of lead paint poisoning. Which of the following

activities would the nurse most likely complete? (Select all that apply.) a. Administering medications to those with signs of lead poisoning b. Assessing community members for any health problems c. Setting up a blood screening program with the local health department d. Encouraging local landlords to improve the condition of their housing e. Educating the public on the dangers of lead paint ANS: C, D, E

The nurse’s role is to understand the roles of each respective agency and organization, know the public health laws, and work with the community to coordinate services to address the community’s needs. Other needed interventions include organizing a blood-lead screening program through the local health department, educating local health providers to encourage them to systematically test children for lead poisoning, and working with local landlords to improve the condition of their housing stock.

Educating the community of the hazards of lead paint falls within the roles of the public health nurse. Administering medications to those with signs of lead poisoning is not a typical role of the nurse when dealing with lead poisoning. Assessing community members for any health problems is too broad of an intervention and does not address the specific need of the nurse working with lead poisoning in the community.

2. Which of the following are the major sources of air pollution in the United States? (Select all that apply.) a. Burning of fossil fuels b. Waste incineration c. Wood burning fireplaces d. Motor vehicles e. Coal-fired power plants ANS: A, B, D, E

Motor vehicles are the greatest single source of air pollution in the United States. The burning of fossil fuels (diesel, industrial boilers, and power plants) and waste incineration are two other major contributors. Wood burning fireplaces are not one of the major sources of air pollution that has been identified.

3. A nurse wants to use the principles of risk and outrage to improve an environmental hazard in the community. To accomplish this,

which of the following actions would be taken by the nurse? (Select all that apply.) a. Advertise in the media throughout the entire surrounding area. b. Communicate the correct information in a timely fashion. c. Share all the data found on the community assessment. d. Talk to those affected or those worried about the situation. e. Conduct a community-based survey to identify risks.

ANS: B, D

The correct information must be given in a language the audience—namely those at risk or worried about the risk—can understand.

Use the communication channels the neighborhood residents use and meet at a common meeting place of the community. A survive is appropriate, but the question is focused on distribution of the found information. It is wasteful of resources to advertise in media throughout a wider region or to meet at a central regional facility when only community residents will be interested or involved.

Sharing all the data would be overwhelming, and much of the data might not be relevant. Using epidemiological statistics would not be meaningful to those without the education or experience to be able to draw an appropriate conclusion.

4. Which of the following strategies would a nurse expect to be implemented by a typical state environmental agency? (Select all that

apply.) a. Acting, through unannounced inspections, to ensure compliance b. Completing a community assessment c. Monitoring hazardous substances to uphold established standards d. Obtaining and analyzing samples to confirm compliance e. Involvement in the permitting process established by the state ANS: A, C, D, E

The organization and approach to environmental protection vary somewhat among states, but the common essential strategies of prevention and control via the permitting process, establishment of environmental standards, and monitoring, as well as compliance and enforcement, are found in every state. Completing a community assessment is not a strategy that is typically implemented by a state environmental agency, rather that typically occurs at the local level.

5. Which of the following actions would a nurse take when serving as an advocate for the community? (Select all that apply.) a. Asking questions related to health implications at policy meetings b. Calling the local health department to report problems at the hospital c. Serving as a source of information at public meetings d. Volunteering to serve on health-related committees e. Conducting a health-related screening at a day care center ANS: A, C, D

Advocacy roles of the community-oriented nurse include attending policy meetings to obtain health-related information, holding public meetings (or serving on panels at meetings) to provide health-related information, serving on health-related committees, and informing local media about environmental hazards in the community. Calling the local health department to report problems at the hospital and conducting a screening at a local day care center do not demonstrate the nurse advocating for the community as the hospital and the day care do not represent the entire community.

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Chapter 09: Evidence-Based Practice Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse executive is implementing evidence-based practice at a community nursing center that serves a large Cuban immigrant

population. Which of the following actions would be the most helpful for the nurse? a. Review clinical policies with cultural competency experts from the local university. b. Conduct weekly staff meetings to discuss which methods work best when helping immigrants. c. Invite Cuban immigrants from the community to serve on the center’s advisory board. d. Send personnel to conferences and seminars that focus on treating Hispanic immigrants.

ANS: C

To determine whether practice is serving the needs of the population, the nurse will need to consult the population served. This means that evidence should be applied with input from the community. For example, decisions related to the services to be offered in a nurse-managed clinic should be made with input from the clinic’s advisory board, which should include community leaders and consumers of the clinic’s services. Information about the population needs to come from the population itself, not from cultural competency experts within the community or from the staff members. Cuban immigrant needs may not be the same as those of Hispanic immigrants from other places such as Mexico or Spain.

2. A community health nurse is determining the best way to address an outbreak of a new infectious disease using evidence-based

practice (EBP). Which of the following actions would the nurse most likely take? a. Review policies and procedures. b. Review outcomes of clinical trials. c. Review several nursing textbooks. d. Review reputable sites on the Internet.

ANS: B

Research findings, knowledge from basic science, clinical knowledge, and expert opinion should be considered sources of evidence for EBP. The use of policies and procedures is only helpful if they have been written using EBP, and depending on when they were written, there may be evidence that supports the use of a different practice. The problem with nursing textbooks is that many are not grounded in evidence-based practice, because the concept is relatively new to the United States. Scanning the Internet for ideas is helpful only if evidence-based practice sites are accessed, and most internet sites are not EBP sites.

3. A nursing administrator wants to develop a work environment conducive to the implementation of evidence-based practice (EBP).

Which of the following actions would best achieve this goal? a. Conducting market research to determine customer satisfaction with EBP b. Eliciting opinions from nurses on how EBP will affect workload c. Purchasing computers and Internet access for use by employees d. Sending staff to conferences related to incorporation of EBP into practice ANS: C

A lack of computers and Internet access can create a barrier to implementation of EBP in community-based nursing agencies. If these are provided, nurses can quickly access current evidence-based findings and recommendations. Conducting market research will not change the work environment to make it more conductive to implementing EBP. Learning about nurses’ opinions about how it will affect workload would not impact the work environment and make it more conducive to implementing EBP. Rather the administrator would need to discuss the benefits of the use of EBP with the staff. Sending staff to a conference, although it may change staff attitudes, would not necessarily change the work environment.

4. A busy school health nurse concerned over the rising incidence of obesity wants to implement evidence-based practice (EBP) but

faces barriers because of time constraints. Which of the following actions should the nurse take first? a. Identify students who are obese so that they may be closely monitored for weight control success or failure. b. Evaluate best practices to determine those that have the highest success rates for weight control in children. c. Schedule physician appointments for obese children. d. Develop an obesity management program for children whose body mass index exceeds normal.

ANS: B

The first step of the seven-step EBP process is step zero, which involves a curiosity about the interventions that are being applied; this is not described in any of the topic descriptors. Step one requires asking questions in a “PICOT” format; this is not described in any of the topic descriptors. Step two involves searching for the best evidence to answer the question. This is done through evaluating best practices. The first step of the seven-step EBP process is step zero, which involves a curiosity about the interventions that are being applied; this is not described in any of the topic descriptors. Step one requires asking qu estions in a “PICOT” format; this is not described in any of the topic descriptors. Step two involves searching for the best evidence to answer the question. This is done through evaluating best practices.

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5. The nurse has been reading extensively on a particular clinical problem, using both the closest medical library and the Internet.

Which of the following would be the most helpful source? a. A journal with a whole issue devoted to research on that clinical problem b. A randomized controlled clinical trial related to that clinical problem c. A researcher who has built a career on studying that clinical problem d. A systematic review related to the clinical problem ANS: D

A systematic review is an approach to identifying, appraising, and synthesizing research evidence to evaluate and interpret all available research that is relevant to a particular research question. Systematic reviews can be accessed from most databases.

Systematic reviews require more rigor and contain less opinion of the author than typical reviews of the literature. An entire journal devoted to research on a clinical problem may be helpful, but it is unknown what type of research is being published in that journal.

A well-designed systematic review can provide stronger evidence than a single randomized controlled trial. A researcher alone does not provide the best evidence, rather one would need to look at the information that has been published by the researcher in peer-reviewed journals.

6. A school health nurse plans to use evidence-based practice (EBP) to guide the development of health education programs most

likely to increase retention of learning in elementary schoolchildren. Which of the following would be the best way to use EBP in this situation? a. Ask other school health nurses what they included in their own education programs. b. Compare and contrast randomized controlled trials related to learning in elementary schoolchildren. c. Develop a series of games to accompany the programs developed to promote health. d. Seek out and examine health education programs for elementary schoolchildren on the Internet.

ANS: B

Randomized controlled trials are generally ranked as the highest level of evidence. EBP is not collected by word of mouth; rather the nurse must look in the literature to obtain the best information. There is no evidence that a series of games will assist with the retention of learning based on what is stated in this question. This may be an appropriate activity, but this information must be gathered from the literature. Searching the Internet for ideas is helpful only if evidence-based practice sites are accessed, and most Internet sites are not EBP sites.

7. After finding several studies related to the clinical problem, a nurse knows the studies must be evaluated. Which of the following

characteristics should be present in the literature? a. Federally supported multiagency clinical studies b. Multiple high-quality studies with large sample sizes and consistent findings c. Research studies done by multidisciplinary teams in multiple settings d. Controlled clinical trials ANS: B

The Agency for Healthcare Research and Quality (AHRQ) reviewed 40 systems used to evaluate the quality of studies and strength of evidence. The report identified three domains for evaluating systems that grade the strength of evidence: quality, quantity, and consistency. The quality of a study refers to the extent to which bias is minimized. Quantity refers to the number of studies, the magnitude of the effect, and the sample size. Consistency refers to studies that have similar findings, using similar and different study designs. Federally supported multiagency clinical studies, research studies completed by multidisciplinary teams in multiple settings, and controlled clinical trials do not necessarily meet the three domains for evaluating systems to grade the strength of the evidence: quality, quantity, and consistency. These are the criteria that should be used to evaluate the literature, so additional information is needed about these studies in order to evaluate them.

8. A nurse is familiar with evidence-based practice (EBP) and wants to implement it into the care of clients. Which of the following

would present the biggest challenge? a. Assessing one’s current practice and accessing evidence-based resources b. Convincing administration that EBP is beneficial c. Distinguishing EBP from practice based on old standards d. Showing clients that EBP will improve their health outcomes ANS: A

The first step toward implementing evidence-based practice in nursing is recognizing the current status of one’s own practice and believing that care based on the best evidence will lead to improved client outcomes. After the nurse has assessed his or her own practice and accessed EBP resources, the next steps would be to talk with administration and implement EBP into practice. Without self-reflection first, the nurse would be ineffective in implementing EBP. The challenge for the clinician is how to access the evidence and integrate it into practice, thus moving beyond practice based solely on experience, tradition, or ritual.

9. Which of the following groups is pressuring clinicians the most to use evidence-based practice (EBP)? a. Administrators b. Insurance companies c. Nurses d. Physicians ANS: B

Much of the pressure to use evidence-based practice comes from third-party payers and is a response to the need to contain costs and reduce legal liability. Nurses, physicians, and administrators are not pressuring the use of EBP as much as insurance companies as these are not the payers of health care.

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10. A nurse implements an education program that incorporates computer games to reinforce learning for a group of older adults.

Although the research demonstrates evidence of improved retention of this information, the nurse experiences exactly the opposite with this group. Which of the following is the most likely cause of such poor outcomes? a. Failure to consider client and setting differences b. Inadequate incorporation of evidence into practice c. Inferior quality of the available research evidence d. Lack of skills when evaluating the evidence ANS: A

EBP cannot be applied as a universal remedy without attention to client differences. When EBP is applied at the community level, the best evidence may point to a solution that is not sensitive to cultural issues and distinctions and thus may not be acceptable to the community. For example, computer games may be excellent for younger groups but are often poorly suited for older Americans who may face challenges with learning new technology. Because the nurse did not consider the client differences, the intervention was unsuccessful. This does not mean that the research had poor quality, was not evaluated correctly, or was not correctly incorporated into practice. The nurse should not assume that an EBP intervention will work in a different setting or with a different population than what it has been intended.

11. A health care provider is concerned about the high number of clients with type 2 diabetes mellitus who have poor glucose control.

What would be the best reference for the provider to implement evidence-based practice (EBP) in the management of this problem? a. Published protocols b. Current research findings c. Opinions of colleagues d. Nursing journals ANS: B

EBP in community-oriented nursing challenges nurses to integrate outcomes of the best evidence into their clinical practice.

Current research findings will explicate evidence of the most successful interventions. (Randomized controlled trials are the gold standard of research for EBP). Protocols and opinions often reflect tradition rather than the most current scientific evidence.

Although many nursing journals are peer reviewed, many are not and, even if peer reviewed, many are not research based or focused on scientific evidence.

12. Staff members have agreed to implement evidence-based practice; they have chosen a specific problem and searched the literature.

The group has selected the interventions that seem the easiest to implement. Which of the following actions would the staff take next? a. Assess the quality of the evidence in the literature. b. Decide how best to orient the staff and community to the proposed changes. c. Eliminate all nursing interventions that are not evidence based. d. Choose another specific problem for the next literature search.

ANS: A

After the group has chosen the topic and evaluated the literature for approaches that seem feasible, specific interventions are chosen. The quality of the evidence must be assessed before recommending specific changes or writing a protocol to resolve the problem. Grading the strength of evidence or determining the quality, quantity, and consistency of research studies must be done before making recommendations for practice. Deciding how to orient staff and the community to the change would occur at the end of the process after the findings have been summarized, and written recommendations or protocols have been developed.

Elimination of nursing interventions that are not evidence based would be part of the written recommendations and proposal that happen at the end of the process. The nurse should not plan another literature search or topic to explore until after completing the process with the current issue.

13. A school nurse is developing a primary prevention strategy for school-aged children. Which of the following interventions would

the nurse most likely implement? a. Developing individualized exercise programs for overweight children b. Drafting policy for increases in noncompetitive physical activity programs c. Monitoring body mass index (BMI) in children to identify elevations before they become difficult to manage d. Notifying parents and/or guardians of their child’s height-weight scale in comparison with national norms ANS: B

At the primary prevention level, campaigns to support regular exercise, greater emphasis on school-based physical education programs, and environmental policy initiatives to create or enhance places for physical activity in communities can make significant contributions to improving the lifestyle of sedentary children. Exercise programs are an example of tertiary prevention.

Monitoring BMI in children is an example of secondary prevention. Notifying parents of their children’s height-weight scale increases family awareness but does not meet the definition of a preventive measure.

14. Which of the following is the best way to increase the number of persons who come to their screening test appointments? a. Reminding clients via telephone, e-mail, or mail b. Emphasizing long life and happy family when conditions are caught early and

treated successfully c. Pointing out how inexpensive and convenient screening tests are d. Stressing the dangerousness of the condition if not caught early ANS: A

Client reminders and recalls via telephone, e-mail, or mail—or a combination of these strategies—are effective in increasing compliance with screening activities such as those for colorectal and breast cancer. Emphasizing the importance of screening, how it is inexpensive, and the dangers of the condition if it is not diagnosed early can all occur as clients are reminded of the screening via telephone, e-mail, or mail. Without the reminder, clients are likely to lose sight of the benefits of receiving the screening.

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15. A nurse manager wants to facilitate incorporation of evidence-based practice (EBP) in the clinical setting. Which of the following

would be the best strategy to accomplish this goal? a. Eliminate all protocols and standards that are not evidence based. b. Encourage group reflection on the ideals and expectations of nursing care. c. Refer agency nurses to Internet sources of research findings. d. Support nurses using practice-oriented research findings in decision-making.

ANS: D

EBP demands changes. It requires incorporating more practice-oriented research and more collaboration between clinicians and researchers. Emphasis should be on decision- making using the varied sources of evidence. The environment and climate must be supportive in order to implement EBP. Rather than eliminating protocols and standards that are not evidence based, the nurse manager should make it a priority to begin to update these practices based on EBP. Self-reflection on one’s own nursing practice and how EBP can be implemented would be more important than group reflection on the large ideals of nursing practice. Referring the nurses to the Internet for ideas is helpful only if evidence-based practice sites are accessed, and most Internet sites are not EBP sites.

MULTIPLE RESPONSE 1. A nurse has decided to increase the evidence base of current nursing practice in an agency. Which of the following describes a

barrier that could be encountered by the nurse? (Select all that apply.)

Colleagues who do not know how to search the literature or critique research Dedication to the history and tradition of the agency Little or no research published in the clinical area of concern Several meta-analyses in the literature with inconsistent results The agency is unable to provide sufficient funds to support the plan

a. b. c. d. e.

ANS: A, B, C

Barriers to evidence-based practice exist when the following are limited or lacking: time, access to journal articles, search skills, critical appraisal skills, and an understanding of research terminology. Other barriers include miscommunication about the process; inferior or unavailable research or other evidence; unwillingness of organizations to fund research or make decisions based on evidence; and concern that evidence-based practice will decrease emphasis on individual client needs or the nurse’s clin ical decisions. Dedication to the history and tradition of the agency may pose a barrier as this may influence the philosophy of the practice environment and the willingness to embrace EBP. The numbers of meta-analyses in the literature, regardless if the results are consistent or not, would not be a barrier to the practice environment when implementation is considered.

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Chapter 10: Epidemiological Applications Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse is using analytic epidemiology when conducting a research project. Which of the following projects is the nurse most

likely completing? a. Reviewing communicable disease statistics b. Determining factors contributing to childhood obesity c. Analyzing locations where family violence is increasing d. Documenting population characteristics for healthy older citizens ANS: B

Epidemiology refers not only to infectious epidemics but also to other health-related events. The goal of analytic epidemiology is to discover the determinants of outcomes—the how and the why. Analytic epidemiology looks at the etiology (origins or causes) of disease. It discusses the disease in terms of how and why. Descriptive epidemiology considers health outcomes in terms of what, who, where, and when. It discusses a disease in terms of person, place, and time.

2. A nurse is employed as a nurse epidemiologist. Which of the following activities would most likely be completed by the nurse? a. Eliciting the health history of a client presenting with an illness b. Evaluating the number of clients presenting with similar diseases c. Performing a physical examination of an ill client d. Providing treatment and health education to a client with a disease ANS: B

Epidemiology monitors the health of the population by examining measures of morbidity, especially incidence proportions, incidence rates, and prevalence proportions and learning about the risk for disease, the rate of disease development, and the levels of existing disease in a population, respectively. Epidemiology differs from clinical medicine, which focuses on the diagnosis and treatment of disease in individuals.

3. Which of the following actions by Florence Nightingale demonstrates her role as an epidemiologist? a. She convinced other women to join her in giving nursing care to all the soldiers. b. She demonstrated that a safer environment resulted in decreased mortality rate. c. She obtained safe water and better food supplies and fought the lice and rats. d. She met with each soldier each evening to say goodnight, thereby giving

psychological support.

ANS: B

Nightingale examined the relationship between the environment and the recovery of the soldiers. Using simple epidemiological measures, she was able to show that improving environmental conditions and adding nursing care decreased the mortality rates of the soldiers. Nightingale used statistics to document decreased mortality rates when the environmental factors were improved.

Asking other women to assist with providing nursing care, obtaining safe water, and meeting with each soldier are not interventions that demonstrate the use of epidemiology (the relationship between the health events and the determinants or factors that influence those patterns).

4. Which of the following statements describes how nursing in the community is more challenging than nursing in an acute care

setting? a. There is limited access to information useful to the nurse in giving care in the community. b. More paperwork and forms are required when giving care in the home. c. It is more challenging to control the environment in the community. d. Specialization isn’t possible in the community setting.

ANS: C

In the community, nurses often use epidemiology, since the factors that affect the individual, family, and population group cannot be as easily controlled as in acute care settings. It is essentially impossible to control the environment in the community. Nurses working in the community have multiple resources that can be used to access information about the community. There may be additional paperwork and forms to complete in the home environment, but the lack of control of the environment is a larger challenge than the completion of paperwork. Community health nursing is recognized as a specialty within nursing.

5. Several small communities have applied for grant funding from the state department of health to help decrease their teenage

pregnancy rate. Which of the following communities should the nurse suggest receive funding first? a. Community A—with 23 single teenage pregnancies in a city of 500 b. Community B—with 45 single teenage pregnancies in a city of 1000 c. Community C—with 90 single teenage pregnancies in a city of 2000 d. Community D—with 90 single teenage pregnancies in a city of 1500 ANS: D

The pregnancy rates of A, B, and C are 45-46:1000, whereas the rate in Community D is 60:1000. Without doing any actual math, it should be fairly obvious that 23:500, 45:1000, and 90:2000 are all about the same proportion but that 90:1500 is a larger proportion.

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6. Between 2010 and 2015, 1000 of 10,000 young women age 17 to 20 years at a university tested positive for a sexually transmitted

infection (STI). Of the 1000 diagnosed STIs, 300 were gonorrhea and 500 were chlamydia. Which of the following statements best summarizes these findings? a. The proportion of cases of gonorrhea to all STIs was 300:1300. b. The proportion of cases of gonorrhea to chlamydia was 300:500. c. The proportion of cases of gonorrhea to all STIs was 50%. d. The proportion of STIs to the total population was 100:1000.

ANS: D

A proportion is a ratio in which the denominator includes the numerator. If the proportion is small, we can express the number per 1000. The answer of 100:1000 correctly summarizes that 1000 of 10,000 (or 100:1000) young women had the problem. The answer of 300:1300 adds the total of the numerator to the denominator, which is unnecessary because the gonorrhea cases were already included in the denominator. In the answer of 300:500, the ratio comparing gonorrhea to chlamydia does not meet the epidemiological definition of proportion (i.e., the denominator must contain the numerator). Although proportions may be expressed as percentages, in the answer of 50%, the percentage reflects the number of gonorrhea cases to all STIs, which doesn’t summarize the total STI problem.

7. The nursing staff has attempted to screen the entire African-American population in the community for diabetes. Which of the

following would provide immediate verification of the success of the nursing staff’s efforts? a. An epidemic of diabetes will be recognized. b. The incidence of diabetes will increase in the community. c. The prevalence of diabetes will decrease in the community. d. The risk for diabetes in the community will increase.

ANS: B

If the screening has been successful, more diabetes will be diagnosed and, hopefully, treated. Thus, the incidence of new cases will increase. Overall, prevalence will also increase, but that is not one of the answer options. An epidemic occurs when the rate of disease, injury, or other conditions exceeds the usual level of that condition. The prevalence (measure of existing disease in a population at a particular time) of diabetes would also increase. The risk for diabetes would not increase rather it would be more likely that the disease would be detected.

8. In a particular community, several high school students were diagnosed with diabetes mellitus type 2 during the annual high school

health fair. Over the next few years, the nursing staff developed and implemented educational programs about the risk factors for diabetes mellitus type 2 and proper nutrition. Which of the following would be the most useful for the nurses to use to determine if they are having any impact? a. The epidemic of diabetes in the high school is gradually ending. b. The incidence of diabetes is slowly decreasing during screening events. c. The prevalence of diabetes is slowly decreasing during screening events. d. The risk for diabetes is slowly increasing over time.

ANS: B

Incidence rates and incidence proportions are the measure of choice to study etiology because incidence is affected only by factors related to the risk of developing disease and not to survival or cure. If the educational programs are having the desired impact, the incidence of diabetes being diagnosed will decrease in future screenings. Prevalence is a fairly stable number over time, but incidence reacts more quickly to changes in risk factors or intervention programs. In order for an epidemic to have occurred, the rate of the illness would have had to exceed the usual level of that condition. There is no evidence in this question to support that the disease was at an epidemic level in this population. If the educational programs are effective, the risk for diabetes should be slowly decreasing over time.

9. This year 600 of 8000 young women age 17 to 20 years at a university health center tested positive for a sexually transmitted

infection (STI). Which of the following terms best describes this data? a. An epidemic b. Incidence c. Prevalence d. Risk ANS: C

Prevalence is the measure of existing disease in a population at a particular time. Because we do not have baseline data, we have no way to conclude that this is an epidemic with higher-than-normal results from the screening. Incidence refers to new cases, whereas prevalence means all cases. We don’t know whether the finding represents the first time a woman was told she had an STI or whether she had previously been diagnosed with the problem. Therefore, we can’t say whether these are new cases (incidence), but the results do represent all cases (prevalence). Risk is the probability of developing an STI, but no risk factors are discussed.

10. A nursing staff has successfully screened for diabetes in the community. Which of the following might best persuade the health

board to increase funding for diabetic clinics in this community? a. An epidemic of diabetes is now recognized and must be addressed. b. The incidence of diabetes is now higher than previously recognized in the community. c. The prevalence of diabetes is now higher than previously recognized in the community. d. The risk for diabetes in the community could decrease if funding is received.

ANS: C

Prevalence is a fairly stable number. Prevalence proportions reflect duration in addition to the risk for getting the disease.

Prevalence is useful in planning health care services because it is an indication of the level of disease existing in th e population and therefore the size of the population in need of services. An epidemic occurs when the rate of disease, injury, or other conditions exceeds the usual level of that condition. Incidence is affected only by factors related to the risk for developing the disease and not survival or cure. The nurse is proposing to increase funding for diabetic clinics, and having more diabetic clinics would assist those who already have the disease, so it would have limited impact on decreasing the risk of developing the disease among members of the community.

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11. A public health nurse found that out of the 70 people who ate the potato salad at a school picnic, 63 developed symptoms of food

poisoning. Which of the following best describes the attack rate? a. 63% b. 70% c. 90% d. 100% ANS: C

The attack rate is the proportion of persons exposed to an agent who develop the disease. Because 63 of the 70 persons became ill, the attack rate is 63:70, or 90%. Sixty-three (63) is the number of clients who developed symptoms of food poisoning. Seventy (70) is the total number of people who ate the potato salad at the school picnic. These numbers need to be used as part of the formula to calculate the attack rate. One hundred (100) does not represent any part of the formula that would be used to calculate the attack rate.

12. A man is diagnosed with prostate cancer. Which of the following data should the nurse know to answer the man when he asks,

“What are the chances I’ll survive this thing?” a. Attack rate b. Case fatality rate c. Cause-specific morbidity rate d. Crude mortality rate ANS: B

The case fatality rate (CFR) is the proportion of persons diagnosed with a particular disorder (i.e., cases) who die within a specified period. The CFR is considered an estimate of the risk for death within that period for a person newly diagnosed with the disease.

Persons diagnosed with a particular disease often want to know the probability of surviving. The CFR provides that information.

The attack rate is the proportion of persons exposed to an agent who develop the disease. The cause-specific mortality rate is an estimate of the risk for death from some specific disease in a population. The crude mortality rate is an estimate of the risk for death for a person in a given population.

13. Which of the following statistics is used by countries to compare the success of their health care systems? a. Attack rate b. Infant mortality rate c. Proportionate mortality ratio d. Cause-specific mortality rate ANS: B

Infant mortality is used around the world as an indicator of overall health and availability of health care services. The attack rate is the proportion of persons exposed to an agent who develop the disease. The cause-specific mortality rate is an estimate of the risk for death from some specific diseases in a population. The proportionate mortality ratio is the proportion of all deaths resulting from a specific cause.

14. A nurse is examining all of the various factors which can lead to disease. Which of the following models would the nurse most

likely use? a. Epidemiologic triangle b. Health promotion c. Levels of prevention d. Natural history of disease ANS: A

The epidemiologic triangle categorizes factors as agent, host, or environment. The model encourages the health care provider to examine all the influences that lead to increased risk. Levels of prevention are actions taken to improve health outcomes. Health promotion addresses health improvement, not the risk for disease.

15. A nurse is examining the various factors that lead to disease and suggesting several areas where nurses could intervene to reduce

future incidence of disease. Which of the following models would the nurse most likely use? a. Epidemiologic triangle b. Health promotion c. Levels of prevention d. Web of causality ANS: D

The web of causality model recognizes the complex interrelationships of many factors interacting to increase or decrease the risk for disease. Causal relationships (one thing or event causing another) are often more complex than the epidemiologic triangle conveys. Levels of prevention are actions taken to improve health outcomes. Health promotion addresses health improvement not identification of where nurses could intervene to reduce future incidence of disease.

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16. Which of the following actions would a nurse take to reduce the high incidence of coronary artery disease (CAD) in a community? a. Introduction of a heart-healthy curriculum beginning in the first grade,

presentations on diet and exercise for the community at large, and special education sessions for high-risk populations b. Provision of online activities related to prevention of cardiac disease, smoking reduction programs, and blood pressure screenings c. Distribution of handouts, including age-appropriate games, self-assessments, and education on heart-healthy lifestyles; availability of community screenings for hyperlipidemia in persons age 35 and older; and walking programs for those affected with CAD d. Enrollment of clients with CAD into cardiac rehabilitation programs, routine evaluation of effectiveness of CAD treatment regimens, and participation in clinical trials that evaluate interventions for those diagnosed with CAD ANS: C

Distributing handouts includes all three levels of prevention to target all members of the population. Targeting all members of the population and implementing all levels of prevention increase the likelihood of positive outcomes for the community as a whole.

Education in schools, the community, and high-risk populations focuses only on primary prevention activities. Online activities focus only on primary and secondary preventions. Efforts focused only on those who already have CAD are not primary prevention.

17. A school nurse wants to decrease the incidence of obesity in elementary school children. Which of the following describes a

secondary prevention intervention that the nurse could implement? a. Giving a presentation on the importance of exercise and physical fitness b. Designing a game in which students select healthy food choices c. Weighing students to identify those who are overweight d. Putting students on a diet if they weigh greater than 20% of their ideal weight ANS: C

Secondary prevention refers to interventions that increase the probability that a person with a condition will have the condition diagnosed early. Health screenings are the mainstay of secondary prevention. Weighing students and assessing whether the weight is higher than recommended will allow for early intervention so that obesity may be avoided. Giving a presentation and designing a game are both examples of primary prevention. Placing overweight students on a diet is an example of tertiary prevention.

18. A nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of

prevention is being used by the nurse? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Treatment, but not prevention ANS: C

Interventions that prevent worsening of a condition are tertiary prevention activities. In this instance, the client alr eady has a health problem (osteoporosis). By advising adequate dairy intake, the nurse aims to ensure that enough calcium is available to limit worsening of the osteoporosis. Primary prevention would focus on interventions that reduce the risk of one getting the disease.

Secondary prevention addresses screening tests to detect the disease at the earliest stage possible. Treatment is not a level of prevention.

19. A nurse has only a regular blood pressure cuff when conducting a health screening for all of the residents of a community. Which

of the following may be lacking when obtaining blood pressure readings? a. Reliability b. Sensitivity c. Specificity d. Validity ANS: D

Validity is the accuracy of a test or measurement, or how closely it measures what it claims to measure. With only one regular BP cuff, the nurse cannot obtain accurate measurements on those who are extremely obese or extremely thin. A thigh cuff and a pediatric cuff would allow the nurse to obtain accurate—that is, valid—measurements. Reliability refers to the consistency or repeatability of the measure. If the wrong size blood pressure cuff is used, it is likely that the same wrong blood pressure would be repeatedly obtained. Sensitivity and specificity are the two ways that validity can be described. Sensitivity quantifies how accurately the test identifies those with the condition or trait. Specificity indicates how accurately the test identifi es those without the condition or trait. With the wrong size blood pressure cuff, the sensitivity and specificity of the screening would be in question.

20. A nurse is administering a tuberculosis (TB) skin test to a client who has acquired immune deficiency syndrome (AIDS). Which of

the following results should the nurse anticipate when using this screening test? a. Decreased positive predictive value b. Decreased reliability c. Decreased sensitivity d. Decreased specificity ANS: C

Persons with immune deficiencies may have a negative tuberculosis skin test even though they are infected. Sensitivity is the extent to which a test identifies those individuals who have the condition being examined. AIDS is an acquired immune deficiency; thus, clients with AIDS may have a false-negative response to TB skin tests; that is, they have the disease but the test is not sensitive enough to detect infection in these individuals. Therefore, there is decreased sensitivity with those clients. A positiv e predictive value is the proportion of persons with a positive test who actually have the disease, interpreted as the probability th at an individual with a positive test has the disease. In this case, it is likely that if the individual has the disease, it will not be detected. Reliability relates to the consistency or repeatability of the measure. Because of the client’s altered immune status, it is likely that the same results would be obtained if the test was to be repeated. Specificity indicates how accurately the test identifies those without the condition or trait. In this case, it is likely that a false-negative reading would be obtained, so the specificity may not be accurate.

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21. Persons in an auditorium may have been exposed to a disease. If they are infected, it is crucial that they receive immediate

treatment and not take the disease home to their families. Which of the following characteristics would be most important to consider when selecting the screening test to be used? a. The negative predictive value b. The positive predictive value c. The sensitivity of the test d. The specificity of the test ANS: C

Because it is most important to identify every case, the sensitivity of the test is crucial. High sensitivity is needed when early treatment is important and when the identification of every case is important. A negative predictive value is the proportion of persons with a negative test who are actually disease free. A positive predictive value is the proportion of persons with a positive test who actually have the disease, interpreted as the probability that an individual with a positive test has the disea se. Specificity indicates how accurately the test identifies those without the condition or trait.

22. A woman is sitting in a corner of the clinical waiting room, crying audibly. The nurse asks, “What’s wrong? Can I help?” The

woman responds, “They just told me I have a positive mammogram and I need to see my doctor for follow-up tests. I know I’m going to die of cancer. How can I tell my family?” Which of the following information does the nurse need to know in order to help the woman cope with this finding? a. The negative predictive value of mammography b. The positive predictive value of mammography c. The reliability of mammography d. The validity of mammography ANS: B

The positive predictive value is the proportion of persons with a positive test who actually have the disease, interpret ed as the probability that an individual with a positive test has the disease. A negative predictive value is the proportion of pe rsons with a negative test who are actually disease free. Reliability relates to the consistency or repeatability of the measure. Val idity in a screening test is typically measured by sensitivity (how accurately it identifies those with the condition) and specific ity (how accurately the test identifies those without the condition).

23. The administration at a local medical center examines the trends in health problems when developing long-range plans for staffing

and space allocation. Which of the following sources of information would be most helpful? a. Local data drawn from a professional survey in the city b. The National Health Interview Survey c. The National Hospital Discharge Survey d. The state’s vital statistics ANS: A

For many studies, however, the only way to obtain the needed information is to collect the required data in a study specifically designed to investigate a particular question. Both the National Health Interview Survey and the National Hospital Discharge Survey provide information on the health status and behaviors of the national population. A state’s vital statistics are the birth and death certificates within the state which would not give the administration the information that they are looking for in this community.

24. Statistics clearly demonstrate that there are significantly more cases of a disease in one particular neighborhood than in all the rest

of the city. Assuming all else is the same, which of the following is the most likely explanation for a single neighborhood having such a different pattern of illness? a. A cultural or ethnic concentration in the neighborhood b. The geographic location of the neighborhood within the city c. A statistical fluke without meaning d. The time of year the different statistics were collected throughout the city ANS: A

The most probable reason is that there is a cultural or ethnic concentration in that particular neighborhood that has a different lifestyle pattern, resulting in different health outcomes. The assumption is made that all things in the city are the same, thus the geographical location would not be a likely explanation for the difference. However, location may play a role at times with increased incidence of disease depending on exposure to certain environmental factors which could place the population at risk. A statistical fluke does not provide a likely explanation for the difference. There are times when there are cyclical patterns of disease.

However, the question states that the assumption should be made that all else is the same, so one can assume that the data were collected within the city at the same time.

25. Two women seem to agree on almost everything from favorite music to favorite media stars to the best way to prepare a meal.

Which of the following best explains this similarity in the two women? a. They are both members of the same birth cohort. b. They are close friends. c. They attended the same school. d. They both go to the same church.

ANS: A

Being born at about the same time would mean both women have lived through similar social events and media occurrences and therefore would have much in common. Being close friends is probably the result of the similarity rather than the cause. Going to the same school or the same church, depending on the size of the institutions, might not result in any personal interaction whatsoever.

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26. A nurse reports that in comparison to all the children in a particular school, the children who are members of the Cub Scouts have

0.3 risk for obesity before entering the sixth grade. Which of the following recommendations would the nurse make to the new parents of two boys who had just moved into this school’s neighborhood? a. Discourage the parents from enrolling their sons in Cub Scouts because of the risk. b. Don’t say anything about Cub Scouts, because it isn’t relevant to nursing care. c. Encourage the parents to enroll their sons in Cub Scouts. d. Share the finding and let the parents draw whatever conclusions they feel appropriate.

ANS: C

Relative risk is an estimation of the risk of acquiring a problem for those who are exposed compared with those who are unexposed. As the risk for obesity is less for those that are members of Cub Scouts, joining the group is protective and reduces the incidence among members. Parents should be encouraged to enroll their sons in Cub Scouts as joining the group is protective and reduces the risk for becoming obese. The finding should be interpreted for the parents, and the protective aspect of joining the group should be explained.

27. A principal comments to the school nurse that it seems there are a lot more problems with asthma among the students than there

were before the school was remodeled a couple of years ago. The nurse investigates the principal’s observation by reviewing all the school records to determine visits to the health office because of asthma by week and month for the past 5 years. Which of the following best describes the type of study the nurse is conducting? a. Descriptive epidemiological study b. Ecological study c. Prospective cohort study d. Retrospective cohort study ANS: D

Retrospective cohort studies rely on existing records to define a cohort that is classified as having been exposed or unexposed at some time in the past. In this case, the issue is whether there is some health risk in the new building addition that is increasing frequency of visits to the school nurse because of asthma. In a descriptive epidemiological study, the disease is investigated in terms of person, place, and time. An ecological study is a bridge between descriptive and analytic epidemiology, looking at variations in disease rates by person, place, or time and trying to determine if there is a relation of disease rates to variations in rates for possible risk factors. A prospective cohort study, or subjects who do not have the outcome under investigation, are classified on the basis of the exposure of interest at the beginning of the follow-up period.

28. Which of the following types of study should the nurse researcher choose if the goal is to identify the long-term benefits and risks

of a particular nursing intervention for senior citizens living in the community? a. Cross-sectional study b. Ecological study c. Clinical trial d. Retrospective analysis ANS: C

The goal of a clinical trial is to evaluate the effectiveness of an intervention. Clinical trials are generally the best way to show causality. A cross-sectional study provides a snapshot of a population or group. An ecological study is a bridge between descriptive and analytic epidemiology, looking at variations in disease rates by person, place, or time and trying to determine if there is a relation of disease rates to variations in rates for possible risk factors. A retrospective analysis relies on existing records to define a cohort that has been exposed or unexposed at some point in the past.

29. A teacher recommends that surveys to obtain data on drug use be given to high school students when they meet for various school

organizations. Which of the following best describes why the nurse would reject this suggestion? a. This method of data collection would result in classification bias. b. This method of data collection would result in confounding bias. c. This method of data collection would result in personal bias. d. This method of data collection would result in selection bias.

ANS: D

Any study is subject to bias resulting from selective choice. There may be a difference between students who choose to belong to an organization and students who choose not to join an organization. Selection bias occurs when selection procedures are not representative of the population as a whole. In this instance, the goal is to determine drug use of all students at the school. If only students who join school organizations are selected, those who do not join organizations will not be represented. Classification bias occurs once subjects are enrolled in the study and relates to how information is collected. Confounding bias results from the relationship between the outcome and the study factor and some third factor that was not accounted for. Personal bias deals with personal opinions and attitudes of the researcher which may interfere with the proper selection of the participants.

30. A nurse is investigating a bacterial illness that has caused a health problem in the community. Only some of the people exposed to

the bacteria have become ill. Which of the following factors best explains why this would have happened? a. Chemical agent factors b. Environmental factors c. Host factors d. Physical agent factors ANS: C

The epidemiologic triangle includes the agent, host, and environment. Only differences in host factors can explain why some became ill and some were able to fight off the bacterial infestation. The epidemiologic triangle includes the agent, host, and environment. The bacteria were the agent, so chemical and physical agents are not relevant. The environment was apparently the same for everyone, since all were exposed to the bacteria.

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MULTIPLE RESPONSE 1. Which of the following explains why contagious infections are becoming a central focus of public health? (Select all that apply.) a. Americans are fearful of terrorists using biological agents. b. Awareness of human susceptibility to animal diseases has been publicized. c. Drug-resistant strains of old diseases have evolved. d. Media coverage exaggerates the dangers of exposure to crowds. e. The American population has become more health conscious in the last 20 years.

ANS: A, C

New infectious diseases and new forms of old diseases, such as drug-resistant strains of TB, have emphasized the dangers of infectious diseases. Potential threats from terrorist use of infectious agents have also emphasized infectious diseases. There has not been any increased awareness of human susceptibility to animal diseases that has caused contagious infections to become a central focus of public health. Also, media coverage has not exaggerated the danger of exposure to crowds when it comes to contagious infections. While health and wellness is a higher priority for many Americans, the interest is not a factor in focus on contagious infections.

2. A nurse is concerned about the high incidence of sexually transmitted infection (STIs) in the community college population and

sets up a special STI screening. Which of the following groups of students would be encouraged to attend? (Select all that apply.) a. Sexually active students currently receiving treatment for an STI b. Sexually active students who had been screened the previous year c. Students who are not sexually active and do not plan to become sexually active d. Students who are sexually active but never “go all the way” e. Students who are freshmen or new transfers ANS: B, D

Those who are at risk to develop the problem should be encouraged to attend the screening. This should be anyone who is or plans to be sexually active to any degree. Those already diagnosed with the problem are not at risk, because they already have the condition and are no longer at risk for developing it. Thus, it would not be beneficial for this population to attend the screening as they have already been diagnosed. Students who are not sexually active do not need to attend the screening as they are not at risk for contracting an STI because they are not having sex.

3. A nurse is planning to host a health screening at a large urban mall. Which of the following variables will help the nurse determine

which screenings should be included? (Select all that apply.) a. Adequate space for persons to lie down after testing until side effects are reduced b. Health problems for which the specific population is at risk c. Whether adequate privacy can be obtained for the invasive or embarrassing procedures d. Whether health care providers are available to follow up on any positive screening results e. Ability to provide the individual health screenings free to the public ANS: B, D

The screening tests should be reliable, valid, fast, and inexpensive. Results should be known immediately. Ethically, nurses should not screen for any problem unless they can refer those with positive results to a source for follow-up testing and treatment. The screening tests should have few side effects, be minimally invasive, and be capable of detecting enough new cases to warrant the effort and expense. No tests should be used that have negative side effects, are invasive, or cause embarrassment.

4. A nurse believes a new mouth care procedure (MCP) is exacerbating a client oral tissue problems. Which of the following must be

present for the nurse to go to administration with confidence that the MCP is causing problems? (Select all that apply.) a. A plausible explanation of how the new MCP could cause harm b. A strong feeling that the MCP is the cause c. Consistently seeing mouth inflammation in many of the patients who have received the MCP d. Documentation from patient records that mouth inflammation in clients did not occur until after the new procedure was implemented e. A less expensive option for appropriate oral care ANS: A, C, D

Strength of association is suggested by the fact that patients who did not receive the MCP and patients seen on the floor before the new MCP did not have problems, whereas patients who received the new MCP are having problems. Seeing the problems in many of the patients suggests a consistency. The fact that those who had the procedure more often have worse problems suggests a dose-response relationship. A plausible explanation of how the new procedure could cause harm enhances the biological risk.

Although one would hope that previous testing would have been done before the product was released to market, the product could be safe for healthy persons but a risky process for those with compromised immunity or those who are under stress. Feelings alone are not convincing. A study should be set up to confirm or dispute the nurse’s hypothesis. Cost of the initial procedure is not a relevant factor.

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Chapter 11: Infectious Disease Prevention and Control Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following is the number one cause of death worldwide? a. Chronic diseases (heart disease, cancer, stroke) b. Infectious diseases c. Injuries (accidental or purposeful) d. Terrorism ANS: B

Infectious diseases, however, are still the number one cause of death worldwide. In countries with higher standards of living, where people live longer, chronic diseases—heart disease, cancer, and stroke—are the leading causes of death. Injuries and ter rorism are not the number one cause of death worldwide.

2. Which of the following places best describes where the incidence of Vancomycin-resistant Staphylococcus aureus (VRSA) and

methicillin-resistant S. aureus (MRSA) is currently rising? a. Areas where people share dressing or bathing facilities b. Daycare centers and schools c. Long-term care facilities d. Senior citizen centers ANS: A

Vancomycin-resistant Staphylococcus aureus (VRSA) and methicillin-resistant S. aureus (MRSA) remain problems for people who acquire the bacteria in the hospital, but there is a growing incidence of community-acquired MRSA in places where people closely share facilities such as locker rooms, prisons, and other close bathing areas. Daycare centers, schools, long-term care facilities, and senior citizen centers are not places where the incidence of VRSA and MRSA is rising. These are not places where people are closely sharing dressing and bathing facilities.

3. During an outbreak of hepatitis A, nurses are giving injections of hepatitis A immunoglobulin to selected susceptible persons.

Which of the following best describes the type of immunity that will follow the administration of these injections? a. Active immunity b. Acquired immunity c. Natural immunity d. Passive immunity ANS: D

Passive immunity refers to immunization through the transfer of a specific antibody from an immunized individual to a non-immunized individual, such as the transfer of antibody by the administration of an antibody-containing preparation (immune globulin or antiserum). Passive immunity from immune globulin is almost immediate but short-lived. It often is induced as a stopgap measure until active immunity has had time to develop after vaccination. Active immunity occurs as antibodies develop due to exposure to the antigen. Acquired immunity is the resistance acquired by a host as a result of previous natural exposure to an infectious agent. Natural immunity refers to a species-determined, innate resistance to an infectious agent.

4. A man loudly protests his increased property tax bill right after the public health department has made a plea for more funds.

“Why,” he asks, “should my tax dollars be used to pay for their children to be immunized?” Which of the following would be the best response by the nurse? a. “Immunizations are required by law, and if their parents can’t afford it, you and I will have to pay for it.” b. “It’s just the right thing to do.” c. “Only by making sure most kids are immunized can we stop epidemics that might hurt all of us.” d. “We’re a religious God-fearing community, and we take care of each other.”

ANS: C

Herd immunity is the resistance of a group of people to invasion and spread of an infectious agent because a high proportion of individual members of a group are resistant to the infection. Higher immunization coverage will lead to greater herd immunity, which in turn will block the further spread of the disease. The purpose of immunization laws is to promote herd immunity.

Receiving immunizations helps to block the further spread of the disease as more members of the community become resistant to the infection.

5. Which of the following components of the epidemiologic triangle contributes most to a female client developing a vaginal infection

caused by fungi after successful treatment of her strep throat with antibiotics? a. Agent b. Environment c. Host d. Agent and host ANS: B

The antibiotic therapy eliminates a specific pathological agent, but it also may alter the balance of normally occurring organisms in the woman’s body, which causes a change in the vaginal environment and allows normally present fungi to proliferate, resulting in a yeast infection. The agent is the factor that is causing the disease or illness. The host is the human or animal that becomes infected.

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6. Which of the following best represents an example of infectious disease spreading via a vector? a. Being bitten by an infected mosquito b. Disease spreading from infected mother to infant via the placenta c. A group of partygoers hugging and shaking hands d. Two persons, one of whom is infected, sharing a glass of soda ANS: A

Vectors include mosquitoes, which can transmit the infectious agent by biting the host. Vertical transmission is the passing of infection from parent to offspring via placenta. Horizontal transmission is the person-to-person spread of infection through (among other ways) contact. Common vehicle refers to transportation of the infectious agent from an infected host to a susceptible host via food, water, milk, or other substance.

7. Which statement made by the nurse best describes the effect vaccines have had on tuberculosis (TB)? a. Tuberculosis is no longer a threat in most of the world. b. Tuberculosis has developed resistance to the all antibiotics. c. The treatment has helped greatly reduce the incidence of TB in the United States. d. The incidence of TB has remained constant since the 20th century.

ANS: C

In 1900, communicable diseases were the leading causes of death in the United States. Since that time, improved sanitation and nutrition, the discovery of antibiotics, and the development of vaccines has ended some epidemics such as diphtheria and typhoid fever and greatly reduced the incidence of others such as tuberculosis (TB).

8. Which population is best protected against pertussis by the DTaP vaccine? a. Young children b. The pre-teen c. The teen d. Adult ANS: A

More than 200,000 children previously got pertussis each year. Two vaccines protect again this disease: DTaP protects young children from diphtheria, tetanus, and pertussis; and Tdap protects preteens, teens, and adults.

9. Which of the following data would most likely be collected in a syndromic surveillance system? a. Incidence of bioterrorism attacks b. Number of air travelers c. Incidence of school absenteeism d. Number of influenza vaccines administered ANS: C

Syndromic surveillance systems use existing health data in real time to provide immediate analysis and feedback to those charged with investigation and follow-up of potential outbreaks. These systems incorporate factors such as the previously mentioned temporal and geographic clustering and unusual age distributions with groups of disease symptoms or syndromes (e.g., flaccid paralysis, respiratory signs, skin rashes, gastrointestinal symptoms) with the goal of detecting early signs of diseases that could result from a bioterrorism-related attack. Syndromic surveillance systems may include tracking emergency department visits sorted by syndrome symptoms as well as other indicators of illness including school absenteeism and sales of selected over-the-counter medications. In recent years, the tracking of cold medicines used to make crystal methamphetamine has received considerable attention. Syndromic surveillance systems use existing health data—the number of air travelers is not existing health data. It is the intention of syndromic surveillance systems to detect early signs of diseases that could result from a bioterrorism-related attack; thus, the system is not measuring the incidence of bioterrorism attacks. Administration of influenza vaccines should decrease the prevalence of this disease. Therefore it is unlikely that the administration of vaccines would be data that is collected; the incidence of the influenza would be more likely to be examined.

10. The nurse is trying to determine if a disease occurrence needs to be reported to the state health department. Which of the following

resources should the nurse use to answer this question? a. Centers for Disease Control and Prevention Weekly Report b. Communicable Diseases Weekly Report c. Nationally notifiable infectious diseases on the CDC website d. State health department website ANS: D

Requirements for disease reporting in the United States are mandated by state rather than federal law. The list of reportable diseases varies by state. State health departments, on a voluntary basis, report cases of selected diseases to the Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. The CDC updates these conditions annually, and the list can be found under the heading of Nationally notifiable infectious diseases on the CDC website. The weekly reports may provide information about the current incidence or prevalence of certain diseases, but it will not provide the nurse with information about what is required to be reported.

11. There is great concern in the nurse’s community over three local cases of West Nile virus. Which of the following actions should

the nurse take to get the community involved in addressing this problem? a. Ask the state department of health for assistance. b. Demand that everyone over age 65 become immunized immediately. c. Encourage immunization of all children under 12. d. Have an educational campaign to remove any containers of standing water.

ANS: D

Periodic outbreaks of West Nile virus appear to result from a complex interaction of multiple factors, including weather—especially hot, dry summers followed by rain, which influences mosquito breeding sites and population growth.

Removing standing water will remove mosquito breeding sites. Currently, there is not a vaccine available for humans; an equine vaccine does exist, and work is under way to develop a vaccine for both birds and humans. The state health department would most likely not become involved in this local health problem, rather this may be the role of a local health department.

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12. Which of the following is the most probable cause of the increase in new emerging infectious diseases? a. Activities or behavior of humans, including changes in the environment b. Increasing urbanization and growth in new housing materials c. New infectious agents are evolving throughout the world d. Overpopulation in many areas, creating a need to reduce global population ANS: A

Most of the emergence factors are consequences of activities and behavior of the human hosts and of environmental changes such as deforestation, urbanization, and industrialization. For example, the rise in households with two working parents has increased the number of children in daycare, and with this shift has come an increase in diarrheal diseases such as shigellosis. Urbanization is not a problem, but increasing development into formerly unaffected areas such as rainforests is. The environmental changes around the world are causing new infectious agents to emerge, not evolve. The environmental changes that occur because of overcrowding is the issue, not the population itself.

13. Which of the following best describes the current goal in relation to communicable diseases? a. To control political borders so diseases cannot spread further b. To exterminate specific infectious agents one by one c. To expand health care facilities to improve infectious disease treatment d. To achieve worldwide immunization to control new cases ANS: B

The goal of prevention and control programs is to reduce the prevalence of a disease to a level at which it no longer poses a major public health problem. In some cases, diseases may even be eliminated or eradicated. The goal of elimination is to remove a disease from a large geographical area (e.g., a country or region of the world), such as has been done with polio in the Americas.

Eradication is the irreversible termination of all transmission of infection by extermination of the infectious agents worldwide, as has been done with smallpox. Because of the large amount of international travel, it is impossible to prevent the spread of diseases from occurring worldwide. The expansion of health care facilities would not improve the treatment of infectious diseases, rather improved sanitation could assist in this. The goal for the spread of communicable diseases is eradication, not control of new cases.

14. Which of the following biological warfare agents poses the greatest bioterrorism threat to a community? a. Anthrax b. Botulism c. Smallpox d. Tularemia ANS: A

Because of factors such as the ability to become an aerosol, the resistance to environmental degradation, and a high fatality rate, inhalational anthrax is considered to have an extremely high potential for being the single greatest biological warfare threat.

Botulism, smallpox, and tularemia do not have the ability to be transmitted through a resistant aerosol that is highly fatal.

15. Which of the following public health actions has been particularly instrumental in reducing childhood infectious diseases in the

United States? a. Answering parents’ questions about the safety and importance of vaccines today b. Educational campaigns to all health care providers about the importance of immunizations whenever a child is seen c. “No shots, no school” legislation, which legally requires children be immunized before school d. Offering all immunizations to all children free of any charge ANS: C

Vaccines are one of the most effective methods of preventing and controlling communicable diseases. One of the most effective programs has been the “no shots, no school” legislation, which has resulted in the immunization of most children by the time they enter school. Hopefully, all nurses answer questions, remind colleagues to think about immunizations whenever a child is seen, and encourage continuing free or low-cost immunization clinics. These interventions have not been particularly instrumental in reducing childhood infections.

16. A student comes to the college health clinic with typical cold symptoms of fever, sneezing, and coughing, but the nurse also notes

small white spots on the inside of the student’s cheeks. Which of the following actions should be taken by the college health nurse? a. Inform all students, staff, and faculty of a possible rubella epidemic. b. Inform all students, staff, and faculty of a possible measles epidemic. c. Reassure the student that it is just a bad cold and will soon pass. d. Tell the student to take two acetaminophen and drink lots of fluids.

ANS: B

Measles is an acute, highly contagious disease that, although considered a childhood illness, is often seen in the United States in adolescents and young adults. Symptoms include fever, sneezing, coughing, conjunctivitis, small white spots on the inside of the cheek (Koplik spots), and a red, blotchy rash beginning several days after the respiratory signs. Measles is serious. Around 10% of measles cases require hospital admission. It can lead to pneumonia and encephalitis, and it can kill. Persons who may have been exposed should be informed that anyone under 18 who has not received both immunization doses should receive measles vaccine.

The student is displaying symptoms of measles, not rubella. Symptoms of rubella include a low-grade fever, runny nose, headache, and a rash that starts on the face and spreads to the rest of the body. The white spots (Koplik spots) should make the nurse suspect that the client has measles, not just a bad cold in which case the nurse would recommend the acetominophen and fluids.

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17. An instructor is reviewing Salmonella infections with her class. Which of the following comments indicates that the student needs

further review on how Salmonella is spread? a. “Certain pets and farm animals may be Salmonella carriers.” b. “It is possible to transmit Salmonella by person-to-person contact.” c. “Salmonella may be spread by spores that form once contaminated blood is exposed to the air.” d. “Salmonella outbreaks are usually due to contaminated meat, poultry, and eggs.”

ANS: C

Anthrax (not Salmonella) forms spores when infected blood is exposed to air. Meat, poultry, and eggs are the foods most often associated with salmonellosis outbreaks. Animals are the common reservoir for the various Salmonella serotypes, although infected humans may also fill this role. Animals are more likely to be chronic carriers. Reptiles such as iguanas have been implicated as Salmonella carriers, along with pet turtles, poultry, cattle, swine, rodents, dogs, and cats. Person-to-person transmission is an important consideration in daycare and institutional settings.

18. Which of the following is the most common vector-borne disease in the United States? a. Babesiosis b. Ehrlichiosis c. Lyme disease d. Rocky Mountain spotted fever ANS: C

Lyme disease became a nationally notifiable disease in 1991 and is now the most common vector-borne disease in the United States. Babesiosis, Ehrlichiosis, and Rocky Mountain spotted fever are all diseases borne by ticks as the vectors. These are not the most common vector-borne diseases.

19. A student reports to the college health nurse that her academic work has been going downhill because of lack of sleep. “My

3-year-old probably misses her babysitter since she has started going to the big daycare center. She hasn’t been sleeping well and keeps scratching her bottom. Hopefully, she’ll adapt to daycare soon.” Which of the following information should the nurse provide to the student? a. “Dry skin in winter weather can cause itchiness; try to put on lotion before bedtime.” b. “Your daughter may have pinworms; let me teach you how to check for this.” c. “Perhaps your child is not developmentally ready for group play.” d. “Try to arrange more one-on-one time with your 3-year-old.”

ANS: B

Enterobiasis (pinworm infection) is the most common helminthic infection in the United States with about 42 million cases a year.

This infection is seen most often among children in institutional settings. Pinworms cause itching, especially around the anus, which can result in a lack of sleep for both child and caregiver. The nurse should suspect that the underlying problem is pinworms, not dry skin. These symptoms do not demonstrate a developmental delay or the need for additional one-on-one time.

20. Which of the following is the most common vector-borne disease is a result of travelers introducing the disease to the United

States? a. Dengue b. Malaria c. Onchocerciasis (river blindness) d. Yellow fever ANS: B

Globally, malaria is the most prevalent vector-borne disease, with over 2.4 billion people at risk and more than 275 million cases reported each year. About 2000 cases of malaria are diagnosed in the United States each year. The vast majority of cases in the United States are in travelers and immigrants returning from countries where malaria transmission occurs, many from sub-Saharan Africa and South Asia. Dengue is rarely transmitted in the United States. Onchocerciasis and Yellow fever are not reported as common vector-borne diseases.

21. At a town meeting with public health officials to discuss a communicable disease outbreak, a nurse is asked to explain what is

meant by the phrase “a virulent organism.” The nurse explains that this means the organism causing the disease is able to do which of the following? a. Bypass normal immunological response mechanisms b. Invade major organ systems c. Produce toxins and poisons that weaken the body d. Produce very severe physical reactions ANS: D

Virulence is the ability to produce a severe pathological reaction. Bypassing the normal immunological response mechanisms, invading major organ systems, and producing toxins and poisons that weaken the body are not correct definitions of virulence.

22. A client is using a primary prevention strategy to prevent infectious disease. Which of the following actions is the client most likely

taking? a. A client receives a tetanus booster every 10 years. b. A client receives a tetanus booster after stepping on a nail. c. A client receives tetanus immunoglobulin after stepping on a nail. d. A client with tetanus is given antibiotics and is placed on seizure precautions.

ANS: A

Tetanus boosters given before exposure are a measure of primary prevention because exposure has not yet occurred. If given after exposure (i.e., the client may be infected but disease has not developed), they are considered secondary prevention (similar to the textbook examples of immunoglobulin and rabies immunizations given after exposure). Immunoglobulin would be given if the client had not been previously immunized; however, this again is after exposure, so it is secondary prevention. Because the client has the condition, treatment is aimed at prevention of further injury.

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23. Which of the following infectious disease interventions best represents the use of secondary prevention? a. Clients with HIV infection are encouraged to use condoms to protect sexual

partners. b. Clients with HIV infection are given medications to improve immunological response. c. Health care workers are encouraged to receive annual vaccinations for influenza. d. Health care workers are required to have a tuberculosis skin test or chest X-ray.

ANS: D

Tuberculosis screening for health care workers is an example of secondary prevention. TB skin tests and chest X-rays are methods of tuberculosis screening. Encouraging clients with HIV to use condoms is an example of primary prevention, because the goal is to prevent exposure to the partner. Encouraging annual influenza vaccinations is also an example of primary prevention. Giving clients with HIV medications is an example of tertiary prevention, because the goal is to reduce complications in those already having the infection.

MULTIPLE RESPONSE 1. Five students order meals at a local restaurant. Which of the following students are at highest risk for illness? (Select all that

apply.) a. The first student asks for a salad with chicken strips and dressing on the side. b. The second student asks for a hamburger, very rare. c. The third student orders a tuna salad sandwich with extra mayonnaise. d. The fourth student orders a breakfast meal with two very soft-poached eggs and toast. e. The fifth student asks for a vegetable platter and a side of hummus.

ANS: B, D, E

Escherichia coli O157:H7 can produce a strong cytotoxin that can cause a potentially fatal hemorrhagic colitis. Hamburger is often involved in outbreaks, since the grinding process exposes pathogens on the surface of the whole meat to the interior of the ground meat, effectively mixing the once-exterior bacteria thoroughly throughout the hamburger so that searing the surface no longer suffices to kill all bacteria. Also, hamburger is often made of meat ground from several sources. The best protection against foodborne pathogens is to thoroughly cook food before eating it. Salmonella is also transmitted by undercooked foods such as eggs, poultry, dairy products, vegetables and seafood. Consequently, students eating very rare hamburger and undercooked eggs are at high risk. The food items requested by the first (salad with chicken strips and dressing) and third (tuna salad sandwich with extra mayonnaise) students are at the lowest risk for illness. These foods have been thoroughly cooked which helps to assure that potential bacteria have been destroyed.

2. Which of the following symptoms suggests smallpox as opposed to the more common and much less dangerous chickenpox?

(Select all that apply.) a. Child appears only mildly ill until late stages in smallpox. b. Lesions appear in various stages in the same area of the body rather than all at once. c. Rash lesions are most abundant on the face and extremities, not on the trunk. d. Rash occurs 2 to 4 days after sudden onset of fever rather than with the fever. e. Vesicles do not collapse when punctured.

ANS: C, D, E

Symptoms of smallpox include rash lesions on face and extremities (“centripetal”), rash that occurs 2 to 4 days after onset of fever, and vesicles that are deep seated and do not collapse on puncture. Symptoms of chickenpox include a sudden onset with slight fever and mild constitutional symptoms, rash that is present at onset, rash progression is maclopapular for a few hours, vesicular for 3 to 4 days, followed by granular scabs, rash is “centifugal” with lesions most abundant on the trunk or areas of the body usually covered by clothing, lesions appear in “crops” and can be at various stages in the same area of the body, and vesicles are superficial and collapse on puncture.

3. The advanced practice nurse explains that the client has an upper respiratory infection (URI) and suggests several measures that

might make the client more comfortable. Which of the following best describes why the nurse doesn’t just prescribe antibiotics as the client repeatedly requests? (Select all that apply.) a. Antibiotics are expensive, whereas the support measures would be almost free of cost. b. Viral diseases are not affected by antibiotics. c. Clinics cannot afford to continually give antibiotics to anyone who asks for them. d. The more antibiotics are prescribed, the more infectious agents develop resistance to such drugs. e. Antibiotics are not particularly effective against coughs and nasal congestion.

ANS: B, D

Antibiotics are not effective against viral diseases, a fact found unacceptable to many clients looking for relief from the misery of a cold or flu. The inappropriate prescribing of antibiotics contributes to the growing problem of infectious agents that have developed resistance to once-powerful antibiotics. There are many broad-spectrum antibiotics that are inexpensive. Typically, insurance providers or clients are paying for the cost of prescription antibiotics, not the clinic. So, although the health care s ystem is impacted by these increased costs it is most likely not impacting the clinic itself.

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Chapter 12: Communicable and Infection Disease Risks Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following sexually transmitted diseases can be prevented through immunization? a. Chlamydia b. Gonorrhea c. Hepatitis B d. Genital Herpes Simplex ANS: C

Hepatitis B infection can be prevented by immunization; vaccines for the remaining options are not yet available. There are not yet vaccines for chlamydia, gonorrhea, or genital herpes simplex.

2. Which of the following provides the best explanation as to why people do not immediately seek medical treatment when they first

become ill with HIV? a. They are afraid to get tested for fear that the results will be positive. b. They avoid the problem (maybe it will go away). c. They don’t recognize their symptoms as possibly being due to HIV. d. It is too expensive to get an HIV test.

ANS: C

When HIV enters the body, it can cause a flu-like syndrome referred to as a primary infection or acute retroviral syndrome. This may go unrecognized. The symptoms are similar to flu or a bad cold including sore throat, lethargy, rash, fever, and muscle pain.

An antibody test at this stage is usually negative. So the person or a medical provider may not recognize the illness as HIV. Thus, it is not worthwhile to be tested during this stage of the illness. This information supports the incorrectness of the other options.

3. A client was clearly very relieved when an HIV test came back negative. “Thank goodness. I’ve had sex several times without a

condom, and when one of my friends said he was sick, I think I panicked.” Which of the following would be most important to emphasize to the client immediately? a. Abstinence is the only way to be certain you are HIV free. b. Sex should be restricted to one partner. c. The test could be wrong and the client might still have an HIV infection. d. The test would not cover any recent infection, so if the client has had recent unprotected sex, the test should be repeated in 3 months.

ANS: D

The client needs to understand that the test cannot identify infections that may have been acquired within the previous 3 months before the test. Appearance of the HIV antibody can take up to 12 weeks; thus, this test could be negative now, but positive in 3 months. All persons who have an STD test should be counseled about risk reduction activities before and after the test is done. This information supports the incorrectness of the other options.

4. A student asks the nurse at the student health clinic how AIDS is diagnosed. Which of the following statements would be the best

response by the nurse? a. “A diagnosis of AIDS is made when a screening test called an enzyme-linked immunosorbent assay (ELISA) is confirmed by the Western blot test.” b. “A diagnosis of AIDS is made when antibodies to HIV are detected about 6 weeks to 3 months following possible exposure.” c. “A diagnosis of AIDS is made when antibodies to HIV reach peak levels of 1000/ml of blood.” d. “A diagnosis of AIDS is made when CD4 T-lymphocytes drop to less than 22 cells/mm.”

ANS: D

AIDS is defined as a disabling or life-threatening illness caused by HIV; it is diagnosed in a person with a CD4 T-lymphocyte count of less than 22 cells/ml with or without documented HIV infection. The HIV antibody test (usually the EIA) is the most commonly used screening test for determining whether the antibody to HIV is present but does not confirm AIDS. Positive results with the EIA are tested further with the Western blot test. However, false-negative results are frequent between 6 weeks and 3 months following exposure.

5. The correctional health nurse is doing a quick assessment on a newly admitted inmate who is HIV positive. Which of the following

diseases should the inmate receive screening for immediately? a. Herpes zoster b. Hepatitis B c. Hepatitis C d. Tuberculosis ANS: D

HIV-infected persons, who live near one another, such as in correctional facilities, must be carefully screened and deemed noninfectious before admission to such settings. A person with HIV is more susceptible to opportunistic infections, the most common of which is TB. Hepatitis B and hepatitis C are both transmitted through blood and body fluids which are not as highly contagious as tuberculosis which is transmitted through airborne droplets. Herpes zoster (shingles) is spread by direct contact with fluid from the rash blisters. None of the other options are as directly related to HIV as an opportunistic disease.

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6. A school nurse asks a class about the ways HIV can be transmitted. Which of the following comments by a student indicates a need

for additional teaching? a. “I wouldn’t sit next to someone with HIV.” b. “Having unprotected sex with someone who is infected spreads HIV.” c. “Sharing needles when shooting up drugs spreads HIV.” d. “Transfusions of blood products that are contaminated can spread HIV.” ANS: A

HIV is not transmitted through casual contact such as touching or hugging someone who has HIV infection. It is not transmitted by insects, coughing, sneezing, office equipment, or sitting next to or eating with someone who has HIV infection. HIV can be transmitted through exposure to blood, semen, vaginal secretions, and breast milk and by sharing needles, syringes, and other equipment used to prepare injectable drugs. It can also be spread by perinatal transmission from mother to child through delivery or breastfeeding and by transfusions of contaminated blood. Worldwide, the largest number of HIV infections result from heterosexual transmission.

7. In the United States, which group is most affected by a new HIV diagnosis? a. Women having heterosexual relationships b. White IV drug abusers c. Young Black gay and bisexual men d. Men who have sex with other men ANS: C

Although new HIV diagnosis in general has declined, young Black gay and bisexual men are the most affected, with an 94% increase in diagnosis. The largest number of new infections in 2018 was in men who had sex with other men, and this was followed by heterosexual transmission. HIV infections in women are primarily due to heterosexual contact or IV drug use. This information supports the incorrectness of the other options.

8. Which of the following best explains why some health clinics allow clients to be tested for HIV anonymously with no record of the

client’s name, address, or contact information? a. Client doesn’t actually ever have to be told the results of the test. b. Client may be engaged in illegal activities (drug use). c. Client plans on not paying for the test, and collection agencies will not be able to harass them. d. Client wants to be sure care providers don’t share results with their family.

ANS: B

An advantage of anonymous testing may be that it increases the number of people who are willing to be tested, because many of those at risk are engaged in illegal activities. The anonymity eliminates their concern about the possibility of arrest or discrimination. If testing is anonymous, the client is given an identification code number that is attached to all records of the test results and is not linked to the person’s name and address. Demographic data such as the person’s sex, age, and race may be collected, but there is no record of the client’s name and associated identifying information. Thus, the client is able to know the results of the test while staying anonymous. It would be a violation of HIPAA for the providers to share the results of this test or any other medical information with family members. The follow-up related to payment is not a main concern for the population who is requesting anonymous testing.

9. A nurse is providing education to a client about the use of PrEP. Which of the following statements would the nurse include as part

of this teaching? a. “Side effects of PrEP include extreme lethargy and joint pain.” b. “PrEP has been shown to be effective in preventing transmission of the disease from sharing needles.” c. “The effectiveness of PrEP will depend on your adherence to the medication regimen.” d. “PrEP will prevent you from contracting HIV and hepatitis B.” ANS: C

Pre-exposure prophylaxis, or PrEP, is a new HIV prevention method for people who do not have the infection but would like to reduce their risk of becoming infected. PrEP requires taking a pill to prevent the HIV virus from getting into the body. This prevention method requires strict adherence to taking the medication and having regular HIV testing; it is also used in combination with other HIV prevention methods rather than in isolation (CDC: PrEP, 2012b). It has been shown to be effective for people at very high risk for HIV infection through sex; the results about its effectiveness with injection drug users are not yet available.

Extreme lethargy and joint pain are not common side effects of PrEP. PrEp provides protection against HIV, not against hepatitis B. 10. A male client visits the clinic office reporting a yellow-green discharge from his penis. Which of the following STIs has the client

most likely contracted? a. Gonorrhea b. Syphilis c. Herpes simplex virus 2 d. Human papillomavirus ANS: A

The symptoms for gonorrhea in a male include a burning sensation when urinating, or a white, yellow-green discharge from the penis. Some men may get swollen or painful testicles. In men, gonorrhea can cause epididymitis, a painful condition of the testicles that if untreated can lead to infertility. Symptoms of syphilis may not appear for several years after contracting the disease. The first stage of syphilis is called primary syphilis when a chancre, a firm, round, small and painless lesion, develops. Signs and symptoms of HSV-2 infection range from no symptoms to painful lesions or blisters around the genitals, rectum, or mouth. Most people with HPV are asymptomatic.

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11. A client is being treated for secondary syphilis. Which of the following signs and symptoms would the nurse anticipate the client

would exhibit? a. Chancre at the site of entry b. Jaundice c. Difficulty coordinating muscle movements d. Skin rash without itching ANS: D

Secondary syphilis occurs when the organism enters the lymph system and spreads throughout the body. Signs include skin rash on one or more areas of the body and do not cause itching. Other symptoms may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. A chancre at the site of entry is a symptom of primary syphilis.

Difficulty coordinating movements is a sign of tertiary syphilis. Jaundice is a sign of congenital syphilis.

12. Which of the following best explains why chlamydia is a major focus of public health efforts? a. It has more serious long-term outcomes than other STDs. b. It can cause problems in infants born to infected mothers. c. It is not frequently seen in the United States. d. It is so difficult and expensive to treat.

ANS: B

Like gonorrhea and other STDs, chlamydia can cause neonatal complications in infants born to infected mothers. It is treated rather easily with antibiotics. Chlamydia does have serious long-term outcomes for the client, but so do syphilis and other STDs. However, unlike syphilis, which in its later stages is rare in the United States, chlamydia is the most common reportable infectious disease in the United States and hence is a major focus of public health.

13. Which of the following statements best explains why HSV-2 infection is more challenging for a client than gonorrhea infection? a. HSV-2 is a viral infection that is both chronic and incurable. b. HSV-2 is extremely expensive to treat. c. HSV-2, like HIV, is almost impossible to diagnosis in the early stages. d. Once a person has been treated for HSV-2, the person is immune to further

outbreaks.

ANS: A

Unlike gonorrhea, there is no cure for HSV-2 infection; it is considered a chronic disease. Recurrence with HSV-2 is common. The treatment for HSV-2 may be episodic or suppressive for frequent recurrence, which is not expensive to treat. HSV-2 may be asymptomatic but does appear as vesicles, painful ulceration of penis, vagina, labia, perineum, and anus with lesions lasting 5 to 6 weeks.

14. When a nurse discovers that a woman has been treated for cervical cancer, the nurse asks the woman whether she has ever been

tested for HIV or other STDs. The woman is offended and asks why the nurse would ask her such a thing. Which of the following statements would be the best response from the nurse? a. “Cervical cancer treatments may decrease immunity, so that it is easier to acquire STDs.” b. “Cervical cancer usually is caused by HPV, and often the presence of one STD is accompanied by other STDs.” c. “The presence of an STD in women with cervical cancer may lead to congenital defects in offspring.” d. “The presence of an STD in a woman with a history of cervical cancer has been associated with a relapse of the cancer after treatment.”

ANS: B

The link between HPV infection and cervical cancer has been established and is associated with specific types of the virus. In 80% to 90% of cases of cervical cancer, evidence of HPV has been found in the tumor. Additionally, HSV-2 infection is linked with the development of cervical cancer. Because the presence of an STD increases the risk for the presence of other STDs, it is essential to screen for this information. There is no evidence that the presence of an STD in women with cervical cancer will lead to congenital defects in offspring. The presence of an STD increases the risk for another STD. There is no evidence of relapse of cervical cancer when there is presence of an STD. 15. Which of the following best describes the characteristic appearance of lesions of human papillomavirus (HPV)? a. Solitary growth with elevated borders and a central depression b. Elevated growths with a “cauliflower” appearance c. Thin-walled pustules that rupture to form honey-colored crusts d. Vesicles that ulcerate and crust within 1 to 4 days ANS: B

HPV causes genital warts that appear as textured surface lesions, with what is sometimes described as a cauliflower appearance.

The warts are usually multiple and vary between 1 and 5 mm in diameter. The other descriptions are not characteristic of lesions of the human papillomavirus (HPV).

16. A client who is very upset says to the nurse, “But we always used a condom! How could I have genital warts?” Which of the

following would be the best response by the nurse? a. “Are you positive you always used a condom?” b. “Condoms don’t always work.” c. “The condom might have had a tear in the latex.” d. “Contact may have occurred outside the area that the condom covers.”

ANS: D

Warts may grow where barriers, such as condoms, do not cover, and skin-to-skin contact may occur. The challenge of HPV prevention is that condoms do not necessarily prevent infection. Thus, even with correct usage and the use of undamaged condoms, transmission may still occur.

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17. Which of the following statements best explains why many health care providers are more afraid of getting hepatitis B (HBV) than

HIV? a. Everyone would assume the person infected with hepatitis B is a drug user. b. Having HBV would mean no further employment in health care. c. The fatality rate is higher and occurs sooner with HBV. d. There is no treatment for HBV, which can be a very serious illness.

ANS: D

Unlike HIV, there is no treatment for hepatitis B, and although some persons never have symptoms and others fight off the disease, many suffer from chronic hepatitis B, a very serious illness. Others may become chronic carriers of the disease. There are multiple populations that have a high prevalence of HBV including injection drug users, persons with STDs or multiple sex partners, immigrants, and refugees and their descendants who came from areas where there is a high endemic rate of HBV, health care workers, clients on hemodialysis, and inmates of long-term correctional institutions. Those who are infected with HBV are still able to work in health care. There is no evidence that the fatality rate is higher or sooner with HBV than with HIV. 18. A nurse explained to a new mother that because she had tested positive for the hepatitis B virus, her newborn son would need the

hepatitis B vaccine immediately and then also an immune globulin injection. “Wait,” said the new mother. “Why is my son getting two shots?” Which of the following statements would be the best response by the nurse? a. “One injection protects your son, while the other encourages his body to build up immunity.” b. “One shot keeps your son from getting sick, while the other is a typical vaccine to prevent you from accidentally infecting him.” c. “Since you’ve already been infected with the virus, your son needs twice as much protection.” d. “The second shot is just to make sure the first one works.”

ANS: A

Because infected persons may not have any symptoms, all pregnant women should be tested for HBsAg. If the mother tests positive, her newborn needs hepatitis B immune globulin to provide passive immunity and thus prevent infection. In addition, the newborn is given the hepatitis B vaccine at birth, with two follow-up injections, to build active immunity to the infection. One of the shots provides passive immunity and the other provides active immunity. The active immunity continues to be built up by receiving two follow-up injections weeks later.

19. A client diagnosed with tuberculosis (TB) asks why the nurse is required to watch the client swallow the medication each day.

Which of the following statements is the best response by the nurse? a. “Clients with TB are often noncompliant, so if I directly observe, you will be sure to take the drugs that have been ordered.” b. “This therapy is recommended to make sure that you receive the treatment you need and the infection doesn’t become resistant to the drugs.” c. “This is to make sure you take your medication if your condition becomes so advanced that you do not have enough cerebral oxygenation to remember.” d. “Tuberculosis medications are very expensive so this method ensures that government money doesn’t get wasted on those who will not take the drugs.”

ANS: B

It is important to be respectful to clients and to consider their perspective and psychological health while also respon ding truthfully.

Directly observed therapy (DOT) programs for TB medication involve the nurse observing and documenting individual clients taking their TB drugs. When clients prematurely stop taking TB medications, there is a risk that the TB will become resistant to the medications. This can affect an entire community of people who are susceptible to this airborne disease. DOT ensures that TB-infected clients receive adequate medication. Thus, DOT programs are aimed at the population level to prevent antibiotic resistance in the community and to ensure effective treatment at the individual level. Many health departments have DOT home health programs to ensure adequate treatment. The risk to client and the community if the client does not follow the treatment regimen is that the TB will become resistant to these medications. It does not have to do with the possibility of noncompliance by the patient, that the patient will not remember, or related to the cost of the medications.

20. A nurse is concerned about the prevalence of tuberculosis among migrant farm workers. Which of the following activities would be

best to use when implementing tertiary prevention? a. Administer purified protein derivative (PPD) to contacts of those with tuberculosis. b. Initiate directly observed therapy (DOT) for tuberculosis treatment. c. Provide education about the prevention of tuberculosis to members of the migrant community. d. Use skin tests to screen migrant health workers for tuberculosis infection.

ANS: B

Tertiary prevention is carried out among persons already infected with the disease. In this instance, DOT ensures compliance with treatment to cure the disease and to prevent worsening or the development of secondary problems. Administering purified protein derivative (PPD) to contacts of those with tuberculosis is secondary prevention as this is an at-risk population. Providing education about the prevention of tuberculosis to members of the migrant community is a primary prevention strategy as it is aiming to prevent the disease from occurring. Using skin tests to screen migrant health workers for tuberculosis infection is secondary prevention as it is a screening aimed at early detection of the disease.

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21. A mother felt very guilty that her baby was born HIV positive. When the nurse suggested the usual DPT and MMR immunizations,

the mother was extremely upset. “Don’t you know HIV children are immunosuppressed?” she exclaimed. Which of the following would be the nurse’s best response? a. “All children have to have these immunizations before they can attend school.” b. “Being HIV positive, your child is more likely to catch an infection and be very ill if not immunized.” c. “I’m so sorry; I forgot for a moment your child was HIV positive.” d. “The American Pediatric Association requires all health care providers to offer these immunizations to all parents; it is your choice whether or not to accept them.”

ANS: B

Because of impaired immunity, children with HIV infection are more likely to get childhood diseases and suffer serious consequences of the diseases. Therefore, DPT, IPV, and MMR vaccines should be given at regularly scheduled times for children infected with HIV. Other immunizations may also be recommended after medical evaluation. Although this child is HIV positive, there is no medical reason why the child should not be immunized. Many states do have a “no shots, no school” law, but exceptions can be made. The APA does recommend immunizations for most children, but this is not the best answer.

22. A nurse was reading PPD tests 24 hours after another nurse had administered them. Which of the following findings would cause

the nurse to interpret the test as positive? a. 15 mm of erythema in a client with HIV infection b. 5 mm of induration in an immigrant from a country where TB is endemic c. A 5-mm ruptured pustule with purulent drainage in a homeless client d. 10 mm of swelling and increased firmness in a client recently released from a correctional facility ANS: D

For a PPD test to be positive, induration (swelling with increased firmness) must be present. A diameter of 10-mm induration would be a positive finding in an immigrant from a region with high TB infection. Erythema alone does not indicate a positive finding. A 5-mm induration is not large enough to indicate a positive finding. A small pustule in a homeless client undoubtedly is an infection but may not be due to the PPD test.

23. A high school student is planning to volunteer at the hospital after school, so he or she needs to have a Mantoux test before

beginning. Which of the following information should the nurse provide to the new volunteer? a. “I will be using tiny tines to administer the TB antigen to the skin on your arm.” b. “Notify the clinic immediately if you experience any redness or itching at the test site.” c. “The areas should be kept dry until you return; cover it with plastic wrap when bathing.” d. “You will need to return in 2 to 3 days to have any reaction interpreted.”

ANS: D

The Mantoux test is a TB skin test that involves a 0.1-ml injection containing 5 tuberculin units of PPD tuberculin (not tines as in the TB tine test). The site should be examined for a reaction 48 to 72 hours (2 to 3 days) after injection. Only induration should be measured, and the results should be recorded in millimeters. The Mantoux test involves a 0.1-ml injection not tines as in the TB tine test. Slight redness or itching at the test site may occur, but that should resolve on its own and does not require the client to notify the clinic. The client can engage in normal activities; the site does not need to be kept dry.

MULTIPLE RESPONSE 1. A woman and man who have come to the health clinic begin to argue loudly. “You gave me an STI!” the man yells. The woman

screams back, “Not me. I don’t have an STI!” Which of the following statements would be most appropriate for the nurse to say to them? (Select all that apply.) a. “Actually, you’re very fortunate to have been tested, so you and your partner can begin treatment before more serious damage is done.” b. “Some STIs may not have any symptoms, so you need to be tested for other conditions and treated if necessary.” c. “Sometimes the test is inaccurate, so before getting too upset, you should ask to be tested again.” d. “You may be able to get treatment from your pharmacist so you won’t have to be embarrassed like this again.” e. “Some STIs are spread in ways that are non-sexual in nature.”

ANS: A, B, C

Often cases of gonorrhea and chlamydia are asymptomatic, so treatment may not be sought and these infections are spread to others through sexual activity. Similarly, during latency, syphilis has no symptoms. It should be noted, however, that STI test results can sometimes be incorrect and the coexistence of other medical conditions may cause a false-positive test result. Having a partner retested, if the results were negative, would also suggest retesting the first person. The pharmacist must receive an order from the primary care provider in order to dispense a prescription.

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2. The public health nurse comes to the hospital to see a client just diagnosed with hepatitis A. The nurse says, “I’m sorry to bother

you when you’re not feeling well, but I need to ask you a few questions.” Which of the following questions would be most appropriate for the nurse to ask the client? (Select all that apply.) a. “Do you know how you got this infection?” b. “Who lives with you?” c. “Where are you employed?” d. “Where do you usually eat?” e. “Are you sexually active?”

ANS: B, C, E

The nurse should ask about sexual contacts and ask who (if anyone) lives with the client because the named individuals will need to have immune globulin administered to hopefully prevent the spread of hepatitis A and a community epidemic. The nurse should also ask about the client’s place of employment because certain settings warrant special considerations. For example, in restaurants, hospitals, daycare centers, or other institutions, the lack of careful hand-washing by an infected worker can result in contamination of many others. Hepatitis A can be spread through food contaminated by an infected food-handler, contaminated produce, or contaminated water. However, this mode of transmission is not very common in the United States.

3. In which of the following cases would the school nurse be correct to advise the parents of an HIV-infected child to keep the child

home from school? (Select all that apply.) a. The child develops allergies with sneezing. b. The child is unable to control body secretions. c. The nurse is not comfortable with being responsible for the child. d. There is an outbreak of chickenpox in the school. e. The child persists in biting behavior.

ANS: B, D, E

Not attending school may be advisable if cases of childhood infections, such as chickenpox or measles, occur in the school, because the immunosuppressed child is at greater risk for suffering complications. Alternative arrangements, such as homebound instruction, might be instituted if a child is unable to control body secretions or displays biting behavior. HIV-positive children are encouraged to obtain routine immunizations, because their immune systems are compromised and they are more susceptible to such infections. To date, no cases of HIV infections being transmitted in a school setting have occurred in the United States. Thus, the nurse should not be fearful of providing care to this child.

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Chapter 13: Community Assessment and Evaluation Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following is the best brief definition of community? a. A geographic area or political division under common leadership b. A group sharing a common bond such as a profession or occupation c. A group working together to confront a common problem d. A social group with common goals within a geographic area ANS: D

According to WHO, a community is “A group of people, often living in a defined geographical area, who may share a common culture, values and norms, and are arranged in a social structure according to relationships which the community has developed over a period of time. Members of a community gain their personal and social identity by sharing common beliefs, values and norms which have been developed by the community in the past and may be modified in the future.” The correct answer includes aspects of people, place, and function or aims. In addition to sharing geographic boundaries and leadership, a community also has common values and interests. In addition to sharing a common bond, members within a community have to interact with one another. A group working together to confront a common problem only addresses the aspect of function; it does not address people or place.

2. A nurse is practicing in the community but also has the community as the target of practice. Which of the following best describes

the activities of this nurse? a. Providing care to an active caseload of 50 families in the neighborhood b. Inviting all the parents of asthmatic children in the school to meet together for mutual support c. Sharing assessment findings and health goals with every community group that will listen d. Writing articles for the local newspaper highlighting the various programs and services of the local health department ANS: C

Meeting with all interested community groups is the only way to keep the focus on the community rather than on individuals.

Although it is not possible to know the nurse’s goals from the nurse’s behavior, giving care to select groups does not represent the whole community. Publicizing services increases knowledge but doesn’t necessarily help eligible clients access care.

3. Persons often point out that smokers choose to light their cigarettes; alcoholics lift the glass to their mouth, and drug addicts inject

or ingest their drugs. Which of the following statements best describes why nurses don’t simply focus on helping persons who engage in poor health behaviors to behave appropriately? a. Addicts don’t have the willpower to change their behavior. b. It is too rewarding to continue the behavior for a person to be able to change. c. Laws and policies must reward good healthy behaviors and punish unhealthy behaviors to help individuals recognize the importance of change. d. Society must offer healthy choices, offer support, and practice helpful policies.

ANS: D

Change for the benefit of the community client often must occur at several levels, ranging from the individual to society as a whole.

Lifestyle-induced health problems cannot be solved simply by asking or encouraging individuals to choose health-promoting habits. Society also must provide healthy choices. Most individuals cannot change their habits alone; they require the support of family members, friends, community health care systems, and relevant social policies. Change in society is helpful for addicts to change their behavior. Many times, certain aspects of society limit an individual’s ability to make change on their own. Laws and policies within society must support individuals to make healthy lifestyle choices.

4. A nurse is focusing on the process dimension of a community’s health. Which of the following interventions will the nurse most

likely implement? a. Assessing the health care services available in a community b. Establishing screening programs to diagnose diseases as early as possible so that the treatment can begin c. Implementing health promotion activities such as education programs d. Planning for new programs to be developed based on identified needs ANS: C

When the emphasis is on the process dimension—usually the level of intervention of the nurse in community health—the best strategy is usually health promotion, such as various primary prevention strategies. The other responses represent the structure dimension of the community. Structure is defined as the services and resources within the community. This includes service use patterns, treatment data from various health agencies, and provider-to-client ratios.

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5. A nurse has invited community members to participate as full partners in creating changes to improve the health of the community.

Which of the following may be an unexpected consequence of this action? a. A change in the distribution or redistribution of power and influence b. An increase in awareness of the importance of health c. Continued ongoing interest in community health activities d. Improved family functioning and involvement in health activities ANS: A

Collaborative practice models involving the community and nurses in joint decision-making and specific nursing roles are required.

Nurses must remember that collaboration means shared roles and a cooperative effort in which participants want to work together.

These participants must see themselves as part of a group effort and share in the process, beginning with planning and including decision-making. This means sharing not only the power but also the responsibility for the outcomes of the intervention. By having the community members involved in creating the health change, it is likely they will have an increased awareness of the importance of health, an ongoing interest in the health of the community. These things should occur because the community is more educated about its health because of its involvement. Being involved will not necessarily result in improved family functioning, so this consequence will most likely not occur.

6. During the assessment phase, the nurse compiles and interprets available data and draws conclusions as to the community’s

strengths and concerns. Which of the following best describes why the nurse would also conduct interviews with key informants? a. To ensure that others agree with the nurse’s plans for interventions b. To confirm the nurse’s initial findings and conclusions c. To encourage community partners to feel they “own” the data d. To generate non-statistical data such as values, beliefs, and perceived needs ANS: D

Data generation is the process of developing data that do not already exist, through interaction with community members, individuals, families, or groups. Such information might include the community’s knowledge and beliefs, values and sentiments, and goals and perceived needs. Such data are collected by interviews and observation. Interviews with key informants provide data; the purpose is not to ensure agreement with the nurse’s plan or confirm findings. The key informants are formal or informal leaders within the community, and although they may have information to share about the community, it may not be important that they feel that they “own” the data.

7. A nurse just accepted a position in community health and has been assigned to a neighborhood very close to where she lives.

Which of the following best describes the rationale for this assignment? a. To allow participant observation by the nurse b. To ensure that the nurse would care about her intervention outcomes c. To maximize convenience and minimize commuting time for the nurse d. To save gasoline in these difficult economic times ANS: A

Such an assignment allows for participant observation or the deliberate sharing in the life of a community. If the nurse lives in the community, activities such as participating in clinical organizations and church life and reading the newspaper give the nurse “observations” of the community’s life. The nurse should care about the interventions that are performed regardless of where the nurse lives. The priority is that the nurse is knowledgeable of and can observe the community, the assignment does not have to do with the convenience of the nurse.

8. A community health nurse drives through an assigned community before visiting the community groups scheduled for the day. The

nurse then drives through the community again that evening before going home. Which of the following best describes the nurse’s reason for driving through the community twice in the same day? a. On the second trip, the nurse can carefully confirm the results of the first assessment. b. Repeating the experience ensures that the nurse absorbed all the relevant details. c. Driving through twice allows the nurse to see the community when many residents are at work or at school and then again when most are at home. d. When leaving in the evening, the nurse has more time to write down the results of the earlier assessment.

ANS: C

When doing a windshield survey as part of community assessment, the nurse should observe two times: one during the day when people are at work and children are at school and a second time in the evening after work is done and school is out. It is likely that different things are occurring in the community when the nurse drives through the community at different times. Therefore, it is likely that the nurse will learn more about the community by doing this and not necessarily confirm previous findings. If the nurse was interested in writing down the results of the findings, the nurse could use public transportation or ride in a car with another nurse driving for more efficient documentation of her findings; this would not necessarily occur by the nurse driving through the community in the evening.

9. Before beginning to survey the community to assess its health needs and strengths, the nurse reviews various documents, including

local statistical data and the minutes of the previous meeting of the health care agency. Which of the following best explains why the nurse would start with this activity? a. To avoid confronting the community until the nurse is thoroughly oriented b. To become familiar with previous goals and priorities of the agency c. To help get a better understanding of the assigned community d. To save time and effort and perhaps have new insights ANS: D

The nurse uses previously gathered data because it saves time and effort. Many sources of data are readily available and useful for secondary analysis. Being familiar with the community before the assessment is important; however, being thoroughly oriented is not necessary. The nurse should become familiar with the community, not the goals and priorities of the agency. It is helpful for the nurse to better understand the community, but the main reason is to save time and avoid duplication of data that may already exist.

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10. A new nurse is overwhelmed with the needs of the community. Which of the following should be the first priority of the nurse? a. A problem that affects the most disadvantaged residents in the community b. A problem that is very easy and inexpensive to address c. A problem that is of high concern to the community d. A problem in an area in which the nurse has a great deal of expertise ANS: C

Choice of priority must depend on the community’s awareness of the problem—and their motivation to improve it. Other bases for choosing include determining which individuals would be most affected, what benefits to the community would result, what might happen if the problem is not resolved, how much it might cost to address the problem, and how much support for or opposition to the problem seem likely based on community values and priorities. Rather than examining the issues from the perspective of the most disadvantaged residents, the nurse should look at the problem which affects most individuals in the community who may or may not be disadvantaged. The cost of the problem will need to be addressed, but if the problem is not a priority to the community, the agency may be wasting money addressing a problem that the community does not care to solve. If the nurse is unfamiliar with interventions to solve the problem, the nurse should collaborate with others to solve the problem. The priority should be the needs of the community, not the needs of the nurse.

11. Which of the following objectives is most appropriate for the development of a community-oriented nursing care plan? a. All monitored patients will receive abortive therapy for lethal dysrhythmias

within 3 minutes of dysrhythmia recognition. b. Of mothers receiving nutrition counseling, 80% will identify five sources of calcium by the end of class. c. 95% of children will be immunized by 1 year of age. d. There will be a 25% reduction in health disparities by 2015.

ANS: B

Objectives must be precise, behaviorally stated, and measurable. The response that describes mothers receiving nutrition counseling represents a specific, measureable behavior as an objective. Treatment in an acute care setting is not part of a community-oriented care plan. The objective that 95% of children will be immunized by 1 year does not precisely state which children (in a county? in the country?) and does not state which immunizations. (Some are not appropriate to give to children who are only 1-year-old.) A 25% reduction by 2015 is a goal, not an objective.

12. During which of the following activities is the nurse in community health acting as a partner in change? a. Administering vaccinations to preschoolers b. Analyzing community problems to determine the best interventions c. Establishing an elder-care center for older adults living with family members who

work d. Teaching anger management skills to a group of teens in a halfway house ANS: D

Content-focused roles often are considered change agent roles, whereas process roles are called change partner roles. Change partner roles include those of enabler-catalyst, teacher of problem-solving skills, and activist agent. Teaching anger management skills to a group of teens in a halfway house demonstrates the use of a change partner role of teacher of problem-solving skills.

Change agent roles stress gathering and analyzing facts and implementing programs. The nurse establishing an elder-care center is acting as a change agent. The nurses administering vaccinations and analyzing community problems are carrying out other nursing roles.

13. A nurse is assessing a community’s openness to change. Which of the following variables indicate that the community is ready? a. Commitment to current processes and policies b. High socioeconomic status in the community as a whole c. Long history of dependence on the community health agency and its staff d. Minimal level of social participation by community members ANS: B

The ability to change is often directly related to higher socioeconomic status; a perceived need for change; the presence of liberal, scientific, and democratic values; and a high level of social participation by community residents. Not all communities are open to change. Ability to change is often related to the extent to which a community focuses on traditional norms. The more traditional the community, the less likely it is to change. A community that is open to change is likely to be open to changing current processes rather than focusing on tradition. Communities that are open to change typically have a high level of social participation by its residents.

14. A nurse is working toward an objective to “increase to at least 90% the proportion of all pregnant women who receive first

trimester prenatal care.” During which of the following phases of the nursing process would determination of the objective occur? a. Assessment phase b. Planning phase c. Implementation phase d. Evaluation phase ANS: B

Evaluation begins in the planning phase, when goals and measurable objectives are established, and goal-attaining activities are identified. Assessment involves getting to know and understand the community as the client. Implementation involves the work and activities aimed at achieving the goals and objectives. Evaluation is the appraisal of the goals and objectives that hav e been created.

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15. A nurse is assessing the status of a community’s health. Which of the following will the nurse examine? a. Community awareness b. Health facilities c. Health care manpower d. Vital statistics ANS: D

The status of community health involving biological indicators is often measured by traditional morbidity and mortality rates, life-expectancy indices, and risk-factor profiles. Vital statistics are measures of community health status. Health care manpower (e.g., nurses, physicians) and health facilities (e.g., hospitals, clinics) are measures of community health structure. Community awareness is a measure of the process.

16. A nurse is assessing the structure of a community’s health. Which of the following data will the nurse examine? a. The community’s commitment to health b. Health-risk profiles of selected aggregates c. Statistics of morbidity and mortality in comparison with similar communities d. Treatment and service use patterns from local health agencies and care providers ANS: D

Community health, when viewed from the structure of the community, is usually defined in terms of community characteristics, as well as services and resources. Indicators used to measure community health services and resources include service use patterns, treatment data from various health agencies, and provider/client ratios. The community’s commitment to health is part of the process dimension of the community. Health risk profiles and vital statistics are part of the status dimension of the community.

MULTIPLE RESPONSE 1. A community health nurse encourages members of the community to partner and assist in creating health programs. Which of the

following best describes the rationale for this action? (Select all that apply.) a. Partnering results in increased effectiveness b. Involving community members results in contributions of time and money into the program c. Having many partners results in increased publicity for the program d. Participating in planning results in having a vested interest in the outcome e. Involving community partners ensures increased support by the populace ANS: A, D

The primary reason community partnership is crucial is that community members and professionals who are active participants in a collaborative decision-making process have a vested interest in the success of efforts to improve the health of their community. The significance and effectiveness of partnership in improving community health are supported by a growing body of literature.

Community partners do contribute time and money into programs and most likely will increase the publicity for the program; however, this should not be the primary reason for including them in the partnership. Increased populace support is not necessarily assured by community partnerships. Through the partnership, it is likely that the program will have increased success and better outcomes, which should be the primary objective of the nurse.

2. A community health nurse is beginning to work with a newly assigned community. Which of the following would be appropriate

actions for the nurse to take to help ensure acceptance? (Select all that apply.) a. Asking those with whom the nurse interacts in the course of daily living their perception of the community (e.g., clerks in grocery stores or pharmacies) b. Attending community events such as festivals or fairs and interacting with participants c. Becoming involved in and contributing to volunteer community organizations d. Completing a comprehensive physical assessment on nearby neighbors e. Arranging to meet with the community’s governing body ANS: A, B, E

Gaining entry or acceptance into the community is perhaps the biggest challenge in assessment. The nurse is usually an outsider and often represents an established health care system that is neither known nor trusted by community members, who may therefore react with indifference or even active hostility. Entry into the community is critical. Often the nurse can gain entry by taking part in community events, visiting people in formal leadership positions, and clarifying community members’ perceptions of health needs.

While an activity such as volunteering is a positive action, it is not the most efficient way to become involved in the wider community. Completing physical assessments on individuals is an individual-based, not community-based intervention and would not be anticipated to be performed by the community health nurse.

3. A nurse is deciding which alternative interventions should be implemented. Which of the following factors must be considered by

the nurse when making this decision? (Select all that apply.) a. The expected effect or outcome of each possible intervention b. How interested others are in helping in any particular intervention c. The nurse’s own interest in implementing each intervention d. The likelihood that the intervention will resolve the problem e. Change process required to achieve stated objective ANS: A, B, D, E

The nurse can list each possible intervention and then consider the resources or barriers to that particular interventio n, the expected effect of each choice, the likelihood that the activity will help meet the objective and resolve the problem, whether others can be educated to implement the intervention, and the change process necessary to complete the objective. The primary interest should be the concern of the community, not the nurse’s personal interests.

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4. A nurse wants to determine whether health problems have been improved and interventions have been appropriate and successful

over a period of time. Which of the following data should the nurse examine? (Select all that apply.)

Changes in staffing patterns in the health agency Demographic data Education and school statistics Environmental factors Utilization of health services

a. b. c. d. e.

ANS: B, D, E

To see the outcomes of chosen interventions, the nurse would examine changes in demographics, socioeconomic factors, environmental factors, health status, and/or use of health services. Changing in staffing patterns and education and school statistics would not be impacted by a change in the health problems in the community. Epidemiologic data and trends would be the best sources to examine to evaluate the change.

5. Which of the following activities are considered to be part of the core competencies for public health professionals? (Select all that

apply.) a. Defining variables relevant to current public health problems b. Obtaining and interpreting information regarding risks and benefits to the community c. Implementing nursing care and subsequent evaluation outcomes d. Maintaining public health departments throughout the United States e. Focusing on health concerns of the individuals residing within the community ANS: A, B

Eleven core competencies for the nurse and other health providers working in the community have been defined by the Council on Linkages Between Academia and Public Health Practice. Defining variables relevant to current public health problems and obtaining and interpreting information regarding risks and benefits to the community are two of the eleven core competencies.

Implementing nursing care focuses on care for individuals and not the community; it is not one of the core competencies. Public health nurses have various roles within the community, they may or may not work for a public health department. It is not within the scope of public health nurses to be responsible to maintain these departments.

6. A community health nurse has been recently hired to work in an unfamiliar community. Which of the following persons would be

the effective key informants for the nurse? (Select all that apply.) a. Community’s immigrant group activist b. Federal senators and representatives c. Health board members d. The town mayor e. Local Clergy ANS: A, D, E

Informant interviews, which consist of directed talks with selected members of a community about community members or groups and events, are basic to effective data collection. Talking to key informants is a critical part of the community assessment. Key informants are not always those who have a formal title or position. Key informants often have an informal role within the community. Examples of informal key informants would include a member of a minority group who is listened to by other members of the group, a church leader, and a parent who is active and vocal about the school health curriculum. Key informants should be formal or informal leaders within the community. Based on the information provided, it is not known if the federal senators, representatives, and health board members fulfill these roles within the community.

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Chapter 14: Health Education in the Community Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A member of a community weight-loss group has maintained a healthy weight for 2 years through healthy eating and daily

exercise. Which of the following steps of the affective domain is this participant demonstrating? a. Analysis b. Application c. Evaluation d. Knowledge ANS: C

Steps in the affective domain have the learner doing the following in this sequence: knowledge, comprehension, application, analysis, synthesis, and evaluation. During evaluation, the learner adopts behaviors consistent with the new values. In this example, the individual has adopted the behavior, and this has resulted in the ability to maintain the value of a healthy weight. Steps in the affective domain have the learner doing the following in this sequence: (1) knowledge: receives the information; (2) comprehension: responds to what is being taught; (3) application: values the information; (4) analysis: makes sense of the information; (5) synthesis: organizes the information; (6) evaluation. None of the other options are considered in the sequence.

2. A nurse just finished teaching breast self-examination to a large group of women at a professional conference. During the session,

the nurse distributed literature and used culturally appropriate visual aids. However, the session was not as effective as it could have been. Which of the following was the most important thing omitted by the nurse? a. Time for audience members to ask questions and clarify the information b. Explanation of why culturally appropriate images are more acceptable c. Opportunity for the women to practice what they learned d. Use of simple language instead of printed material ANS: C

The learner must have opportunities to practice the new skills being learned. Provide practice sessions during the program because many people may not have the time, facilities, motivation, and/or support to practice at home what they have learned. Because breast self-examination is a psychomotor skill, the emphasis should be placed on the learner having the ability to perform the skill after the conference. The most important aspect should be the time for practice in this situation, and not on the time for questions.

The nurse would not need to explain to the audience why culturally appropriate images are acceptable, rather these should have been incorporated into the session. Having printed materials is important so that the learner has a reference after leaving the conference.

3. A nurse is providing an educational program about testicular self-examination (TSE). Which of the following would be the best

learning objective for this program? a. Each participant will state why TSE is important and explain how to do it. b. Each participant will describe how to do TSE and discuss the dangers of testicular cancer. c. 90% of the men will correctly demonstrate testicular self-examination. d. 100% of the men will do a testicular examination correctly on a model.

ANS: C

If the goal is to learn TSE, the best goal is for the person to be able to do TSE correctly. Being able to state why it is important is a helpful first step, as is practice on a model, but to be sure the person can really do the procedure, you need to allow practice time and feedback until the person can demonstrate the procedure properly.

4. A nurse planned a presentation about the latest trends in disaster planning for the senior nursing students at the local college.

However, when the nurse began to share the information, the students were talking to one another and essentially ignoring the nurse. Which of the following actions should be taken by the nurse? a. Ask the students why they are being so rude. b. Explain why the information is crucial to their current clinical practice. c. Nothing; let the instructor of the course handle the problem. d. Tell a joke to get the students’ attention.

ANS: B

Before learning can take place, you need to gain the learner’s attention. One way to do this is by convincing the learner that the information about to be presented is important and beneficial to them personally. Asking the students why they are being so rude would not be a professional response by the nurse. The nurse should take responsibility for gaining the attention of the audience and not expect the instructor to do so. Gaining the students can best be accomplished by telling the students why it is important rather than telling a joke.

5. Which of the following statements by the client indicates the client is experiencing a learner-related barrier to new information

about type 2 diabetes management? a. “I know about diabetes; my sister has it.” b. “I Don’t like to read’ just tell me what I need to know.” c. “It won’t change my life; it’s type 2 diabetes.” d. “It can’t be that hard to learn; I don’t have to take shots.”

ANS: B

One of the most important learner-related barriers is low literacy. Nurses often deal with individuals and populations who are illiterate or who have low literacy levels. These individuals may be embarrassed to admit their reading deficit to health care providers, and educators and may try to appear to understand when they really do not. Denying the impact or the importance of learning about a new diagnosis is problematic but not considered a primary barrier.

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6. A nurse uses lecturing as the primary method of educating clients. Which part of the education process is missing? a. Evaluation b. Experience c. Participation d. Understanding ANS: C

Educators should include participation. Lack of participation is a barrier to learning. Merely sitting and listening to someone lecture are not as effective as discussion, even when the presentation is stimulating, interesting, and dynamic. Evaluation occurs at the end of the education; evaluation is not necessarily missing when an educator uses lecture as the primary method of education. The nurse may be able to include experiences as part of the lecture when educating clients. It may be difficult to assess understanding if lecture is the primary method of education; however, the nurse should be able to use nonverbal clues to assess understanding. Also, the use of lecture does not mean that understanding is missing from the process.

7. The nurse gives a very informative and engaging presentation and then gives everyone in the audience a handout that outlines the

presentation. Later, the nurse discovers that many of the handouts were thrown away before the audience left the building. Which of the following educational principles has the nurse forgotten? a. Audiences expect PowerPoint or video presentations, not lectures. b. Many Americans do not have a high reading level. c. People want photographs and images, not wordy outlines. d. The nurse gave them too much information too fast for them to want to cope with it all.

ANS: B

Most health information is printed at a tenth-grade reading level, which is too difficult for almost half of the adult readers in the United States. If people cannot read or understand the material, they discard it. Although visual images are certainly helpful, it does not explain why the handouts were discarded. Audience’s expectations of the use of PowerPoint or video presentations or receiving too much information too fast do not explain why the handouts were thrown away. If the nurse covered information too fast, it is likely that the participants may have been more inclined to keep the handout.

8. Which of the following statements regarding the Health Belief Model is accurate? a. Cues to action are an important component of the model. b. Multiple methods of education should be used when implementing this model. c. The first stage experienced in this model is the pre-contemplation stage. d. To successfully implement this model, ongoing maintenance of the behavior must

be considered.

ANS: A

The Health Belief Model includes six components that attempt to answer the question of what motivates an individual to do something. These components are perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. The Health Belief Model does not indicate the number of methods of education that should be used. The pre-contemplation stage is part of the Transtheoretical Model. Maintenance is part of the Precaution Adoption Process Model.

9. A nurse is planning an educational program about cardiovascular disease. Which of the following would be the optimal time for the

nurse to elicit feedback from program participants? a. At the beginning of the program b. At the program midpoint c. Immediately following program completion d. Throughout the program ANS: D

Not only should learners receive feedback but the educator should also elicit feedback from learners throughout the educational process. On the basis of the feedback that the educator receives from learners, the implementation and presentation of the educational program can be modified. Obtaining feedback only at one point in time during the program does not give the nurse enough feedback as to what is happening throughout the presentation. In order for the educator to modify the teaching process and better meet the learner’s needs, evaluation data should be obtained at multiple points in time.

10. When evaluating an educational program, the nurse discovers that only 25% of community members met the learning objectives.

Which of the following parts of the program should be improved? a. Educator b. Content c. Learners d. Objectives ANS: A

Ultimately, the educator is responsible for the success or failure of the educational process and the development of learner knowledge, skills, and abilities. If evaluation reveals that the learning objectives are not being met, the nurse must determine why the instruction is not effective. The educator is responsible for presenting the material creatively and meaningfully in new ways to increase learner retention and ability to apply the new knowledge. The educator determines how content can be tailored to the learner. The educator determines the objectives.

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11. A man says, “I just can’t get myself to leave the house and go for a 30-minute walk each day. I wish I could think of some way to

motivate myself.” Which of the following would be the best action for the nurse to take? a. Establish a written contract between him and his employer that states walking is required each day. b. Recognize the reasons why 30 minutes of walking each day is one of the best health promotion activities he can choose. c. Join a group that walks early each morning. d. Set up rewards, such as a nice snack after he gets back from walking.

ANS: C

Health behavior is influenced by the groups to which people belong. Having someone else to walk with is an effective way to maintain the behavior. Group support often helps people make needed changes for health that they are unable to accomplish on their own or with the help of just one individual. The role of the employer is not to dictate employee health behaviors, so having a written contract would be inappropriate. The man may already recognize that walking is one of the best health promotion activities he can choose; however, he has expressed that he is lacking motivation. Setting up rewards for himself may be helpful; however, it may not be enough to get him motivated to take action. Group support may help him to get motivated.

12. A nurse is meeting to discuss problems and solutions with a group of teenagers who have been newly diagnosed with diabetes. One

teenager states, “My mom found this particular brand of popcorn that has only 15 carbohydrates in the whole giant bag.” Which of the following best describes the group purpose that is being served by the teenager’s statement? a. Maintenance function of encouraging everyone to continue the discussion b. Maintenance function of helping everyone feel comfortable talking about food c. Task function of resolving problems about what to nibble during movies d. Task function of sharing information and resources ANS: D

A task function is anything a member does that deliberately contributes to the group’s purpose. Members with task-directed abilities are attractive to the group. These traits include strong problem-solving skills, access to material resources, and skills in directing. The teenager’s statement shared information about a good resource for the group. Maintenance functions help members affirm, accept, and support one another, resolve conflicts, and create social and environmental comfort. The teenagers’ comment does not support a maintenance function of the group, rather it focuses on a task function by contributing to the group’s purpose.

13. A nurse invited all the teenagers who were newly diagnosed with diabetes to a group meeting to discuss issues they all had in

common. One teenager replied, “I don’t know if I want to share all the problems I’m having with strangers.” Which of the following is the best nurse response? a. “Don’t share anything with anyone until you’re comfortable doing so.” b. “I can understand what you are saying.” c. “No one will require you to do anything you don’t want to do.” d. “The purpose of the group is to have a safe place to share problems with others who may be having similar problems.”

ANS: D

During the first phase, potential participants do not know whether they can trust one another. The primary task of the leader at this point is to clarify the purpose. The response explaining that “the purpose is to have a safe place” both recognizes what was said and clarifies the purpose of the group. The statements of “Don’t share anything until you’re comfortable” and “No one will require you to do anything…” are supportive, but they do not recognize the phase of development of the group. The statement “I understand…” offers the client empathy but does not reinforce the purpose of the group.

14. The leader of an Alzheimer’s support group surveys the members of the group to determine the best time for the group to meet.

Which of the following norms is being supported through this action? a. Group norms b. Task norms c. Maintenance norms d. Reality norms ANS: C

Maintenance norms create group pressure to affirm members and maintain their comfort. Maintenance behaviors include identifying the social and psychological tensions of members and taking steps to support those members at high-stress times.

Maintenance norms often refer to things such as scheduling meetings at convenient times and in an accessible and comfortable space. Group norms set the standards for the group members’ behaviors, attitudes, and perceptions. Task norms are the commitment to return to the central goals of the group. Reality norms occur when members reinforce or challenge and correct their ideas of what is real.

15. A nurse established an ongoing group meeting of teenagers with diabetes. In the early stages, the nurse was very directive in

arranging location, providing low-carbohydrate drinks and snacks, steering the discussion, and trying to meet all the teenagers’ needs. After the group had been meeting for about 3 months, the nurse noticed that the group members no longer simply accepted everything the nurse suggested. Instead, the teenagers began making decisions themselves, and eventually, the nurse no longer controlled the group. Which of the following most likely happened to cause this shift? a. The group became cohesive enough to share leadership tasks. b. Teenagers don’t like feeling dependent on adults with power. c. Teenagers often rebel against adult authority. d. The nurse was overwhelmed and lost control of task process.

ANS: A

In the beginning, the nurse used an authoritarian style because the nurse was responsible for the group direction. After a group is well established, nurses may best facilitate leadership by relinquishing central control and encouraging group members themselves to determine the norms for their group. As the group matured, continuing an authoritarian style would have resulted in low morale and lack of cohesion, not necessarily a rebellion against adult authority. The group naturally progressed to leading its elf based on normal group development. This did not occur because of the teenagers’ attitudes, behaviors, or because of the feelings of the nurse.

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16. A group of teenagers with diabetes become upset and angry because they cannot agree on whether or not to have meetings during

summer vacation. Which of the following should the nurse do to be effective in helping the teenagers resolve the conflict? a. Admit that it is difficult for everyone to agree on everything; then ask whether the group can try to decide how to agree on the issue. b. Assume adult authority and announce that meetings will be suspended until fall. c. Recognize that most of the teenagers want to have the meetings, but two are being stubborn; ask the two deviant members to leave the group. d. Suggest that the group avoid discussing it further but rather think about it over the next week and try to discuss the situation more rationally next week.

ANS: A

Open communication and recognition that conflict is inevitable may allow the group to focus on a procedure for fairly resolving the conflict. If the nurse were to respond to conflict by avoiding (suggesting that they avoid further discussion), forcing with power (assuming adult authority), capitulating, or excluding some members (asking the deviant members to leave), the behavior would fail to satisfy the concerns of those involved.

MULTIPLE RESPONSE 1. The nurse is scheduled to teach carbohydrate counting to middle-aged adults newly diagnosed with diabetes. Which of the

following actions will the nurse need to take when teaching this population? (Select all that apply.)

Appeal to the need for autonomy and choice.

Emphasize that anyone with diabetes must know this information.

Explain how to cope with being a guest at a dinner.

Recognize that this audience will depend on the instructor to set goals for learning. e. Reinforce learning with handouts. a. b. c. d.

ANS: A, C

Because the nurse is working with middle-aged adults, the assumption can be made that they are members of Generation X. This generation tends to be self-directed, likes to work with teams, and may need to develop skills because they are not as likely to be as tech savvy. Members of this group can tolerate delayed gratification; they want clear information with practical value; and they are able to have fun and engage in games and activities when appropriate. Because of this, the best approach will be to use adult experiences and practical problems as learning motivators—for instance, appealing to adults’ sense of autonomy and choice, basing examples on practical adult situations such as cooking meals or eating in restaurants, and discussing how clients can cope with possibly awkward situations such as being a guest at dinner but having diet restrictions. This generation tends to be self-directed so they most likely will not depend on the instructor to set goals for learning or need the instructor to emphasize how important it is to know this information. Reinforcement with handouts are generally helpful. Members of this generation are likely to have the intrinsic motivation to accomplish these things on their own.

2. Which of the following characteristics must a learner possess to successfully master psychomotor learning? (Select all that apply.) a. The necessary ability to perform the skill b. An open mind to learn the new skill c. A sensory image of how to perform the skill d. Opportunities to practice the skill e. Desire to learn the skill ANS: A, C, D

Psychomotor learning is dependent on the learners meeting the following three conditions: having the necessary ability including both cognitive and psychomotor abilities, having a sensory image of how to carry out the skill, having opportunities to practice the new skill. Having an open mind to learn a new skill and wanting to learn the skill are important. However, it is not necessary in order to master psychomotor learning.

3. Which of the following strategies should be used when providing educational programs for children? (Select all that apply.) a. Emphasize how to build learning from previous experiences. b. Use simple words to enhance understanding. c. Use objects to help increase their attention. d. Emphasize the importance of the long-term consequences. e. Use concrete examples to reinforce learning ANS: B, C, E

When providing educational programs for children, the nurse should use more concrete examples and word choices; use objects or devices to increase attention; incorporate repetitive behaviors into games to help with knowledge retention and acquirin g new skills. When working with adults, emphasis should be placed on previous experience. This is not as important when working with children as they have had more limited experiences. Children are not concerned with long-term consequences, rather they focus on consequences and activities that will occur in the near future (short-term).

4. A client tells a nurse, “I know all about this already. I read about it on the Internet” and then begins to summarizes what he has

learned. Because some of this information seems incorrect, what questions would be effective for the nurse to ask? (Select all that apply.) a. Were you able to find what you wanted easily on the website? b. Did the website say when the information was updated? c. Did the website state who was responsible for the information? d. Did you enjoy reading the material on the website? e. Did the information sound correct to you?

ANS: A, B, C

To assess the quality of information, the nurse should attempt to find information about the authors, the purpose of the site (to share information or sell a product?), any available editorial reviews, the date of the material, the design of the site (easy to navigate? well organized?), etc. Assessing if the material was enjoyable to read or sounded correct does not help the nurse to assess the quality of information that was read by the client.

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Chapter 15: Case Management Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following best describes case management? a. A tool of health maintenance organizations b. Targeted toward a specific segment of the population c. Implemented with individual clients d. Used to monitor the health status, resources, and outcomes for an aggregate ANS: C

Case management, in contrast to the definition of care management, involves activities implemented with individual clients in the system. Managed care is a tool of health maintenance organizations. Care management is an enduring process in which a population manager establishes systems and monitors the health status, resources, and outcomes for an aggregate—a targeted segment of the population or a group.

2. Which of the following best describes why planning care for an individual is so challenging in today’s health care system? a. Because today’s clients have high expectations of the health care system b. Because multiple providers, payers, and settings have to be coordinated c. Because of the new high technology constantly being created and used for client

treatment d. Because so many different health care providers are in the acute care setting today ANS: B

Case management practice is complex because of the coordinating activities of multiple providers, payers, and settings throughout a client’s continuum of care. Planning care is so challenging because of the complexities of the system, not the high expectations of the population, new technology, or different providers. Coordination of all of these aspects of care, not just one of them, is what makes planning so difficult.

3. Which of the following best describes the primary problem that can result from health care today being given by many different

care providers? a. Clients are not sure which provider to see first. b. Health care providers have to make referrals to other providers. c. Clients sometimes are not sure who their primary provider is. d. Overuse, underuse, or gaps in care may result.

ANS: D

A particularly challenging problem is the fragmenting of services, which can result in overuse, underuse, gaps in care, and miscommunication. Clients who have a primary care provider typically know who that provider is and recognize that this is the provider that should be seen first. The referral system is not a primary problem with health care being given by various providers. It is the fragmentation of services that causes the problems within the system.

4. Which of the following public health nurse applicants is the least qualified for a position of case manager in a rural county? a. A 24-year-old who has a master’s degree in public health b. A 34-year-old who will be moving from a large city c. A 44-year-old who was born and raised in the community d. A 54-year-old who, until recently, was a member of the community’s school

board ANS: B

Case management competency requires the following knowledge and skills: knowledge of community resources and financing methods; written and oral communication and documentation skills; negotiation and conflict resolution skills; critical thinking processes to identify and prioritize problems from the provider and client views; and identification of best resources for the desired outcomes. Because communities are unique, someone new to the area will lack knowledge of community resources and financing methods. There is nothing in the descriptions of the other public health nurses that indicates a lack of current knowledge or skills.

5. Which of the following best explains why every client doesn’t receive care from a case manager? a. Case management time is demanding; thus it is restricted to complex cases. b. Many health agencies do not employ case managers. c. Most clients would not benefit from case management. d. Most nurses do not know how to function as case managers.

ANS: A

Case management can be labor intensive, time consuming, and costly. Because of the increasing number of clients with complex problems in nurses’ caseloads, the intensity and duration of activities required to support the case management function may soon exceed the demands that the direct caregiver can meet. Health agencies continue to employ more case managers as the cost spent for the care saves the agency money in the long term. Because case management is labor intensive and costly, it is unrealistic for all clients to have a case manager although additional clients could benefit from case management. Nurses fulfill the roles of advocate, care coordinator, and referral agent which are necessary to function as case managers.

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6. The nurse suggests use of telehealth to assess how a client is progressing. Which of the following resources must be available for

continuing care to be implemented? a. A primary care provider who is willing to use wireless prescriptions and plans of care b. Family permission for the nurse to make home visits c. Long-distance telephone service or a computer with Internet access d. Willingness of the caregiver to drive the client to the nearest clinic ANS: C

Telehealth is an organized health care delivery approach to triage and to provide advice, counseling, and referral for a client’s health problem using phones or computers with cameras. The client is usually in the home, and the nurse is at an office, health care facility, or phone bank location. Wireless prescriptions and plans of care are not necessary for a client who is receiving telehealth services. Home visits may not be necessary for a telehealth client. Through the use of telehealth, the need to visit clinics is decreased.

7. A nurse is using a case management plan to maximize patient care outcomes. Which of the following describes an important

consideration that should be made by the nurse? a. Case management plans should be used only by nurses to manage care. b. Case management plans should be individualized for each client. c. Case management plans provide additional expense to the client and family. d. Case management plans focus on the natural progression of the disease.

ANS: B

Adaptation of the case management care plan to each client’s characteristics is a crucial skill for standardizing the process and outcome of care. It links multiple provider interventions to client responses and offers reasonable predictions to clients about health outcomes. Institutions report that sharing case management plans with clients empowers the clients to assume responsibility for monitoring and adhering to the plan of care. Case management plans should link the care that is provided together and involve multiple providers. Case management is part of the standard of care that is provided and does not provide an additional expense to the client, although it may cause an additional expense to the agency. Disease management, not case management, focuses on the natural progression of the disease.

8. A client spends a great deal of time on the Internet or reading articles related to diabetes and its long-term effects. One day, the

client asks why the nurse has not suggested a life care plan. Which of the following would be the best response by the nurse? a. “Life care plans are only for young persons who are newly diagnosed.” b. “Life care plans are primarily used to determine long-term financial needs for legal reasons.” c. “You are receiving appropriate care for your diabetes without serious side effects, so a life care plan isn’t currently appropriate.” d. “I was waiting for you to express interest in having a life care plan.”

ANS: C

Life care plans are typically used for clients experiencing catastrophic illness or adverse events resulting from professional malpractice. Others who benefit from life care planning are those who have sustained injury when younger and whose care requirements have changed as a result of aging. Life care plans are typically used for clients experiencing catastrophic illness or adverse events resulting from professional malpractice, not young persons with a newly diagnosed illness. The life care plan is a customized, medical-based document that provides assessment of all present and future needs (i.e., medical, financial, psychological, vocational, spiritual, physical, and social), including services, equipment, supplies, and living arrangements for a client. These plans may be used by either a plaintiff or a defense lawyer to analyze damages. They are also used to set financial rewards, which can be used to pay for care in the future and create a lifetime care plan.

9. Which of the following Medicaid clients would most likely receive case management? a. An elderly person b. A person receiving rehabilitation following an injury c. A person who has a high-cost chronic disease d. A person with acute illness ANS: C

Some states, through their Medicaid programs, are developing disease management programs for high-cost chronic diseases among their populations, such as asthma and diabetes. An elderly person is most likely to receive Medicare services, not Medicaid services. Additionally, there is not any information that states that the elderly person has a high-cost chronic disease . A person who is receiving rehabilitation following an injury or who has an acute illness does not have a diagnosis that warrants case management, as case management is reserved for those with high-cost chronic diseases.

10. Which of the following best describes the goal or priority of the nurse advocate? a. To gain organizational and governmental support for the promotion of nursing

objectives b. To improve community service needs identified by research findings c. To integrate evidence-based practice guidelines in the provision of community

nursing service d. To promote the client’s rights and self-determination ANS: D

In today’s practice, the nurse advocate makes the client’s rights the priority. Thus, the goal of advocacy is to promote self-determination in a constituency or client group. Integrating evidence-based practice is part of the role of the nurse as a researcher. Gaining organizational and government support and improving community service needs identified by research are not roles of the nurse as an advocate. In the advocate role, the nurse promotes the self-determination of the group.

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11. A case manager advocates for a client by helping an insurer understand the client’s needs and desires and by helping the client

understand programs and benefits offered by the insurer. What role is the nurse? a. Arbitrator b. Systems allocator c. Mediator d. Negotiator ANS: D

Negotiating is a strategic process used to move conflicting parties toward an outcome. Parties must see the possibility of achieving an agreement and the costs of not achieving an agreement. As a systems allocator, the nurse distributes limited health care resources according to a plan or rationale. Mediating is the process of assisting parties to understand each other’s con cerns and to determine their conclusion of the issues. The mediator has no authority to decide, whereas an arbitrator is legally allowed to suggest an appropriate outcome.

12. A nurse reviews with the client what can be expected during the next 3 days, as well as how the client should expect to feel each of

those days. The client laughs and says, “You’ve got my care all mapped out.” Which of the following tools is the nurse using to determine what will happen when? a. Care planning b. Critical pathway c. Demand management d. Use management ANS: B

Critical paths are tools that name activities to be used in a timely sequence to achieve desired outcomes for care with measureable outcomes. Care planning involves developing a plan of care for an individual. Use management attempts to redirect care and monitors the appropriate use of provider care and treatment services. Demand management seeks to control use by providing clients with correct information to empower themselves to make healthy choices, to use healthy and health-seeking behaviors to improve their health status, and to make fewer demands on the health care system.

13. A nurse, client, family, and other care providers meet to discuss what will be the best approach to use to continue care. Which of

the following best describes why the nurse suggests changing the goal from obtaining appropriate long-term care placement to ensuring that the client’s recovery is beneficial and safe? a. To consider all possible consequences of long-term care placement b. To encourage the group to review the client outcomes in the different settings c. To expand the goal so that different solutions can be generated and considered d. To help the group focus on the critical aspects the client’s family considered most important ANS: C

One problem with seeking solutions is stating the problem in such a narrow fashion that only one possible outcome is acceptable. To avoid this, the nurse may restate the problem. By expanding the goal, different solutions can be generated. Clients and advocates may feel limited in their options if they generate solutions before completely analyzing the problems, needs, desires, and consequences. Changing the goal allows other possibilities, which may or may not include long-term care, to be considered. The client outcomes in different settings are not being addressed at this time. Examining the aspects that the family feels is most important can better be considered by broadening the goal.

14. The case manager explains to two disagreeing parties that coming to an agreement will save personnel costs for both of them.

Which of the following terms best describes this action? a. Assertiveness b. Collaboration c. Cooperation d. Compromising ANS: B

In collaborating, an individual attempts to work with others toward solutions that satisfy the needs of both parties. Assertiveness is the ability to present one’s own needs. Cooperation is the ability to understand and meet the needs of others. When compromising, an individual attempts to find a mutually acceptable solution that partially satisfies both parties.

15. A nurse is using the problem identification phase of the case management process. To which of the following phases of the nursing

process does this correspond? a. Assessment phase b. Diagnosis phase c. Planning phase d. Implementation phase ANS: B

The diagnosis phase of the nursing process is analogous to the identification of the problem in the case management process. It is during this phase that the case manager determines conclusions based on the assessment. During the assessment phase, the nurse develops networks with the target population and disseminates written materials. In the planning phase, the nurse validates and prioritizes problems with all participants. When working through the implementation phase, the nurse contacts providers and negotiates contracts and services.

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16. A nurse is completing a case management advocacy activity which corresponds to the implementation phase of the nursing process.

Which of the following activities would the nurse most likely use? a. Asking the client what is most important b. Seeking appropriate referrals for the client c. Assuring the client that his wishes will be supported d. Determining the order in which actions will occur ANS: C

Assuring the client is a component of the advocacy process that corresponds to the implementation phase. Asking the client what is most important is a way to illuminate values, which occurs in the assessment phase. Seeking appropriate referrals for the client occurs in the assessment phase. Determining the order in which actions will occur is a prioritization of action, which occurs in the planning phase.

17. A case manager implements a primary prevention activity. Which of the following actions would the nurse most likely complete? a. Advocating for the client whose values conflict with those of the medical service

provider b. Collaborating between nursing and occupational health personnel c. Educating a group regarding community services that are available if ever needed d. Resolving conflict between a primary care clinic and a tertiary health care facility ANS: C

Primary prevention involves the use of the information exchange process to increase the client’s understanding of how to use the health care system. Primary prevention occurs at a point before illness or problem exists. In the remaining options, the client has a problem for which interventions have been employed.

MULTIPLE RESPONSE 1. Which of the following are the primary goals of case management? (Select all that apply.) a. To ensure that care coordination occurs across the continuum b. To emphasize evidence-based clinical decision-making c. To manage resource use and control expenses d. To stress the advantages and benefits of community-based care e. To reduce institutional care as a means of achieving wellness ANS: A, B, C, E

The goals in case management are to reduce institutional care while maintaining quality processes and satisfactory outcomes; manage resource use through protocols, evidence-based decision-making, guideline use, and disease management programs; and control expenses by managing care processes and outcomes. Case management involves more aspects of care than only care that occurs in the community. Thus, stressing the advantages and benefits of community-based care is not part of the primary goals of case management.

2. A case manager is concerned about exposure to possible lawsuits. Which of the following are appropriate actions to take to

minimize this risk? (Select all that apply.) a. Assure clients they can appeal any decision. b. Carefully document client involvement and reasons for decisions. c. Share client information with the other involved providers and agencies. d. Confirm credentials and capabilities of providers or agencies to give care. e. Being mindful to maintain effective lines of communication with all clients.

ANS: A, B, D, E

Elements that reduce risk exposure include clear documentation of the extent of participation in decision-making and reasons for decisions; records demonstrating accurate and complete information on interactions and outcomes; use of reasonable care in selecting referral sources, which may include confirming credentials and capabilities of providers and agencies; maintaining good communication with clients; and informing clients of their rights of appeal. In compliance with the Health Insurance Portability and Accountability Act (HIPAA), no nurse is allowed to share information with others without written consent of the client.

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Chapter 16: Disaster Management Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following best defines a disaster? a. Any event that results in multiple deaths b. Devastation that cannot be relieved without assistance c. Devastation that covers a broad geographic area d. When the event results in multiple injuries and deaths as well as property damage ANS: B

A disaster is any human-made or natural event that causes disruption, destruction, or devastation that cannot be relieved without external assistance. A disaster does not need to involve injuries or deaths. The devastation may not cover a broad area, rather the main concept of the definition of a disaster is that it cannot be relieved without assistance.

2. Which of the following best describes countries that bear the greatest burden of disasters? a. Arid regions that are prone to drought b. Developing countries with limited resources c. Industrialized countries with much to lose d. Water-boundary regions that are prone to floods and hurricanes ANS: B

Disasters create the most devastation in developing countries. The people of low socioeconomic status suffer the most because their houses are less sturdy and have fewer resources and less means of social security. The climate and location of the country do not relate to its risk of bearing the burden of disasters. Industrialized countries have a higher socioeconomic status and can better address disasters if they occur.

3. What is the purpose of the National Response Framework? a. Create a new branch of government that deals with bioterrorism. b. Establish a way for the Red Cross to carry out its mission. c. Define roles, responsibilities, and relationships critical to effective emergency

preparedness. d. Extend presidential power to act quickly upon weapons of mass destruction.

ANS: C

The National Response Framework, a successor to the National Response Plan, “helps define the roles, responsibilities, and relationships critical to effective emergency planning, preparedness, and response to any emergency or disaster.” The NRF serves as a guide for conducting a nationwide all-hazards response that is flexible and adaptable and that links all levels of the government with nongovernmental organizations and the private sector. The US Department of Homeland Security was developed in 2002 to develop and coordinate the implementation of a comprehensive national strategy to secure the United States from terrorist threats or attacks. Eventually, the NRF was developed within this department. The National Response Framework helps to provide a linkage for the Red Cross to other organizations but does not assist with it carrying out its mission. The NRF does not change presidential power.

4. When does disaster management begin? a. Before the disaster occurs b. During the disaster c. Immediately following the disaster d. During the recovery period ANS: A

Disaster management includes the four stages of a disaster: prevention, preparedness, response, and recovery. The first stage of prevention (or mitigation) occurs before the disaster occurs. Disaster management that occurs during the disaster is called response.

Recovery occurs following the disaster. Nothing can be done as the actual disaster is occurring.

5. A nurse is focused on mitigation of disasters at the international level. Which of the following activities would the nurse most

likely complete? a. Provide community educational programs and training on how to prepare for disasters. b. Request donations be sent to the affected area. c. Develop a notification procedure to be used by the international disaster relief office. d. Recruit volunteers to be a part of the disaster team that will travel to the afflicted area.

ANS: A

Mitigation refers to actions to prevent specific disasters from occurring or to reduce the severity of a disaster’s effects if it cannot be avoided. To provide community educational programs on disaster preparedness is the only intervention that addresses mitigation. Requesting donations be sent to the affected area occurs during the disaster and is known as the response. Developing a notification procedure would occur as part of the preparedness stage. Depending on the timing of the recruitment, this would be part of either the preparedness or the response stage.

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6. Which of the following should family members have readily available to best cope with a disaster? a. Gloves, mask, and other personal protective equipment b. A copy of the nurse’s professional license c. A 5-day supply of water d. Where they will meet in case of an emergency ANS: D

Families are best protected by having the skills and knowledge to cope with a disaster, including details such as where families will reunite in the event of an emergency. The nurse should have his or her own copy of the professional license. It is recommended that a 3-day supply of water (1 gallon per person per day) be part of an emergency planning kit. Gloves, mask, and other personal protective equipment are recommended for the professional nurse to have available as an emergency supply.

7. A nurse is working with a community during the preparedness stage of disaster management. Which of the following events would

the nurse anticipate occurring? a. Heightened inspection and increased security in the community b. Incorporation of provision of pets into local disaster plans c. Purchase of personal protective equipment for all citizens d. Assembly of disaster kits for the home, workplace, and car ANS: D

Disaster kit assembly for the home, workplace, and car, especially by nurses, occurs during the preparedness phase. Heightened inspection and increased security is part of the mitigation phase. Individuals should make plans for the provision of their pets through their own personal disaster planning; this would not be part of the community disaster planning. It would not be appropriate or feasible for the nurse to purchase personal protective equipment for all citizens.

8. A community health nurse has invited several agencies in the community to a meeting to discuss the disaster plan for the

community. Which of the following best describes the purpose of this meeting? a. To increase stability in the community b. To improve overall community functioning c. To manage response to disasters in the community d. To enhance communication among agencies in the community ANS: C

The level of community preparedness for a disaster is only as good as the people and organizations in the community make it.

Although natural disasters cannot be prevented, much can be done to minimize further increases in accidents, death, and destruction after impact. A concise, realistic, and well-rehearsed disaster plan is essential for managing the response to disaster. Open, clear, and ongoing communication among involved workers and organizations is critical. A disaster planning meeting among community agencies would not impact the stability or functioning of the community. The communication among the agencies that are present may be improved; however, the group is meeting for a specific purpose so the overall communication may not change, and there may be agencies that are not represented at the meeting.

9. The local hospital, health department, and university together planned and implemented a mock casualty drill, with the university’s

theater and nursing students playing the injured victims. After the drill, which of the following would the nursing students most likely complete? a. Volunteer as leaders in the next casualty drill. b. Evaluate the drill and offer recommendations for more effectiveness in the future. c. Recognize how to respond to a real disaster in the future. d. Write a report on their actions and how they felt during the drill.

ANS: B

The nursing students should be prepared to offer a critique of the drill performance and suggest improvements for the next drill—or for an actual disaster. It would be unlikely that the students would be volunteers at the next drill as typically the ag encies involved with disaster management are the ones who are coordinating and leading these activities. It is unknown if the student will ever be in the same type of disaster as what they completed the drill for, so their involvement may not change their response in the future.

Writing a report and talking about feelings would not be helpful for the agencies to learn what they can do differently if an actual disaster was to occur.

10. Which of the following organizations would direct nurses’ response to a countywide disaster? a. American Red Cross b. Centers for Disease Control and Prevention c. Emergency Management Agency d. The local public health department ANS: C

The first level of disaster response occurs at the local level with the mobilization of responders such as the fire department, law enforcement, public health, and emergency services. If the disaster stretches local resources, the county or city emergency management agency (EMA) will coordinate activities through an emergency operations center (EOC). Generally, local responders within a county sign a regional or statewide mutual aid agreement to allow the sharing of needed personnel, equipment, services, and supplies. The American Red Cross may assist with disaster relief efforts, but this would not be the agency that would direct the response by nurses. The Centers for Disease Control and Prevention is a national agency and would most likely not be involved with a county-wide disaster. The local public health department may be involved in responding to the disaster, but this would not be the organization that is responsible for leading the response.

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11. A nurse is attempting to minimize damage following a bioterrorism attack in the community. Which of the following would be the

most crucial aspect for the nurse to consider? a. Detecting an increase in people with similar signs and symptoms b. Identifying typical chemical or biological agents c. Identifying factors that put people at risk d. Recognizing areas of vulnerability within an area ANS: A

An unannounced dissemination of a biological agent may easily go unnoticed, and the victims may have left the area of exposure long before the act of terrorism is recognized. Therefore, the first and most important aspect is recognizing that an outbreak has occurred by noting the increase in people presenting with similar signs and symptoms. After the similar signs and symptoms have been detected, the next step is striving to identify the biological or chemical agent. Then the nurse will identify factors that place people at risk, implement measures to control the outbreak, and finally, inform the medical and public communities about treatments, health consequences, and preventive measures.

12. Which of the following older adults is most in need of psychological support? a. The older adult who keeps asking if loans will be available for him to rebuild b. The older adult who keeps asking if he can go back home yet c. The older adult who keeps lamenting the loss of his family photos d. The older adult who keeps talking about how expensive his home theater was and

how he will never be able to afford to replace it ANS: C

Older adults react deeply to the loss of personal possessions because of the high sentimental value attached to the items. Family photos are a part of family history and are not replaceable. This type of a loss warrants psychological support. Homes and electronic equipment can be replaced, so the older adult may be able to eventually access loans to rebuild his home and replace his equipment. Because these things are replaceable, it is likely that the older adult will be able to better cope with thes e losses than with something that is irreplaceable. Depending on the loss of the older adult, he or she may have a need for relocation rather than returning home.

13. A community is experiencing the honeymoon phase following a disaster. Which of the following is most likely to occur in the

community? a. First responders work tirelessly to save others. b. Survivors share their stories. c. Medical personnel experience exhaustion. d. Community organizations rebuild the community.

ANS: B

During the honeymoon phase, survivors rejoice for their survival and may share their experiences and stories. First responders work tirelessly to save others during the heroic phase. Medical personnel experience exhaustion during the disillusionment phase.

The community begins to rebuild during the reconstruction phase.

14. A nurse was the first on the scene of a disaster and saw people with injuries ranging from minor to serious. Some of those with

minor injuries were helping others. Which of the following injured persons would the nurse assist first? a. Those with life-threatening head and chest injuries b. Those who have life-threatening abdominal injuries c. Those who have serious injuries of limbs d. Those who are hurt but still mobile and functioning ANS: B

Triage is the process of separating casualties and allocating treatment on the basis of the victims’ potentials for survival. The nurse will determine how seriously hurt individuals are and who should get care first, with the first priority being those who have life-threatening injuries but will probably survive if treated quickly. Although the textbook does not address the issue, because of the limited resources in a disaster situation and the fact that only the nurse is currently available to give care, seri ously hurt individuals with head or chest injuries that have only a small chance of surviving are not treated. Those who do not have life-threatening injuries and are mobile and functioning are not given priority during the triage process.

15. A nurse is assessing persons arriving at a shelter following a disaster. Which of the following would be the first action the nurse

should take? a. Limit the amount of equipment and medications brought into the shelter. b. Determine if the person has a psychological condition requiring special attention. c. Assess if this type of facility is appropriate for the person. d. Provide medical care for persons as if they were in a hospital.

ANS: C

Any person who comes to a special needs shelter must be assessed by a nurse to determine whether this type of facility is appropriate. After it has been determined if the facility is appropriate for these people, the nurse can work with them as needed to limit equipment if there is limited space. Assessment of the physical concerns of the people, not the psychological conditions, should be the primary concern of the nurse. The nurse would not be providing medical care at the shelter, rather, the nurse would provide assessments and referrals, assist the client to meet health care needs, keep client records, ensure emergency communications, and provide a safe environment.

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16. A nurse learns about a huge disaster a few states away. Which of the following actions by the nurse would be most helpful in this

situation? a. Donating to any charity that is assisting the victims b. Driving over to the area and volunteering to assist c. Sending clothes and food to the area for distribution d. Training to become a Red Cross disaster volunteer ANS: D

Disaster workers must know what kinds of populations they are attempting to assist. Thus, formal training related to disaster management and response would be important for the nurse to complete. Without having formal training and having official sponsorship, volunteers may not be able to be used. Lack of information or inaccurate information regarding the scope of the disaster and its initial effects can contribute to the misuse of resources. Often too many volunteers who lack official sponsorship convene at the site of disaster and are disappointed when their help cannot be used. Similarly, well-meaning people may send clothes and food to disaster sites. The unneeded contributions of food and clothing add to the stress of coping with the disaster, particularly if refrigeration and storage are not available. Although contributing to an organization such as the American Red Cross is to be encouraged and commended, many fraudulent scam charities may pop up claiming to collect funds for the victims.

17. On the second day after a disaster, a male colleague tells the nurse he has a splitting headache. The nurse notes the colleague is

feeling irritable and having difficulty focusing. Which of the following actions should the nurse take in response to the complaint of headache? a. Explain that the headache and problems focusing are probably the result of worry, so he should concentrate on the work at hand and deal with emotions later. b. Explain that he is experiencing signs and symptoms of psychological stress and recommend that he take some time off for a break. c. Explain to the worker that this is a common problem when multitasking under pressure and suggest that he focus on one task at a time. d. Suspect dehydration and encourage the worker to drink more fluids.

ANS: B

Symptoms of early stress and burnout include minor tremors, nausea, inability to concentrate, difficulty thinking, and problems with memory. Suppressing feelings of guilt, powerlessness, anger, and other signs of stress eventually will lead to symptoms such as irritability, fatigue, headaches, and distortions of bodily functions. It is normal to experience stress, but it must be addressed. The worst thing anyone can do is to deny that it exists. The American Red Cross recommends that the worker get enough sleep and take time away from the disaster (i.e., take breaks). The colleague should deal with his emotions now and not put them off to deal with later. The symptoms that are described relate to early stress and burnout, thus, multitasking or drinking more water are probably not going to help relieve his symptoms.

18. A nurse, after working 2 weeks at the site of the largest natural disaster to hit the United States, returns home. Which of the

following behaviors would suggest the nurse needs professional assistance? a. The nurse becomes angry when family members quit listening to her ongoing stories about the disaster and the problems there. b. The nurse gives a presentation at the local college about the disaster and describes how health professionals were able to assist the victims who were injured. c. The nurse is moody and feels family demands are not really as important as the other members of her family think they are. d. The nurse is very exhausted and asks to have 3 personal days off from employment responsibilities.

ANS: A

The fact that the nurse needs to continue to ventilate about the disaster, even after the family has quit listening, would suggest a delayed stress reaction that is not resolving and therefore warrants professional intervention. The nurse presenting at a college about the disaster demonstrates that the nurse is able to engage in conversations about the disaster after it has occurr ed. It is understandable that the nurse would return exhausted and moody. Indeed, concerns of major importance to family members may seem trivial when compared with problems the disaster victims were confronting.

19. After experiencing a house fire, a 4-year-old child begins sucking his thumb and wetting his bed. Which of the following would be

the most appropriate action for the nurse to take? a. Explain to the child that it is important to be strong and not act like a baby. b. Explain to the family that this behavior is a normal reaction to disaster. c. Recommend admission for inpatient psychological counseling. d. Recommend behavior therapy as a means to overcome regression.

ANS: B

The effects on young children can be especially disruptive. They can resort to regressive behaviors such as sucking their thumbs, wetting their beds, crying, and clinging to parents. This regression is normal in response to the event. Regression is a normal response; thus, it is not necessary to recommend psychological counseling or behavior therapy. It would not be appropriate to explain to a 4-year old child that he or she should be “strong.”

20. Which of the following levels of prevention is being used by a nurse who is helping to develop a community-wide disaster

management plan? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. All prevention levels ANS: A

Primary prevention takes place before a condition occurs. Primary prevention occurs when one participates in developing a disaster management plan for the community. Secondary prevention occurs with at risk populations and is aimed at early diagnosis and treatment. Tertiary prevention occurs after a problem has already been detected or diagnosed. The development of a plan only addresses primary prevention, not the other levels described.

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MULTIPLE RESPONSE 1. Which of the following disasters would implement disaster medical assistance teams (DMATs)? (Select all that apply.) a. Disaster that covers a broad geographic area b. Disaster that is beyond the coping capabilities of the affected state c. Disaster that may result in substantial health and medical problems d. Disaster that may cause a large number of deaths e. Disaster that may cause a large number of injuries both physical and psychosocial ANS: B, C, D

A presidentially declared disaster is one that requires implementation of disaster medical assistance teams (DMATs) because the disaster exceeds the capabilities of the involved state(s) to provide a timely and effective response. Such a disaster has the potential to cause a substantial number of deaths or injuries; substantial health and medical problems; or significant damage to the economic and physical infrastructure. The disaster may not cover a broad geographic area. The criteria for the use of DMATs is that the disaster exceeds the capabilities of the involved state to provide a timely and effective response. This could occur in a small geographic area.

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Chapter 17: Public Health Surveillance and Outbreak Investigation Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse considered copying last month’s surveillance report and changing the date because the number of occurrences per month

had not noticeably changed. Which of the following best explains why the nurse should continue to spend time collecting and reporting data that is always nearly the same? a. Because such data are legally required b. Because it is still part of the nurse’s responsibilities, even if on minimal value c. To determine a local baseline rate and immediately notice any change d. To determine differences among communities in need for state assistance ANS: C

Disease surveillance generates knowledge of a disease or event outbreak patterns. Surveillance systems help nurses and other professionals monitor emerging infections and bioterrorist outbreaks. Surveillance provides a means for nurses to monitor disease trends to reduce morbidity and mortality and improve health. Disease surveillance is not part of a legal requirement. There are many useful purposes for surveillance including monitoring for emerging infections and disease trends. The purpose of the monthly surveillance report is not for comparison among communities, rather it is a description of what is happening within the local community.

2. A nurse attends a conference to learn more about public health surveillance. Why is it so important that the nurse be knowledgeable

about this topic? a. Because nurses are employed in public health agencies b. Because nurses are often the first to recognize and respond to a problem c. Because nurses are responsible for ensuring that action is taken when necessary d. Because nurses are typically the ones to interact with the public and the media ANS: B

Nurses are often in the forefront of responses to be made in the surveillance process whether working in a small rural agency or a large urban agency; within the health department, school, or urgent care center; or on the telephone performing triage services during a disaster. It is the nurse who sees the event first. Nurses may work in a variety of community agencies, including public health agencies. Nurses will collaborate with others to take action as necessary; it would not be the sole responsibilit y of the nurse.

A wide variety of public health professionals interact with the public and the media, not only nurses.

3. A rural public health nurse is spending time reviewing death certificates. Which of the following best explains the purpose of this

activity? a. To ensure that local causes of death are consistent with national causes of death b. To confirm that no local health problems are beginning c. To evaluate effectiveness of health promotion programs d. To obtain mortality data for the local area ANS: D

Mortality data are often the only source of health-related data available for small geographic areas. Vital statistics r eports, such as death certificates, are reviewed. Useful information also comes from administrative data such as discharge reports and billing records. It is not necessary that the local causes of death are consistent with national causes, rather it is important that the nurse be aware of the major causes of mortality in the community so that the needs of the community can be addressed. Mortality data can occasionally be used to evaluate the effectiveness of health promotion programs, but this would not be the primary purpose of reviewing death certificates. Other data can be used to detect the start of local health problems. Analyzing death certificates as the only means of examining local health problems would provide the nurse with data that is not current.

4. Which of the following types of surveillance systems is being used when case reports are routinely sent to local health departments

by health care providers and laboratories, where the data are then summarized and forwarded to those responsible for monitoring such reports? a. Active b. Passive c. Sentinel d. Special ANS: B

In the passive surveillance system, case reports are sent to local health departments by health care providers or labora tories. The case reports are summarized and forwarded to the state health department, national government, or organizations responsible for monitoring the problem, such as the CDC. In active surveillance, the health department nurse may begin a search for cases through contacts to determine the magnitude of the problem. Sentinel surveillance involves looking for trends. Special surveillance is developed when a particular type of data is sought.

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5. In which of the following situations would the nurse most likely use an active surveillance system? a. A newspaper wants to know the incidence of asthma in the community. b. A real-time ongoing communication channel is established to monitor a particular

symptom. c. Several children become ill with gastrointestinal (GI) upset at one local school. d. The nurse is asked to report the incidence of a specific nonreportable common

problem in the community.

ANS: C

In active surveillance, the nurse may begin a search for cases to determine the magnitude of the problem (how widespread it is). An example would be when several school children become ill after eating lunch in the cafeteria or at the local hot dog stand, in which case, active surveillance would be used to investigate the possibility of food poisoning. In the passive surveillance system, case reports are sent to local health departments by health care providers or laboratories. The case reports are summarized and forwarded to the state health department, national government, or organizations responsible for monitoring the problem, such as the CDC. Special surveillance is developed when a particular type of data is sought.

6. Several children were hospitalized for severe vomiting and diarrhea. Which of the following best explains why the nurse would

continue to pursue the cause of the illness even after the children have been discharged from the hospital? a. So that the children’s families know the public health department cared about them b. So that action could be taken to avoid any such future episodes c. Because the children’s parents need to know whom to sue for their medical expenses d. To confirm that the symptoms were due to an infectious disease ANS: B

The objectives of an investigation are to control and prevent disease or death by identifying factors that contribute to the occurrence and implementing measures to prevent occurrences. In this case, the nurse wanted to make sure children did not become ill again when it could be avoided. The further investigation of the illness is not to demonstrate caring on the part of the public health department, rather it assists with learning about what factors contributed to the occurrence. It is unlikely that the pa rents would sue for a hospitalization for severe vomiting and diarrhea. Also, there is no indication that there would be an individual or agency to sue for the symptoms that the child is experiencing. There is no indication as to what caused these symptoms, thus, the nurse would need to do further investigation to determine if they were related to infectious disease or some other contributing factor.

7. A child came to school coughing almost constantly. The next day, six other children in the same school room were coughing.

Which of the following types of outbreak would the nurse suspect? a. Common source b. Mixed c. Propagated d. Intermittent ANS: A

A common source outbreak refers to a group exposed to a common noxious influence, in this case, the ill child who was attending school. A mixed outbreak is a common source outbreak followed by secondary exposures related to person-to-person contact.

Intermittent source cases may be exposed over a period of days or weeks. A propagated outbreak does not have a common source but spreads gradually from person to person over more than a single incubation period.

8. A nurse noted that of 18 children in a daycare center room, 5 became ill. Which of the following best describes a host factor that

may be associated with this illness and who became ill? a. Some of the children were from very low socioeconomic families. b. Some of the children inhaled car exhaust while playing outside. c. The bacterial cause of the illness was easily removed by handwashing. d. The daycare center room was much warmer on three sides in comparison to the side with the floor to ceiling windows.

ANS: A

Factors that must be considered as causes of outbreak are categorized as agents, hosts, and environmental factors. Host factors may be age, sex, race, socioeconomic status, genetics, and lifestyle choices. The cause of the illness and exposure to pollutants are considered agent factors, and the difference in temperature in the room is an environmental factor.

9. In January, a nurse is listening to colleagues talk about the increase in depressed patients asking for help from their primary care

providers recently. The incidence of reports of depression was higher in the last month than in the previous 3 months. Based on this data, which of the following would be the next step for the nurse to take? a. No further action is necessary because depression is known to worsen during the shorter darker days of winter. b. No further action is necessary because this short-term increase may just be a statistical error or even just a mistaken impression by the involved nurses. c. Action should be taken because there must be some cause for this noted increase. d. Action should be taken because this increase may be the beginning of an epidemic and should be investigated.

ANS: A

Typically, any unusual increase in incidence should be investigated. But in the majority of cases, the increased incidence occurs naturally and/or is predictable when compared with the consistent patterns of previous outbreaks. Many illnesses are seasonal.

Seasonal affective disorder (depression) often worsens during the shorter periods of daylight in the winter. The nurse should recognize that depression can be seasonal and not attribute this problem to an error in the data that has been collected . Because this is being recognized as a seasonal problem, there is no need for the nurse to take action. However, the nurse should continue to monitor the data to make sure that this trend does not continue as the weather begins to warm and more hours of daylight occur.

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10. Which aspect of a biological agent is probably the most frightening to those exposed? a. Infectivity b. Invasiveness c. Pathogenicity d. Virulence ANS: D

Virulence refers to the proportion of people with clinical disease who become severely ill or die. It is assumed people could cope with illness but possible death is truly frightening for most. Infectivity refers to the capacity of an agent to enter a susceptible host and produce infection or disease. Invasiveness is the ability of an agent to get into a susceptible host. Pathogenicity measures the proportion of infected people who develop the disease.

MULTIPLE RESPONSE 1. Which of the following describes the purpose of surveillance systems today? (Select all that apply.) a. To obtain data used to fight for increased budgets from taxpayers b. To evaluate the effectiveness of public health programs c. To monitor the incidence of chronic diseases among the local population d. To note and help prevent occupational exposure and diseases e. To help formulate interventions to reduce the incidence of chronic diseases ANS: B, C, D, E

Although surveillance was initially devoted to monitoring and reducing the spread of infectious diseases, it is now used to monitor and reduce chronic diseases and injuries, as well as environmental and occupational exposures. With tight budgets, public health workers must know which programs should be developed and continued based on the most commonly occurring public health problems. Evaluation of the effectiveness of programs requires valid and reliable data. With limited budgets, surveillance systems are important. The taxpayer money should be used in the most effective and efficient ways possible. This involves monitoring the effectiveness of health programming, not asking for increased budgets from taxpayers.

2. A public health department becomes aware of an impending health problem before any problem is reported to the agency. Which of

the following has most likely occurred within the community? (Select all that apply.) a. Doctors are feeling rushed as they interact with each patient. b. Emergency departments are notably busier than usual. c. Nurses are calling in ill to the local hospital. d. Pharmacists are discussing the increase in medication purchases. e. Orders for diagnostic tests have increased over last year at this time.

ANS: B, D, E

Syndromic surveillance systems were developed to monitor illness syndromes or events, as seen in such indirect measures as increased numbers of medication purchases, trips to primary care facilities or emergency departments, orders for cultures or x-rays, and rising levels of school or work absenteeism. These may indicate that an epidemic is developing. Doctors feeling rushed and nurses calling in ill are not unusual events.

3. The outpatient health care data show a notable increase in asthma over the numbers treated the previous year. Which of the

following actions should the public health nurse take first? (Select all that apply.) a. Analyze educational health programs offered to the public last year. b. Congratulate the public health staff on the success of their asthma awareness program. c. Determine whether there are any other data sources that might confirm the apparent increase in asthma. d. Review data with the outpatient clinic staff such as confirming repeat visits versus newly diagnosed cases. e. Determine whether there are any other data sources that might dispute the apparent increase in asthma.

ANS: C, D, E

Before drawing any conclusions, further data should be sought, including confirmation of the current data and their meaning. Data can be inaccurate or collected differently than in the past. What might have led to an increase? Are there other valid sources that might have relevant data? Should surveillance specific to asthma be established? Confirming the data by comparing it to other sources would be the priority. After this has been completed, the next steps would be for the nurse to look at the health programming and community awareness education that has taken place. It would be premature to look at the programming if the initial data obtained is not accurate.

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Chapter 18: Program Management Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following best describes the steps in program management? a. Assess, plan, implement, evaluate b. Identify, initiate, implement c. Organize, operationalize, mobilize, subsidize d. Substantiate, negotiate, evaluate ANS: A

The program management process is similar to the nursing process. Program management consists of assessing, planning, implementing, and evaluating a program. The other steps mentioned in other options are not part of program management. The process of program management, such as the nursing process, consists of a rational decision-making system to help nurses determine the complete process of program development, implementation, and evaluation.

2. Which of the following best describes the ultimate goal of program planning? a. Avoid unanticipated conflicts in the program development phase. b. Provide adequate funding to meet the program’s resource requirements. c. Ensure that health care services are acceptable, equal, effective, and efficient. d. Prevent unnecessary duplication of services.

ANS: C

The comprehensive goal of program planning is to ensure that health care services are acceptable, equal, efficient, and effective.

The other options are aspects of program planning, but they address only limited concerns.

3. Which of the following best describes the purpose of strategic planning? a. To anticipate client needs now and in the future b. To match client needs, provider strengths, and agency resources c. To maximize effective use of agency resources d. To utilize provider strengths and competencies ANS: B

Strategic planning involves the successful matching of client needs, with specific provider strengths and competencies and agency resources. Everyone involved can anticipate what will be needed to implement the program, what will occur during implementation, and what the outcomes will be. Strategic planning addresses the client, agency, and provider. The other responses address only one of these factors not all three of them which all need to be considered during the strategic planning process.

4. Which would be an appropriate descriptor that meets all criteria for defining a client to be served by a program? a. All women ages 40 to 50 who have not had a menstrual period for three

consecutive months b. Immigrants residing in Central County for less than 5 years who have difficulty

understanding care instructions because of limited English proficiency Pregnant women who have received nutritional counseling but whose nutritional status did not improve d. Children ages 18 months to 5 years who have been treated for nutritional deficiencies at the Central County Clinic c.

ANS: B

The client should be defined by biological and psychosocial characteristics, by geographic location, and by the problems to be addressed. For example, in a community with a large number of preschool children who require immunizations to enter school, the client population may be described as all children between 4 and 6 years of age residing in Central County who have not had up-to-date immunizations. This example tells the reader who the client is, what the need is, how large the population is, and where they are located. In order to meet all criteria for defining a client that is to be served by the program, information about the biological and psychosocial characteristics, geographical location, and the problems addressed needs to be included. The incorrect responses do not contain all of this necessary information.

5. After completing a needs assessment, the nurse presents ideas at a community interest meeting that focuses on community needs.

Unfortunately, attendees show essentially no interest in being involved. Knowing that the health problem must be addressed, the nurse proceeds with implementation as planned. Which of the following is the most likely outcome of the program? a. Community members will become increasingly positive about the new program. b. Others will recognize the importance of the program and become involved. c. The public health agency will both publicize and expand the program. d. The program will fail because of the community’s lack of interest.

ANS: D

Perspectives on the program, or what people think about the need for a program, might differ among health providers, agency administrators, policymakers, and potential clients. These groups are considered the stakeholders in the program. Collecting data on the opinions and attitudes of all persons, whether directly or indirectly involved with the program, is necessary to determine if the program is feasible, if there is a need to redefine the problems, or if a new program should be developed or an existing program expanded or modified. If a new or changed program is to be successful, it must not only be available, but also be accessible and acceptable to the people who will use it. If community members do not accept the programming, it is unlikely that they will become increasingly positive about it or invite others to become involved. The public health agency could attempt to publicize and expand the program, but without the acceptance of the community, it will most likely fail.

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6. A nurse is assessing a community to determine the feasibility of implementing a new program on bike safety for youth in the

community. Which of the following aspects should the nurse investigate to make this determination? a. Whether the community, especially agency clients, desire a program b. Whether local politicians support the agency’s idea for a program c. Whether agency professionals think a program is needed d. Whether all involved support the need for such a program ANS: D

Feasibility means the program’s viability, practicality, achievability, or likelihood of success. Everyone involved must be supportive for a program to succeed. What people think about the need for a program, or program feasibility, might differ among health providers, agency administrators, policymakers, and potential clients. Thus, it is important to get all who are involved to support the program.

7. A community is examining which programs are needed within the community, the populations they will target, and how they will

be funded. Which of the following would be the least risky decision for the community to make? a. Choose whichever option is the least expensive of agency resources. b. Choose to do nothing. c. Choose whatever the agency administration prefers. d. Choose whatever the majority of clients prefer.

ANS: B

A “do nothing” decision is always the decision with the least risk to the provider. The need and demand for a program are determined by working with the client. This stage of planning creates options for solving the problem and considers several solutions. Each option for program solution is examined for its uncertainties (risks) and consequences.

8. A nurse checks health department records to compare the number of new teen clients presenting for birth control counseling and

management in the 2 months before and after an education intervention program to decrease teen pregnancy. Which of the following steps of the evaluation process is being completed by the nurse? a. Engage stakeholders b. Justify conclusions c. Gather credible evidence d. Focus on the evaluation design ANS: C

When the nurse gathers credible evidence, the following information is collected: indicators that will be used, sources of data, quality of the data, quantity of information to be gathered, and the logistics of the data gathering phase. Data gathered should provide credible evidence and should convey a well-rounded view of the program. Engaging stakeholders includes those who are involved in planning, funding, and implementing the program; those who are affected by the program; and the intended users of its services. When the nurse justifies conclusions, the conclusions of the evaluation should be validated by linking them to the evidence gathered and then appraising them against the values or standards set by the stakeholders. When focusing on the evaluation design, the nurse will describe the purpose for the evaluation, the users who will receive the report, how it will be used, the questions and methods to be used, and any necessary agreements.

9. A nurse is planning a program to teach cardiac health at the senior citizens’ center. Which of the following is an effectively written

objective for the program? a. By the end of the program, each participant will report walking at least 30 minutes a day at least 5 days each week. b. By the end of the program, each participant will voice a commitment to walk at least 30 minutes a day. c. By the end of the program, each participant will understand the need for physical exercise. d. Each participant will voice a commitment to engage in physical exercise each day.

ANS: A

Useful program objectives must include a statement of the specific behaviors desired, using an action verb that can be seen and measured. Only “will report walking 30 minutes a day at least 5 days each week” has a specific outcome action that can be seen and measured. Voicing a commitment is not an outcome action; it is only a verbal agreement. The verb understand is not an action verb that can be seen and measured.

10. The nurse contacts participants who completed an educational program on breast self-examinations to see whether they have any

questions and to determine whether they are doing breast self-examinations. Which of the following types of evaluation is being implemented by the nurse? a. Final evaluation b. Formative evaluation c. Goal evaluation d. Summative evaluation ANS: D

Summative evaluation assesses program outcomes after the program is completed. Formative evaluation occurs on an ongoing basis while the program exists. Goal evaluation and final evaluation are not types of formal evaluation that are addressed in the textbook.

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11. A nurse is completing a summative evaluation of a program designed to decrease obesity in school-age children. Which of the

following is the most important question for the nurse to ask? a. Are school-age children satisfied with the program? b. Can parents and guardians support the program requirements? c. Has obesity in school-age children decreased? d. What is the program cost compared with the program benefit?

ANS: C

Summative evaluation looks at the end result of the program. The major benefit of program evaluation is that it shows whether the program is meeting its purpose. It should answer the following questions: are the needs for which the program was designed being met? Are the problems it was designed to solve being solved? If the program does not achieve the purpose for which it is designed, important concerns of satisfaction and cost are irrelevant. So if the program purpose is to decrease obesity, the outcome of importance is a decrease in obesity. Formative evaluation serves the purpose of assessing if objectives are met or if planned activities are completed. This type of evaluation begins with an assessment of the need for a program and is ongoing as the program is implemented. The considerations of satisfaction, support, and cost are all issues that could be addressed in planning and ongoing assessment of the program.

12. Evaluation is under way for a statewide program to decrease teen injury and death associated with teens that drive while under the

influence of alcohol. Which of the following questions would best be used for the summative evaluation of the program? a. Are program participants continuing to attend the programs, and do their satisfaction scores indicate that they are pleased with the program? b. How do statistics for injuries and deaths associated with drunk driving compare for teens in the year following the program? c. How does the amount of alcohol intake by teens compare before and after participants enter into the program? d. What problems are identified as the program is implemented?

ANS: B

Summative evaluation is the evaluation to assess program outcomes or as a follow-up of the results of the program activities. The goal is addressed in the question about statistics. Two of the options are examples of questions used for formative evaluation (satisfaction and problems with program implementation). The goal was not to decrease drinking of alcohol but to decrease driving when drinking alcohol.

13. A committee concludes that a program’s objectives were met and that activities received positive ratings from the community; yet

the program will be discontinued because cost was triple the amount anticipated. Which of the following program evaluation measures created a problem? a. Adequacy b. Effectiveness c. Impact d. Sustainability ANS: D

The aspect of program evaluation is sustainability—enough resources (usually money) to continue the program. Other aspects of program evaluation include: adequacy—program addresses the extent of the need; effectiveness—ability to meet program objectives and the results of program efforts; impact—long-term changes in the client population.

14. Based on projected increases in the number of older US citizens, a planning committee wants to establish a day care program for

the community’s older adult population. During which stage is the need for this program being assessed? a. Inactive stage b. Interactive stage c. Preactive stage d. Reactive stage ANS: C

The preactive stage is one in which assessment is based on the projection of a future need. The stages that are not being described are: reactive—defining the problem based on past needs identified by the client or the agency; inactive—defining the problem based on the existing health status of the population to be served; and interactive—describing the problem using past and present data to project future population needs.

15. Which of the following methods would be the most interactive approach to assessing a community’s need? a. Define needs based on the current health status of the community. b. Examine past needs as identified by the agency as well as the community. c. Project future needs based on current trends. d. Use past and current data to project future needs.

ANS: D

The interactive approach to assessing the needs of the community includes describing the problem using past and present data to project future population needs. Projecting a future need describes the preactive stage. The reactive stage defines the problem based on past needs identified by the client or the agency. The inactive stage involves defining the problem based on the existing health status of the population to be served.

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16. A committee of health care professionals would like to establish a countywide program to improve Hispanic immigrant access to

culturally competent health care services. Which of the following persons would be most helpful as a key informant? a. Hospital administrator b. Hispanic community leader c. National expert on cultural competency d. Politician or county official ANS: B

Key informants are leaders in the community who are knowledgeable about community needs. In this scenario, the Hispanic leader most likely knows more about the needs of the Hispanic community than the others listed. The hospital administrator, national expert on cultural competency, and politician are most likely not as knowledgeable about this immigrant population as the Hispanic community leader.

17. A nurse is conducting an assessment to determine whether participants of an educational program felt the stated objectives were

met. Which of the following data sources would the nurse most likely use? a. Community forum b. Interview c. Focus group d. Attitude survey ANS: D

Attitude scales are probably used most often and are usually phrased in terms of whether a program met its objectives. The client satisfaction survey is an example of an attitude scale often used in the health care delivery system to evaluate the program objectives. Focus groups, community forums, and examination of community indicators are all time consuming and not as directed toward evacuating program goals.

18. A nurse is conducting program evaluation. Which of the following would be the first action the nurse would take? a. Choose the type of evaluation to be done. b. Determine who will be involved in the evaluation. c. Identify the goal and objectives for the evaluation. d. Obtain answers to specific questions related to the program being evaluated.

ANS: A

To do a program evaluation, first choose the type of evaluation you wish to do. After the type of evaluation to be done has been chosen, the nurse will identify the goal and objectives for evaluation, decide who will be involved in the evaluation, and finally, answer the questions related to the type of evaluation.

19. Which of the following programs demonstrates the use of tertiary prevention? a. Developing an in-school clinic that provides birth control counseling and

contraception b. Providing a diabetes management program for persons with diabetes mellitus c. Providing cardiovascular fitness evaluations at annual health fairs d. Setting up free blood pressure screenings at popular department stores and

supermarkets ANS: B

The aim of tertiary prevention programs is to reduce complications from disease. Persons with diabetes mellitus already have the disease, thus meaning that tertiary prevention would be implemented with this population. Developing an in-school clinic is a primary prevention (pregnancy has not occurred). Fitness evaluations at health fairs and blood pressure screenings are secondary prevention programs (screening identifies conditions early and determines incidence/prevalence).

MULTIPLE RESPONSE 1. Which of the following are elements of the MAPP (Mobilizing for Action Through Planning and Partnership) Program Planning

Model? (Select all that apply.) a. Generating shared visions and common values b. Assessing priorities in health problems c. Developing a framework for long-range planning d. Choosing health priorities e. Conducting a needs assessment related to community change ANS: A, C

The elements of MAPP include mobilizing community members and organizations, generating shared visions and common values; developing a framework for long-range planning; conducting needs assessments in four areas: community strengths, local public health system, community health status, and focus of change; and implementing the plan. Assessing priorities in health problems and choosing health priorities are part of other program planning models.

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Chapter 19: Healthcare Improvement in the Community Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following best describes one of the main problems in ensuring quality for health care in the United States? a. Consumers believe American health care is of high quality and the best in the

world. b. Every hospital and health care agency has its own approach to data collection and

documentation. c. Finances are the basis of clinical decisions, not quality of care. d. We all agree on what quality is but not on how best to measure it.

ANS: B

Very little is known about quality of care in this country because a variety of definitions of quality are used, and it is difficult to get comparable data from health care providers and agencies. All consumers, including private citizens, insurance companies, industry, and the federal government, are concerned about achieving the highest quality outcomes at the lowest possible cost. Consumers want more information about quality. Both consumers and providers have a vested interest in improving the quality of the health care system.

2. A wealthy factory owner says, “I don’t care about the poor. I just want the best care available for me and my family. Why should I

care if other people don’t get health care?” Which of the following would be the most appropriate response by the nurse? a. “If your employees are ill, who will do the work in your factory?” b. “You might catch a contagious disease from one of your employees.” c. “You have a moral obligation to help those less fortunate.” d. “Your personal insurance and tax costs will go up if your employees have to use community resources when they’re ill.”

ANS: D

Because the speaker’s primary concern is apparently money, an appropriate response must show that the factory owner will lose money if he doesn’t support the health of others in the community. Everyone—consumers, providers, and those who pay the health care bills—benefits if people stay healthy. The focus should be on the larger community and not only on the work needing to be done at the factory.

3. Which of the following information can be gathered by reviewing a community health report card? a. Utilization of health care services in the community b. Demographic information of the community c. Leading causes of morbidity in a community d. Frequency of malpractice claims within a community ANS: C

The term community health report card refers to different types of reports, community health profiles, needs assessments, scorecards, quality of life indicators, health status reports, and progress reports. Community health report cards can be a useful tool in efforts to help identify areas where change is needed, to set priorities for action, and to track changes in population health over time. The report card may be used for tracking leading causes of morbidity and mortality in a community and looking at trends over time to see if public health interventions have improved health care outcomes. Utilization of health care services, demographic information, and frequency of malpractice claims in the community is information that is not found on a community health report card.

4. What event led to the development of the National Health Quality Improvement Act? a. A very famous movie and television star died as a result of a medical error. b. The number of malpractice claims had increased. c. Media such as films highlighted the reality of current medical care. d. Publicity about a few unfortunate cases caused consumers to become concerned.

ANS: B

In response to a growing number of malpractice claims in the United States, the National Health Quality Improvement Act of 1986 was established, which encouraged consumers to become informed about their practitioner’s practice record and created a national clearinghouse of information on provider malpractice records. The media did not play a role in the creation of the National Health Quality Improvement Act. 5. What was the principal problem with early efforts at ensuring quality of care? a. No one knows how to measure quality care. b. Professionals resisted and sabotaged such efforts. c. Standards emphasized structure, not process. d. There were no standards as to what represented quality care.

ANS: C

Early efforts such as the National Health Quality Improvement Act of 1986 emphasized structure rather than process or outcome of care; hence, they did not really address the root issues of quality. Health care professionals are concerned with providing high quality care. Both standards and measures are in place to evaluate quality.

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6. An agency has not created a continuous quality improvement program. Which of the following actions should the agency take to

help ensure quality care within the institution? a. Ensure appropriate policies and procedures are followed. b. Employ highly recommended and credentialed professionals to give care. c. Use administrative action to ensure that quality care is given to clients. d. Write quality care plans for the most typical problems of clients.

ANS: A

Quality assurance/quality improvement (QA/QI) programs remain the enforcers of standards of care for many agencies that have not elected to engage in a program of CQI. These activities are called assurance activities because they make certain that those policies and procedures are followed so that appropriate quality services are delivered. Without proper policies in plac e, it may be difficult to ensure quality care is provided by the professionals employed by the agency. Administrative action is difficult without having policies in place to support such actions. Policies and procedures provide a broader scope of quality than a written care plan.

7. A home-care nurse is encouraging the administration of the agency to increase their quality assurance efforts. Which of the

following best describes a negative outcome from this activity? a. An agency deficiency may become visible. b. An individual may be found at fault and then become fearful of being involved. c. Some agency processes may be questioned. d. Employees at the agency will have to commit extra time to complete this process.

ANS: B

Quality assurance (QA) focuses on the care a client receives within the system and is concerned with the accountability of the provider. A major problem with quality assurance efforts, done by the quality assurance team, is that individuals may be found to be at fault and hence may be fearful of reporting problems or errors. Total quality management and continuous quality improvement are concepts that give direction for managing a system of care, whereas quality assurance focuses on the care a client receives within the system. Continuous quality improvement focuses on processes and possible deficiencies of the organization as a whole so that everyone is involved.

8. How does continuous quality improvement (CQI) differ from quality assurance? a. Quality assurance focuses on client care, whereas CQI focuses on system issues. b. Quality assurance focuses on system issues, whereas CQI focuses on individual

client care. c. Quality assurance measures care at one point in time, whereas CQI is an ongoing

issue. d. Quality assurance focuses on families, whereas CQI focuses on agency issues.

ANS: A

Total quality management and continuous quality improvement are concepts that give direction for managing a system of care, whereas quality assurance focuses on the care a client receives within the system. Total quality management and continuous quality improvement focus on system issues, and quality assurance focuses on individual client care. Quality assurance measures care at multiple points of time. Quality assurance focuses on care of the client, not families, and CQI focuses on management of the system of care.

9. Which of the following is accomplished through the use of traditional quality assurance? a. Implementation of new techniques to improve outcomes b. Implementation of appropriate interventions for diagnosed problems c. Implementation of change when measured performance does not meet standards d. Implementation of research findings to ensure appropriate clinical treatment ANS: C

Traditional approaches to quality assurance are to focus on assessing or measuring performance, to ensure that performance conforms to standards, and to take action to bring about change when care does not meet standards. CQI involves comprehensive data analysis to detect process failures. Thus, implementation of new techniques, interventions, and research findings would require ongoing evaluation of data which is accomplished through CQI, not QA. 10. What is the primary goal of total quality management? a. To confirm the high standards desired in patient care b. To discover and correct errors in task completion c. To focus on the client and teamwork d. To enable organizations to publicize their quality approach to patient care ANS: C

Total quality management is a management philosophy that includes a focus on client, continuous quality improvement, and teamwork. Under TQM, quality is defined as customer satisfaction. Quality assurance is the promise or guarantee that certain standards of excellence are being met for the client in the delivery of care. QI is defined as a structured approach to improving performance.

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11. An agency is beginning to implement a general approach for quality improvement. Which of the following activities would the

agency most likely implement? a. Customer satisfaction is assessed through the use of surveys provided to the client after each appointment. b. The health maintenance organization (HMO) provides incentives to personnel who complete in-house programs on customer service. c. The institution has received accreditation through The Joint Commission. d. The total quality improvement (TQI) team meets to examine how to make the registration process more efficient.

ANS: C

General approaches to quality improvement seek to protect the public by ensuring a level of competency among health care professionals. Examples are credentialing, licensure, accreditation, certification, charter, recognition, and academic degrees.

Customer satisfaction may play a role in achieving one of these general approaches for quality improvement but is not one of the major approaches. Making the registration process more efficient may assist in achieving one of these general approaches but is not one of the major approaches.

12. The pharmacist sent up the wrong medication for the patient. The nurse filled out an incident report when the error was discovered.

Which of the following best describes the likely outcome when the quality improvement team reviews the incident report?

The nurse will receive a commendation for recognition of the error.

The pharmacist will be disciplined.

The pharmacist will be reported to the state pharmacy board.

The CQI team will try to determine how the error occurred.

a. b. c. d.

ANS: D

In quality improvement, people are asked to help identify problems and seek ways to improve system performance. Providing additional recognition or discipline would not be appropriate steps within the quality improvement process. Ongoing quality improvement focuses on what led to the error occurring.

13. A home health care agency has major problems but does not want consumers to know about these problems while the agency

decides what should be done to improve them. Employees are not told to lie, but they are advised not to share information. Which of the following is the most likely outcome of this situation? a. As long as employees do not share what they know, the community will be uninformed. b. By law, comparative information will be available to the public via the Internet. c. Only a few informed persons will know about the problems. d. Secrecy will prevail unless the local newspaper does an investigative report.

ANS: B

In 2003, the Home Health Care Quality Initiative (HHQI) was developed by the USDHHS to provide consumers with data on the quality of home health services. Home Health Compare, posted on the Medicare website, is a home health report card available to consumers nationwide. Because the information is available to the public via the internet, the community will be able to view this data at their will.

14. The nurse admits uncertainty over how to address the needs of a group of clients. The long-term nurse in the area suggests that the

nurse review published evidence-based clinical guidelines. How can the nurse know these guidelines are reliable? a. Because the agency supports their use b. Because the guidelines have been published c. Because the long-term nurse trusts them d. Because they are based on research and expert opinion ANS: D

Evidence-based practice guidelines are protocols or statements of recommended practice developed by professional organizations and based on scientific clinical data and research as well as expert opinion from extensive clinical experience. Such guidelines help a clinician in decision-making. Scientific data is what makes these guidelines reliable, not the support of an agency, the fact that they were published, or that they are trusted by the nurse.

15. The quality improvement team reviews the records of clients on a monthly basis to determine whether protocols for pain

assessment were followed. Which of the following best describes this activity? a. Accreditation review b. Concurrent audit c. Retrospective audit d. Utilization review ANS: C

The retrospective audit, or outcome audit, evaluates quality of care through appraisal of the nursing process after the client’s discharge from the health care system. Accreditation is often linked to governmental regulations that encourage programs to participate in the accrediting process to be reimbursed for services. A concurrent audit is a process audit that evaluat es the quality of ongoing care by examining the nursing process. Utilization review is used to ensure that care is needed and that the cost is appropriate.

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16. The quality improvement team reviews the records of clients on a monthly basis to determine whether protocols for pain

assessment were followed. Which of the following best describes the major drawback to the team’s approach? a. The client is no longer under the agency’s care. b. It is difficult to compare documentation of care to standards of care. c. Records can be inaccurate or incomplete. d. Team members may disagree on whether the standards of care were met.

ANS: A

With this approach, problems are identified only after clients have been discharged. Although the hope is that better care will be given to future clients, nothing can be done about the clients who received less than optimal care. Using a retrospective audit, it is possible to compare documentation of care to appropriate standards which should be established prior to the review. Records should be complete as it is important for nurses to document the care that they are providing.

17. A nurse is invited to join the utilization review team to help the agency avoid giving unnecessary care. Which of the following

difficulties would the nurse most likely confront as client records are reviewed? a. Alternative care options rather than agency care are often encouraged. b. Not all clients fit the pattern and need more care than guidelines suggest. c. The nurse suggests the agency provide guidelines to professionals giving care. d. The agency is now accountable to its clients and their families.

ANS: B

The major disadvantage of utilization review is that not all clients fit the classic picture presented by the criteria u sed to determine approval or denial of care. Alternative care options are many times not considered as it is assumed that clients fit the criterion that has been established. Utilization review does not provide agency guidelines as to how to provide care. Utilization revie w focuses on avoiding providing unnecessary care not on accountability to clients and families.

18. The staff was informed that a Quality Improvement Organization (QIO) would be making an unannounced visit in a few hours.

Which of the following would the hospital nurse expect the QIO team to examine? a. Records of hospital admissions and scheduled procedures b. Nursing care plans of patients with unexpected problems (infections, falls) c. Discharge paperwork of patients discharged in the past 30 days d. Documentation of adherence to nursing standards of care ANS: A

QIOs are directed by the federal government to reduce hospital admissions for procedures that can be performed safely and effectively in an ambulatory surgical setting on an outpatient basis and to reduce inappropriate or unnecessary admissions or invasive procedures by specific practitioners or hospitals. Therefore, the QIO team would examine records to see whether the hospital admissions and all procedures performed were medically necessary. The QIO team would not evaluate nursing care plans, discharge paperwork, or adherence to nursing care standards as that is not the focus of this type of a team. Rather, their focus is on reducing hospital admissions.

19. Which of the components of the PDCA model and Donabedian’s framework is the most crucial? a. Standard b. Outcome c. Process d. Structure ANS: B

The PDCA model and Donabedian’s framework for evaluating health care programs, using the components of structure, process, and outcome, are useful in developing a quality assurance program. Outcome is the most important ingredient of a program, because it is the key to evaluation of providers and agencies by accrediting bodies, insurance companies, and Medicare and Medicaid through PROs, report cards, and other accrediting agencies. Standard, structure, and process are important parts of the PDCA model but are not as important as the outcomes.

20. Stakeholders developing a new community-oriented clinic plan want to include a quality assurance (QA) program. Which of the

following would be the first step in measuring the structure component? a. Criteria that will be used to measure quality b. Philosophy and objectives of the organization c. Requirements of accrediting agencies d. Standards the QA program wishes to achieve ANS: B

The philosophy and objectives of an agency define the structural standards of the agency. Identification of standards and criteria for quality assurance begins with writing the philosophy and objectives of the organization. Criteria to measure quality including requirements of accreditors and standards of the QA program are not part of the structural standards of a quality assurance program.

21. Which of the following best explains why evaluation of client outcomes resulting from nursing intervention is so difficult? a. Client records may not include appropriate data. b. Few tools exist to measure client outcomes. c. Many other factors can also affect client outcomes. d. Measuring client outcomes is extremely time consuming.

ANS: C

The major problem with outcome evaluation is determining which nursing care activities are primarily responsible for causing changes in client status. In nursing, many uncontrolled factors in the field, such as environment and family relationships, have an effect on client status. Appropriate data should be included in all documentation that is recorded by the nurse. Multiple tools exist to measure client outcomes. With appropriate processes in place, it is not time consuming to measure client outcomes.

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22. The management team of the Central County Community Health Agency wants to analyze the cost of homebound client services.

Which of the following records are most likely to provide useful data? a. Clinical records b. Financial records c. Morbidity and mortality records d. Provider service records ANS: D

The provider service records include information about the numbers of clinic clients seen daily, home visits made daily, transportation and mileage, the provider’s time spent with the client, and the amount and kinds of supplies used. The provider service record is completed on a daily basis by each provider and is summarized monthly and annually to indicate trends in health care activities and costs relative to personnel time, transportation, maintenance, and supplies. A clinical record is th e client health record. This would contain health information for a single client, would not generally include clinic costs, and would be an inefficient source because it identifies service to only one individual. Financial records include extraneous items for the clinic as a whole. Extracting specific data will not be as easy, because they will be from the provider service record. Morbidity and mortality records would not be suitable in this instance.

23. A nurse has identified a need to increase the quality assurance efforts within the home care agency. Which of the following has

most likely occurred? a. Increased number of client complaints and injuries b. Increased costs of providing care c. Reduced number of incident reports d. Reduced government reimbursement (Medicare and Medicaid) ANS: A

The types of problems that may lead to increased quality assurance efforts include client complaints, injury, or death, poor documentation of care, with subsequent denials of reimbursement by third-party payers, lack of or inefficient service, and concerns about client or staff safety. Several factors may influence increased costs of providing care, which may or may not lead to it being a priority of increased quality assurance efforts. An increase in incidence reports, not a decrease, would lead to increased quality assurance efforts. Reduced government reimbursement may lead the agency to consider multiple aspects of care, which may or may not relate a need for increased quality assurance efforts.

24. A nurse is implementing tertiary prevention strategies as part of the quality management process. Which of the following best

describes a strategy the nurse would have used? a. All new employees complete a program on fire safety that details what to do in the event of a fire. b. At the yearly employee picnic, teams compete in putting out trash can fires and in racing while carrying mock victims, using safe evacuation techniques. c. After evaluation of response to an actual fire, new procedures implemented in the fire response protocol are distributed to employees. d. Mock fire drills are carried out twice a year to assess response and readiness in the event of a real fire.

ANS: C

Tertiary prevention involves activities that are carried out when evaluation indicates needed improvement. Thus, examining a response to an actual fire (it has already occurred) is an example of tertiary prevention. A program on fire safety is an example of primary prevention. The employee picnic activity and mock fire drills provide for evaluation of competency (screening) and are thus secondary prevention.

MULTIPLE RESPONSE 1. In which of the following ways does licensing differ from accreditation? (Select all that apply.) a. Licensing applies to the individual, whereas accreditation applies to a program. b. Licensing is required to practice, whereas accreditation is by choice. c. Licensing is required by state law, whereas accreditation is required by federal

law. d. Licensing is required for all professions, whereas accreditation is only available for some. e. Licensing is a cost to the individual, whereas agencies pay for accreditation.

ANS: A, B, E

Licensure controls entrance into a profession or occupation and is mandatory to practice. Accreditation is a voluntary or at least a quasi-voluntary approach used by institutions or programs. Although there are cost differences between licensure and accreditation, individuals pay for licensure, whereas agencies pay for accreditation. Licensure is based on state law, whereas accreditation is dependent upon professional standards. Licensing relates to individual practice and professions, but accreditation relat es to agencies and not individual professions.

2. A nursing committee is responsible for evaluating the process of health care agency in their quality assurance efforts. Which of the

following techniques would most likely be used by the committee members? (Select all that apply.) a. Client satisfaction survey data b. Confirmation of credentials of all health care providers employed c. Patient discharge data over the past one year d. Direct observation by individuals e. Peer review committee audit ANS: A, E

The primary approaches used for process evaluation are the peer review committee and the client satisfaction survey. The techniques used for process evaluation are direct observation, questionnaire, interview, written audit, and videotape of client and provider encounters. Once data are collected to evaluate nursing process standards, the peer review committee reviews the data to identify strengths and weaknesses in the quality of care delivered. Confirming credentials and examining patient discharge data are not typically used for process evaluation.

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Chapter 20: Family Development, Family Nursing Assessment, and Genomics Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. The following people enter the health clinic together: an unmarried man and his 1-year-old son, an unmarried woman with a

year-old daughter, and the man’s married brother, who is separated from his wife. During the assessment, it is determined that both men work and contribute to the household, where all of them live. Which of the following best describes the “family?” a. The group consists of three families: the man and his son, the woman and her daughter, and the brother, who is married even though he and his wife are separated. b. There are two families involved: first, the unmarried man and woman and their two children, and second, the brother, who is married even though he and his wife are separated. c. There is no family here, only three adults sharing resources between themselves and two biologically related children. d. The family includes whoever the adults state are family members.

ANS: D

Nurses working with families should ask an adult member to identify all those considered to be family members and then include those members in health care planning. A “family” may range from the traditional nuclear model with extended family to such “postmodern” family structures as single-parent families, stepfamilies, same-gender families, and families consisting of friends.

The incorrect answers have the nurse determining who is and who is not part of a family. This is not an appropriate action for the nurse to take, rather the nurse should let the client describe and define his or her family.

2. The nurse in community health needs to conduct a family assessment within a commune but is uncertain how to proceed because

family lines appear blurred. The best way to determine the family of a mother and her child is to ask the woman which of the following questions? a. “How many children do you have, and who is the father of each?” b. “Is there a register of families who are members of this commune?” c. “Tell me about your significant other.” d. “Who are the members of your and your child’s family?”

ANS: D

The members of a family are self-defined. The family includes whoever the woman says are family members. The nurse should include all those members in health care planning. Asking who the father of each child is does not help define the family; the client needs to define the family. Knowing if there is or is not a register of families on the commune does not help the client define her own family. The client may or may not include the significant other in her definition of a family, so this may not assist in making this determination.

3. In taking a family history, the nurse in community health finds that this is the second marriage for the previously divorced parents

and that the male partner is the stepparent to the oldest child. For which of the following aspects of the family assessment is data being gathered? a. Dynamics b. Function c. Structure d. System ANS: C

Family structure refers to the organization of the family. This defines the roles and positions of the family members. The family functions refer to the activities and purposes of the family. The family as a system accomplishes activities that serve the individual and society. Family dynamics refers to the interactions and relationships within the family.

4. Which of the following statements best explains why family functions and structures create unique challenges in family nursing? a. Function and structure change over time. b. Function and structure do not apply to all family units. c. Some clients do not have families. d. Traditional families are rare in society.

ANS: A

The functions that families serve evolve and change over time. Some become more important and others less so. Family structures also change over time. The great speed with which changes in family structure, values, and relationships are occurring makes working with families at the beginning of the 21st century exciting and challenging. All family units have functions (activities and purposes) and structure (organization). These functions and structures may be very different among family members, but they do exist. All clients are part of a family, even if they define their family as only themselves. Nurses should be open-minded and recognize that all families are different and a “traditional” family structure may mean something different to different individuals.

5. A nurse is working with a family who is confronting major challenges to their health. Which of the following approaches would be

most helpful for the nurse to use? a. Allowing the family to be noncompliant b. Building on the family’s strengths and resilience c. Labeling the family as resistant d. Recognizing that the family is dysfunctional ANS: B

Families are neither all good nor all bad; families have both strengths and difficulties and have seeds of resilience. Recognizing the family’s strengths gives the nurse assets on which to draw in planning care. The labels of dysfunctional, noncompliant, resistant, or unmotivated all denote families who are not functioning well; however, such labels do not create an environment conducive for positive family change and intervention and should not be used.

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6. The nurse is told that a healthy, functional family consisting of a 25-year-old man and a 24-year-old woman, who are expecting

their first child, would appreciate a nurse coming to their apartment for anticipatory guidance in preparing themselves and their apartment for the baby. Based on that statement, which of the following assumptions can the nurse safely make about the family? a. The family is lacking a strong support system. b. The family’s basic needs are being met. c. The couple’s in-laws are unavailable to share their expertise about childcare. d. The married couple is excited about their first baby.

ANS: B

In functional, healthy, or resilient families, the basic survival needs are met. Healthy families exist based on attachment and affection. There is nothing in the example to suggest that they are married, that their income is low, or that they lack other resources or support systems.

7. A nurse focuses on the care of the individual while viewing the client’s family as a background resource or possible stressor.

Which of the following conceptualizations of family does this nurse’s view represent? a. Client b. Component of society c. Context d. System ANS: C

Family as the context, or structure, has a traditional focus that places the individual first and the family second. In the “family as context” concept, the family serves as either a resource or a stressor to individual health and illness. When family is the client, the family is placed first, and individuals are second. The family is seen as the sum of individual family members. When family is the system, the focus is on the family as the client, and the family is viewed as an interacting system in which the whole is more than the sum of its parts. When the family is seen as a component of society, it is seen as one of many institutions of society, along with health, education, religious, or financial institutions.

8. A nurse asks a family member, “What has changed between you and your spouse since your child’s head injury?” Which of the

following focuses of the family is the nurse assessing? a. The context b. The client c. A system d. A component of society ANS: C

When the focus is on the family as a system, the family is viewed as an interactional system in which the whole is more than the sum of its parts. The approach simultaneously focuses on individual members and the family as a whole at the same time. The interactions between family members are the target for nursing interventions. When family is the client, the family is placed first, and individuals are second. The family is seen as the sum of individual family members. When the family is seen as a component of society, it is seen as one of many institutions of society, along with health, education, religious, or financial institutions. When family is the context, the individual is placed first and the family second. In the “family as context” concept, the family serves as either a resource or a stressor to individual health and illness.

9. Which of the following theories views the family as a whole with boundaries that are affected by the environment? a. Family developmental b. Exosystems c. Bioecological systems d. Family systems ANS: D

The theory that views the family as a whole with boundaries that are affected by the environment is the family systems theory. In this theory, the emphasis is on the whole rather than on individuals. Families are viewed from both a subsystem and a suprasystem approach. The family developmental theory focuses on common tasks of family life and provides a longitudinal view of the family life cycle. The bioecological systems theory describes how environments and systems outside of the family influence the development of a child over time. The definition of exosystems is found within the bioecological systems theory; these are the external environments that have an indirect influence on the family.

10. A nurse organizes care for a family by focusing on the common tasks of family life and considering a longitudinal view of the

family life cycle. Which theory is being applied? a. Family systems b. Bioecological systems c. Family developmental d. Family nursing ANS: C

The family developmental theory focuses on common tasks of family life and provides a longitudinal view of the family life cycle.

In the family systems theory, families are considered social systems, composed of a set of organized, complex, interacting elements. The bioecological systems theory describes how environments and systems outside of the family influence the development of a child over time. Family nursing theory is an evolving synthesis of the scholarship from three different traditions: family social science, family therapy, and nursing.

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11. A new mother is a full-time college student who lives with her parents, because the baby’s father has been imprisoned related to

theft and drug abuse. The infant’s grandmother, although also employed, cares for the child while the young mother attends classes.

Which of the following theoretical frameworks would be most helpful to the nurse when assessing this family’s needs? a. Developmental b. Family nursing c. Bioecological d. Systems ANS: A

Developmental theory explains and predicts the changes that occur to humans or groups over time. Achievement of family developmental tasks helps individual members accomplish their tasks. In this case, the new mother has tasks, whereas her parents have temporarily interrupted their progress in response to their daughter’s (and grandchild’s) needs. In the family systems theory, families are considered social systems, composed of a set of organized, complex, interacting elements. The bioecological systems theory describes how environments and systems outside of the family influence the development of a child over time. Family nursing theory is an evolving synthesis of the scholarship from three different traditions: family social science, family therapy, and nursing.

12. A nurse considers how the environment outside of the family influences the development of a child when planning care for a

family. Which of the following theories is being used by the nurse? a. Bioecological systems theory b. Family systems approach c. Family developmental theory d. Family nursing theory ANS: A

The bioecological systems theory describes how environments and systems outside of the family influence the development of a child over time. In the family systems theory, families are considered social systems, composed of a set of organized, complex, interacting elements. The family developmental theory focuses on common tasks of family life and provides a longitudinal view of the family life cycle. Family nursing theory is an evolving synthesis of the scholarship from three different traditions: family social science, family therapy, and nursing.

13. A nurse is in the termination phase of the nurse-family relationship. Which of the following strategies would the nurse most likely

implement? a. Increasing sessions with the nurse b. Making referrals when appropriate c. Providing a formative evaluation of the relationship d. Refusing additional communication with the family ANS: B

Making referrals when appropriate is part of the termination phase as the nurse ends the relationship with the family. It also includes decreasing contact with the nurse, extending invitations to the family for follow-up, and a summative evaluation meeting for formal closure. If sessions with the nurse were to increase, it would be unlikely that the relationship was going to be soon terminated or ended. Formative evaluation occurs throughout the relationship and is ongoing; an evaluation that would be done at the closure of the relationship would be summative. It would be appropriate for the nurse to extend an invitation for follow-up, not refuse additional communication.

14. A nurse is making an appointment with a family for a nursing visit. Which of the following describes a potential barrier the nurse

may encounter? a. The assessment cannot be done unless the extended family is present. b. It may be difficult to find a convenient time for all family members to be present. c. Nurses have limited time to do home visits. d. Families are often scattered over a large area, making access difficult.

ANS: B

It is important to encourage all family members to attend the meeting. However, it can be difficult to find a convenient time for all family members to attend. Many times, late afternoon or evening appointments are necessary to accommodate the needs of the family. It is probably most important that the immediate, not necessarily the extended, family is present. If the nurse is making an appointment with a family, it would be part of the role of the nurse, and it would be within the scope of the nurse’s practice to make time to complete home visits. The nurse may need to be creative in how to best meet the needs of the family to arrange a meeting.

The larger barrier is finding a common time, not distance of the family member.

15. Which of the following factors must be considered before deciding on an appropriate plan of action? a. Family agrees to the nurse’s plan. b. Family is capable of the required actions. c. Family will learn better coping skills from the nurse’s plan. d. Nurse has informed family how to complete the required actions.

ANS: B

Family theorists stress that any intervention plan must be developed in collaboration with the family, using and enhancing family strengths and increasing independence of family members. The family must have the skills and commitment necessary and to complete the developed plan. The plan cannot be the nurse’s choice alone. Further, the plan must be within the information and skill level of the family, and the family must be committed to the plan and have adequate resources available to implement the plan.

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16. Which of the following terms refers to government actions that have a direct or indirect effect on families? a. Family funding b. Family legislation c. Family planning d. Family policy ANS: D

Government actions that have a direct or indirect effect on families are called family policy. The range of social policy decisions that affect families is vast, such as health care access and coverage, low-income housing, social security, welfare, food stamps, pension plans, affirmative action, and education. Family planning is only one example of family policy that can have a direct or indirect effect on families. Family funding may occur through programs administered by the government, but these programs are developed from family policy. Family policy is broader than only addressing legislative action.

17. A nurse is using the provisions of the Family Medical Leave legislation. Which of the following actions is the nurse most likely to

take? a. Resigning from employment, but retaining health insurance b. Sharing family information with colleagues c. Providing Medicaid to a family who cannot afford health insurance d. Taking a defined time off of work for family events without fear of job loss ANS: D

The Family Medical Leave legislation allows for a family member to take a defined amount of leave for family events, such as births and deaths, without fear of losing his or her job. The Health Insurance Portability and Accountability Act (HIPAA) allows for families to retain health insurance after resigning from employment. HIPAA prevents family information from being shared with colleagues unless they have a need to know based on the care they are providing for the family. The provision of Medicaid is not part of the Family Medical Leave legislation.

18. A nurse is conducting a family assessment. Which of the following behaviors would the nurse recognize as suggestive of a family

with problems?

Before eating, the family prayed, expressing gratitude for their blessings.

During family play, jokes and laughter were heard.

Each person had a private room with a door for alone time.

Most of the conversation was between the father and the eldest daughter.

a. b. c. d.

ANS: D

Limited communication or certain family members dominating the conversation can be suggestive of problems within the family.

Evidence of healthy families can be seen in a variety of observations, including open communication among all members, mutual play with humor, balanced interactions among all members, and expressions of a religious core or other value system, and each member being allowed some privacy.

19. The hospital-based nurse has worked with a client at some length regarding appropriate diet. Based on the family systems theory,

which of the following will most likely occur when the client returns home? a. The family member who prepares food will probably suggest the newly discharged member eat the meals everyone in the family enjoys. b. The family member who prepares food will probably try to modify family meals without obvious change for the family as a whole. c. The family member who prepares food will probably prepare meals based on the diet plan for all the family. d. The family member who prepares food will probably prepare special meals for the newly discharged member.

ANS: B

Family systems typically maintain stable patterns, although families do change constantly in response to stresses. Change in one part of the family affects the total system. However, if family members are supportive, they will want to try to help the ill member.

Therefore, the member who prepares the meals will probably compromise by trying to meet the ill member’s needs without making drastic changes in the overall eating patterns of the family. It is not realistic to expect the whole family to change eating patterns immediately based on the needs of one family member. Because of the rapid change and stress in American society, preparing different sets of meals is not very realistic. If the family member who prepares the meals does not attempt to make some changes, it would not be therapeutic for the family member who is ill.

20. A nurse has just met a family and is completing their family assessment. Which of the following actions should the nurse take

before engaging in self-disclosure? a. Confirm the reason for the appointment. b. Demonstrate cultural awareness. c. Take time to build trust. d. Understand the family dynamics.

ANS: C

The family assessment process is interactive. As the nurse is evaluating the family, the family is evaluating the nurse. Too much disclosure during the early contacts between the family and nurse may scare the family away. The nurse should slow the process down and take time to build trust. Components of building trust with the family would include confirming the reason for the appointment so that the family knows the nature of the visit and demonstrating cultural awareness during interactions. As the nurse completes the family assessment, the nurse will note the dynamics of the family; understanding the family dynamics is not important before engaging in self-disclosure.

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21. A nurse is completing a tertiary prevention activity in a predominantly poor community, where eating clay (pica) is a common

practice. Which of the following actions would the nurse most likely take? a. Assist those who eat large amounts of clay to obtain food stamps after explaining that clay, although filling, does not provide necessary nutrients. b. Initiate early intervention in the school system through education programs designed to focus on healthy food choices. c. Provide laboratory testing and physical assessments to assess for nutritional deficits resulting from clay intake. d. Survey families in the community to determine whether they eat clay and how much clay they eat.

ANS: A

Tertiary prevention is undertaken to prevent additional health problems when a problem has occurred. If the family members are eating clay, it demonstrates that a problem already exists. Early intervention in the school system is an example of primary prevention. Lab testing and surveying families are screening activities to determine whether a problem is present and to catch it in the early phases; such screening activities are representative of secondary prevention.

MULTIPLE RESPONSE 1. A nurse requests to meet a newly referred family in their home. Which of the following best explains the rationale for this request?

(Select all that apply.) a. The nurse can assess the family environment. b. The family will feel more comfortable. c. Families typically welcome others into their home. d. More family members can typically be involved. e. The members tend to be more relaxed.

ANS: A, B, D, E

Advantages to meeting in the family home include the fact that it allows the nurse to see the everyday family environment and observe typical family interactions. Also, more family members can be present, and families are often more comfortable in their own environment. However, a disadvantage to meeting in the family s home is that family members may view this as an intrusion into the only place they feel safe from outside observation; thus, the nurse must be highly skilled in guiding the interactions and setting limits.

2. In comparison with traditional norms, which family functions have become increasingly important in modern American society?

(Select all that apply.) a. Conferring appropriate social status b. Educating the younger members c. Ensuring physical health and safety d. Fostering interpersonal relationships and support e. Promoting mental health and wellness ANS: C, E

Today, the more important functions are fostering relationships (emphasizing how people get along and their level of satisfaction) and promoting physical and mental health. Historically, families have had several functions including financial survival, reproduction, protection from hostile forces, and enculturation, including religious faith, education, and conferring social status.

3. Which of the following must be firmly established before beginning a family assessment? (Select all that apply.) a. Why the data are needed b. How best to interview each individual in the family c. The most convenient time for you to visit the family d. The rationale or purpose of the visit e. Which family members can be available ANS: A, C, D, E

Assessment of families requires an organized plan, including the purpose of seeing the family, which family members can be present, what you are assessing and why, and how will you obtain the necessary data. The preferred time to visit is when most family members will be available. It is more informative to interview the family as a whole so that you can observe family interaction (rather than focusing on interviewing each individual).

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Chapter 21: Family Health Risks Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse was preparing for a home visit to a family where the mother had just been discharged from trauma care after being hit by a

drunk driver. The nurse hoped the family was able to care for her. Which of the following comments from the husband would suggest an energized family? a. “I make most of the decisions so the kids don’t notice much difference.” b. “My daughter is pretty independent; she’s active in both sports and theater.” c. “My son is old enough to get a job and help pay all these medical bills.” d. “My wife taught our daughter how to cook simple meals.”

ANS: B

Pratt proposed the energized family as being an ideal family type that was most effective in meeting health needs. The energized family is characterized by active contact with a variety of groups and organizations (Boy Scouts, church, sports, theater), flexible role relationships, equal power structure, and a high degree of autonomy by each member. Flexible role relationships are not being demonstrated if only the daughter is taught how to cook and only the son is expected to get a job. Equal power structure is not being displayed if the husband makes all the decisions.

2. Using the Neuman Systems Model, which of the following questions would the nurse ask a client to assess physiological health? a. “What helps you to cope with situations involving your wife’s cancer?” b. “How has your child’s illness affected the behavior of your other children?” c. “Tell me about any illnesses your other family members have.” d. “Who do you turn to for support outside your immediate family?”

ANS: C

Physiological health involves issues related to physical wellness or illness. Other components of health in Neuman’s model include psychological health, sociocultural health, developmental health, and spiritual health. Asking about coping and support addresses psychological health, not physiological health. Inquiring about the behavior of the other children addresses developmental health.

3. A nurse is working with a family member to reduce personal health risk. Which of the following recommendations would most

likely be made by the nurse? a. “Be sure to take a 30-minute walk each day.” b. “Call our office if you have any questions or concerns at all.” c. “Come back in 2 weeks for follow-up on your surgery.” d. “Continue to take the drug until it is gone, even if you’re feeling better earlier.”

ANS: A

The factors that determine or influence whether disease or other unhealthy results occur are called health risks. The major categories of risk include inherited biological risk, social and physical environmental risk, and behavioral risk. Exerc ising for 30 minutes a day reduces the risk for many diseases. All the other options are treatment oriented rather than risk avoidance.

4. A nurse is appraising health risks. Which of the following questions would most likely be asked by the nurse? a. “Does your 4-year-old have a booster seat in the car?” b. “Have you noticed any physical problems as you go about your daily routine?” c. “What concerns do you have today?” d. “Why did you decide to come in for a checkup?”

ANS: A

Health risk appraisal refers to the process of assessing for the presence of specific factors in each of the categories that have been identified as being associated with an increased likelihood of an illness, such as cancer, or an unhealthy event, such as an automobile accident. Inquiring about why the client came in for the visit, asking about concerns, and physical problems does not address potential health risks that may need to be addressed for the client.

5. A nurse is conducting a health risk appraisal. Which of the following activities is the nurse assessing when using this tool? a. Health promotion activities b. Illness prevention activities c. Risk reduction activities d. Unhealthy activities ANS: D

Health risk appraisal refers to the process of assessing the presence of specific factors in each of the categories that have been identified as being associated with an increased likelihood of an illness, such as cancer, or an unhealthy event, such as an automobile accident. Therefore, the nurse would assess for unhealthy behavior and activities in the areas of biological and age-related risk, social and physical environment risk, and behavioral risk. Incorrect Activities to promote health, prevent illness, or reduce risks would be advantageous, not risky.

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6. A nurse is implementing risk reduction interventions with a family. Which of the following questions is most important for the

nurse to ask? a. “Did any of the hunters in your family kill a deer this year?” b. “How do you keep your rifles safe from curious children?” c. “Where do you shoot with your handguns?” d. “Where do you keep your rifles locked when it is not hunting season?”

ANS: C

Risk reduction is a complex process that requires knowledge of risks and families’ perceptions of the nature of the risk. In this situation, the nurse was asking questions to determine the family’s perception of risks associated with owning guns. If the family does not perceive the behavior (having guns in the house) as risky, but rather as necessary for food or sport, the nurse must first educate or persuade the family that others may be more comfortable if certain precautionary measures are taken (such as locks on the guns). Rifles are used for food and sport but handguns are often used in crimes and accidents resulting in death. Asking about how guns are kept safe or locked up does not address the families’ perception of the nature of the risk. Asking if any of the hunters killed a deer this year makes the assumption that the family uses the guns for hunting. This perception by the nurse may be inaccurate; it would be more appropriate for the nurse to ask how the guns are used in the home rather than assuming that they are used for deer hunting.

7. A nurse is completing a health risk appraisal with a client. Which of the following comments would cause the nurse to probe

further to determine if the family is in crisis? a. “I can’t visit my husband in the hospital when I’m at work all day. How can I be sure he’s all right?” b. “My husband always handled our finances. Now that he’s gone, I’ll have to learn how to do this.” c. “I don’t know what to do now that my husband is dead. There is no way I can go back to work and also take care of our three children.” d. “What am I supposed to do now that everything we own is gone? Are there any agencies that can help me?”

ANS: C

A family crisis occurs when the family is not able to cope with an event and becomes disorganized or dysfunctional. When the demands of the situation exceed the resources of the family, a family crisis exists. Only the correct response is the person overwhelmed and unable to conceive of how to cope. In incorrect responses, the survivor is considering the problem and trying to learn how to cope or seek resources to cope.

8. A nurse has completed health risk appraisals with several different families. Which of the following families would be of most

concern to the nurse? a. An older couple who has just retired and sold their house, who talk about their new condo in a retirement community. b. Newlyweds who have been saving their money, who want to discuss birth control and family planning in preparation for future pregnancies. c. Parents who come with their child for his prekindergarten physical examination and want to be sure all the child’s immunizations are up to date. d. A woman who is very pleased with her new position at the hospital and wants to have her preemployment examination and drug screen.

ANS: A

Transitions (movement from one stage or condition to another) are times of potential risk for families. Age-related or life-event risks often occur during transitions from one developmental stage to another. Transitions present new situations and demands for families. Moving from the family home to a smaller condo represents a major change in lifestyle. The incorrect responses do not represent major transitions. If the event is normative, or anticipated, it is possible for families to prepare for the event and its consequences.

9. Which of the following best describes a normative life event that can increase the risk for illness? a. A family is involved in a motor vehicle crash. b. A group of teens experiment with recreational drugs. c. A woman is pregnant with her first child. d. The family wage earner is laid off from his job.

ANS: C

Life events can increase the risk for illness and disability. Normative events are those that are generally expected to occur at a particular stage of development or of the life span. Although pregnancy is a normal condition, it carries risks such as the development of eclampsia or more minor health problems such as constipation and hemorrhoids. Additionally, pregnancy (and the birth that follows) will alter family dynamics and may increase risk for psychological stressors. The incorrect responses are not normative life events.

10. A nurse is drawing a genogram. Which of the following would the nurse use to demonstrate a marriage relationship between two

individuals? a. A broken horizontal line b. An X through a circle c. A solid horizontal line d. A solid vertical line ANS: C

Marriage is indicated by a solid line on a genogram. A broken horizontal line indicates a divorce or separation. An X through a circle or square indicates a death. A solid vertical line indicates offspring and children.

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11. Which of the following best describes the use of genomic health care? a. Assists with understanding family relationships b. Assists with determining familial health risks c. Useful in learning about environmental risk factors d. Useful in detecting risk for developing cancer ANS: B

Genomic health care can give health care providers the tools that they need to use a person’s unique genomic information to design and prescribe the most effective treatment for each person and to help clients and families understand some of their health risks that are influenced by their genetic make-up. When nurses obtain a family history and learn about the illnesses and causes of death of biologically related family members, they can then learn about shared genes and environment and lifestyle behaviors that can increase a person’s risks for the same diseases that other family members experienced. Genomic health care involves assessing for health risks based on genetic make-up, not environmental risks or risks posed by relationships or family functioning. Genomic health care is broader than detecting risk for developing cancer.

12. Which of the following families is at high risk for health problems? a. A man agrees that he needs to eat better and exercise more but also expresses how

busy he is at his job. b. A man knows that his grandfather, father, and older brother all died of cardiac

disease. c. A man is currently unemployed and despairs about finding a position. d. A man expresses disappointment that, having been laid off as an executive, his new position pays only about two-thirds of his original salary.

ANS: C

A person who is unemployed and despairing of finding employment is at serious economic risk, which is one of the foremost predictors of health problems. Economic risk is determined by the relationship between family financial resources and the demands on those resources. Having adequate financial resources means that a family is able to purchase the necessary services and goods related to health, such as adequate housing, clothing, food, education, and health or illness care. A man who says he needs to eat better and exercise more appears to have adequate resources as he is employed. The man who has a family history of cardiac disease is not displaying any known risk factors related to income. The man who has been laid off still is receiving an income which should assist him in being able to afford the necessary goods and services he needs in the immediate future.

13. A home health nurse who is visiting a family for the first time asks, “Could we review your extended family and other persons or

groups with whom you interact each week?” Which of the following provides the best rationale for the nurse asking this question? a. To assess the family’s environment and social resources and risks b. To communicate with relevant others as needed c. To determine financial assets available to the family in case of serious need d. To understand the extended family relationships ANS: A

The question by the nurse indicates that she is trying to obtain an ecomap. Ecomaps can provide information about relationships that the family has with others (such as relatives and neighbors), the family’s connections with other social units (such as church, school, work, clubs, and organizations), and the flow of energy, positive or negative, in the family. An ecomap represents the family’s interactions with other groups and organizations. Environmental or social risk and resources can be assessed from an ecomap. An ecomap does not assess extended family relationships or financial assets. An ecomap is not used as a communication method.

14. Which of the following clients would cause the nurse the most concern? a. The client who is currently unemployed but actively seeking a position and

frequently walking from one interview to another b. The client who is not employed but spending time at the gym keeping fit and studying the benefits of organic natural uncooked foods c. The client who is employed and often works 12 hours a day without moving from the computer desk d. The client who is employed but always leaves promptly at 5:00 to pick up the children from the daycare center ANS: C

Personal health habits continue to contribute to the major causes of morbidity and mortality. The pattern of personal health habits and behavioral risk defines individual and family lifestyle risk. The client who doesn’t move from the computer desk is creating great stress and strain on personal physiology and needs to be educated on the benefits of exercise and the risks of cumulative trauma on the body. Multiple health benefits of regular physical activity have been identified; regular physical exercise is effective in promoting and maintaining health and preventing disease. The client who is currently unemployed is demonstrating positive health behaviors by actively seeking employment and walking frequently. The client who spends time at the gym and studies the benefits of organic foods is displaying positive health behaviors by being active and wanting to eat healthy. The client who leaves work to pick up the children at 5:00 is displaying healthy behaviors as he or she is balancing family and work.

15. An occupational health nurse is developing an educational program to address the importance of healthy personal health habits.

Which of the following topics would be most important for the nurse to address? a. Avoidance of alcohol b. Regular physical exercise c. Daily consumption of calcium-rich foods d. Monthly self-breast and testicular examinations ANS: B

Many family health risks can be reduced by careful attention to diet, exercise, and stress management. Regular physical exercise is effective in promoting and maintaining health and in preventing disease. Physical activity can help to prevent obesity, diabetes, heart disease, cancer, osteoporosis, and depression. Avoidance of alcohol and daily consumption of calcium-rich foods are not recommendations for improving personal health habits.

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16. A home health nurse is about to visit a family at their home. However, the nurse is feeling uncomfortable about getting out of her

car because a group of young adults across the street are drinking and fighting among themselves. Which of the following actions should be taken by the nurse? a. Call the agency and ask what she should do. b. Call the family, explain the situation, and try to reschedule. c. Fulfill the nurse’s commitment to the family and enter the home quickly. d. Drive away and notify the family from a safer location.

ANS: D

Personal safety is an issue. Home visits are generally very safe; however, as with all worksites, the possibility of violence exists.

Therefore, the nurse needs to use caution. If a reasonable question exists about the safety of making a visit, the nurse should not make the visit. The home health nurse should be educated about what to do in this situation before it occurs and should not need to call the agency to ask for their advice when faced with this situation. The priority would be to leave the situation before calling the family. The nurse should not place herself in a potentially violent situation by choosing to enter the home.

17. A nurse arrives at a home at the appointment time established with the client over the phone. However, no one answers the door.

Finally, a teenager comes out and says, “My mom said she couldn’t see you and you should go away.” Which of the following actions should be taken by the nurse? a. Demand the teen let the nurse into the home to talk to the mother. b. Interview the child as to how the family is doing. c. Leave a card with information on how to get in touch with the nurse. d. Point out that legally once an appointment has been made the mother needs to be seen.

ANS: C

The contact may be terminated as requested if the nurse determines that either the situation has been resolved or the services have been obtained from another source and if the family understands that services are available and how to contact the agency if desired. However, the nurse should leave open the possibility of future contact. Obviously, the nurse cannot force entrance into the home. It would not be appropriate to coerce a child with misinformation or to interview a child about health concerns without a parent being present.

18. A nurse is completing an initial home visit with a family. Which of the following actions should be taken first by the nurse? a. Assess the family and the home setting for both strengths and problems. b. Determine the family’s expectations of a home visit. c. Establish rapport between the nurse and the family. d. Engage in extended social interaction as would be expected from any guest.

ANS: C

The initial home visit includes the nurse’s self-identification and clarification of role, establishing rapport with the family, assessing the situation, and then determining the client’s expectations. However, without rapport between the nurse and the client, the nurse will be notably less effective at other tasks. Although in some senses the nurse is a guest in the home, the nurse is not there for social purposes but to help the family with health concerns. Building rapport between the nurse and family should occur as the nurse is determining the family’s expectations, as well assessing the family and home setting.

19. A home health nurse is preparing to terminate the first home visit with teenage parents and their new baby. Which of the following

actions will the nurse take before leaving? a. Determine the family’s willingness for another home visit. b. Establish the purpose of the visit. c. Review the family’s learning and other accomplishments of the visit. d. Review the family record and reason for referral.

ANS: C

During the termination phase, the nurse reviews the visit with the family, summarizes what has occurred and what has been accomplished, and may make plans for future visits. The incorrect options listed occur during the previsit phase.

20. During which phase of the home visit does the nurse document what was accomplished? a. Previsit phase b. In-home phase c. Termination phase d. Postvisit phase ANS: D

A major task of the postvisit phase is documenting the visit and services provided. Major tasks of the pre-visit phase are to initiate contact with the family and schedule the home visit. During the in-home phase, the nurse-client relationship is established. During the termination phase, the visit is reviewed with the family and plan for future visits is made.

21. A nurse has just witnessed the signing of an agreement between two parents in which the parents pledge not to yell at each other in

the presence of their children. Which of the following is being demonstrated through this action? a. Contracting b. Family crisis c. Empowerment d. Health risk reduction ANS: A

Contracting is making an agreement between those involved in a shared effort by both nurse and family. The premise of contracting is family control. It is assumed that when the family has legitimate control, their ability to make healthful choices is increased. A family crisis occurs when the family is not able to cope with an event and becomes disorganized or dysfunctional. Making a pledge through contracting is a way to cope with a family crisis. Empowerment reflects a family seeking help with access and control over needed resources, decision-making and problem-solving abilities, and the ability to communicate and to obtain needed resources.

The pledge does not address the multiple components of empowerment. Health risk reduction is based on the assumption that decreasing the number or the magnitude of risks will decrease the probability of an undesired event occurring. The pledge does not address multiple health risks.

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22. A nurse wants to empower the family of a mother who has been newly diagnosed with breast cancer. Which of the following

actions would the nurse most likely take? a. Apply for emergency financial assistance on the family’s behalf. b. Arrange for community members to assist with child care. c. Invite the mother to join a cancer support group. d. Teach the family how to navigate the health care system.

ANS: D

Definitions of empowerment reflect three characteristics of the empowered family seeking help: access and control over needed resources, decision-making and problem-solving abilities, and the ability to communicate and to obtain needed resources.

Approaches for helping individuals and families assume an active role in their health care should focus on empowering, rather than giving direct help.

23. A nurse has been successful in creating improvement in a family’s health. Which of the following characteristics is most likely

displayed by the nurse? a. Skilled at recognizing and strengthening the family’s competencies b. Skilled at obtaining referrals and resources for the family c. Skilled at communication and interpersonal relationships d. Skilled at assessing the family’s main problems ANS: A

The nurse’s approach to the family should be positive and focused on competencies rather than on problems or deficits. The incorrect responses do not address the strengths of the family, rather they focus on obtaining necessary resources, improving relationships, and assessing for problems.

24. Which of the following should be the initial consideration made by a nurse who is working with lesbian, gay, bisexual, and

transgendered (LGBT) families? a. Understanding of same sex marriage laws within the state b. Understanding of personal feelings of working with members of this community c. Assessment of the family structure within the LGBT family d. Assessment of sexual orientation in a safe environment ANS: B

Nurses have an ethical obligation to provide culturally competent care to LGBT families. Some nurses may feel a degree of discomfort discussing sexual orientation with their patients. However, it is important to overcome this barrier to care for LGBT families. Thus, nurses should provide a safe environment for patients to discuss their sexual orientation. After understanding one’s own feelings when providing care for this population, it may be important for the nurse to investigate same sex marriage laws and family structure. It is important to provide clients a safe environment to discuss sexual orientation; however, the nurse must be aware of his or her own feelings before beginning this discussion.

25. A nurse notes that the community has an unusually high prevalence of sexually transmitted infections among teens. Which of the

following best describes a secondary prevention action the nurse could take? a. Conducting a sexual behavior survey with the adolescents b. Establishing in-school education related to transmission of sexual infections c. Providing free condoms at schools and universities d. Providing follow-up educational programs for those diagnosed with an STI ANS: A

Secondary prevention would include screening for risky behavior. Education and distribution of condoms are both primary prevention measures, and follow-up education for those diagnosed and being treated is tertiary to prevent further problems.

MULTIPLE RESPONSE 1. A family asks the nurse to please meet at their home rather than at the clinic. Which of the following best describes why the family

prefers to meet in their home? (Select all that apply.) a. The family won’t have to travel. b. It is cheaper for the family because of reimbursement requirements. c. Meeting at home is much more convenient for the family. d. The nurse won’t be distracted by other clients or responsibilities. e. It would save money for the nurse and the clinic.

ANS: A, C

Advantages of a home visit include client convenience and client control, as well as the fact that it facilitates clients who are unable to travel; it allows more individualized services; and it provides a natural relaxed environment for discussion. However, home visits are expensive for the nurse and the nurse’s employer because of travel costs and the amount of time spent with just one family.

Unfortunately, nurses can be distracted by other tasks regardless of setting. Home visits are cheaper for insurance companies, not for the family.

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2. Which of the following factor(s) may help determine how many home visits are made to a particular family? (Select all that apply.) a. Agency’s policies regarding eligibility for services b. Family’s feelings about the home visit and willingness to continue c. Nurse’s perception of the amount of time needed to complete required tasks d. Reimbursement policies of third-party payers e. Family’s perception of need ANS: A, B, D

Although it is not unusual to have only one home visit with a family, often multiple visits are made. The frequency and intensity of home visits vary not only with the needs of the family but also with the eligibility of the family for services as defined by agency policies and priorities. Although the textbook does not directly discuss the issue, the family’s willingness to work with the nurse is a factor. Also, the nurse cannot make visits unless the agency is being reimbursed for the nurse’s time and expenses, so reimbursement policies of third-party payers are a major influence on the number of visits for which the family may be eligible.

The nurse’s perception of the time needed to give quality care must unfortunately be secondary to other variables, which can control the time available. While the family’s perception of their needs is relevant, it is not the only factor considered when allotting time for visits.

3. The nurse and the family have agreed on an ambitious goal to improve family functioning, but as the family later expresses with

some dismay, they have not been able to change their behavior as easily and quickly as they had hoped. Which of the following must be remembered throughout this process? (Select all that apply.) a. A reassessment of resources should be done if the plan does not work. b. Individual family members must all be willing to make the plan their first priority. c. Goals must be realistic and feasible. d. Ongoing negotiation is central to the process. e. All family members must be involved in setting the goals.

ANS: C, D

In contracting, an important aspect is obtaining the family’s view of the situation and its needs and problems. Goals must be mutually set and realistic. A pitfall for nurses and clients who are new to contracting is to set overly ambitious goals. Because contracting is a process characterized by ongoing renegotiating, the goals are not static. The family’s inability to cha nge “as easily and quickly as they had hoped” does not mean the plan is not workable—only that more time and effort may be necessary. The plan does not need to be the “first priority” for all family members for it to be effective. The plan does need to be mutually set but depending on the situation it may be difficult for this to be the priority for all members of the family. The plan may not be working for a variety of reasons; lack of resources may not be the reason.

4. A nurse enters a family’s home for the first time. Which of the following goals should the nurse have? (Select all that apply.) a. Assessing each family member in detail both physically and psychologically b. Collaborating with the family to establish goals and a plan for meeting them c. Determining the exact relationship between each member of the family d. Exploring the family’s perception of their problems and needs e. Collecting information regarding the perceived issues ANS: B, D

During the beginning phase of the nurse-family interaction, three activities occur—mutual data collection and exploration of needs and problems; mutual establishment of goals; and mutual development of a plan. Assessment of each family member and determining the exact relationship between each member of the family are not part of nurse-family interactions.

5. A nurse calls a family to arrange for the first home visit. Which of the following information should the nurse share with the

family? (Select all that apply.) a. The reason for the visit b. Everything the nurse knows about the family c. How many visits will be planned d. The cost of the visit and how this may be paid e. How the visit’s referral was made ANS: A, D

The nurse should include the reason for the visit, how or from whom the referral was obtained, and a brief summary of what is known about the family’s situation. The nurse should negotiate a time for the visit, preferably when most family members are available. Clients should be told the fee and possible methods of payment before the nurse assesses the family’s willingness for a home visit. If the family does not have a phone, mail can be used to share information. It would be inappropriate for the nurse to share everything that she knows about the family with the family as there may be some information that the family does not need to know. Without visiting the family first, the nurse may not yet know the number of visits that may be planned.

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Chapter 22: Health Risks Across the Life Span Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A school nurse wants to decrease the rate of obesity among children. Which of the following actions in the community would be

most effective? a. Lobby legislators to enact stronger legislation regarding school lunches and snack machines in schools. b. Increase nutrition programs in schools that teach children to make healthy food choices. c. Involve the entire family in the planning and managing of nutrition, especially when a child in the family is obese. d. Provide after-school and summer camps that focus on diet and exercise.

ANS: C

Interventions need to be based on goals of lifestyle changes for the entire family. The goal is to modify the way the family eats, exercises, and plans daily activities. Although it is important to teach nutrition, exercise, and proper food choice, if the family does not, for example, prepare the proper foods from which they can choose, the knowledge of the child is insignificant. Changes need to be made at a more direct level, such as by working with the family, to establish a change. Community-level changes may not impact what is happening within the family in regard to diet and exercise.

2. A nurse wants to establish a program to decrease the death rate among children. Which of the following health problems should be

the target of this program? a. Accidents and injuries b. AIDS c. Childhood obesity d. Vaccine-preventable diseases ANS: A

Injuries are the number one cause of death among children (and young adults up to age 21 years) in the United States. Injuries and accidents are the most important causes of preventable disease, disability, and death among children. Most are preventable.

Obesity, although a significant problem, is not a common cause of death in children. AIDS and vaccine-preventable diseases are not common causes of death among children.

3. A nurse wants to establish a program to decrease the death rate among adolescents. Which of the following programs should be

developed? a. Antialcohol program b. Antismoking program c. Careful driving program d. Safe sex program ANS: C

Motor vehicle accidents are the leading cause of death among children and teenagers. The use of tobacco is a leading cause of preventable death among adults, but not among adolescents. Alcohol use and sexually transmitted diseases are not related to common causes of death among teenagers.

4. Which of the following is of the greatest concern for the nurse who works with high-school students? a. Alcohol use b. Motor vehicle accidents c. Sports-related injuries d. Unprotected sex ANS: B

Motor vehicle-related injuries and violence are the leading causes of morbidity and mortality among adolescents. Thus, this would be the greatest concern for the nurse working with high-school students. Alcohol use, sports-related injuries, and unprotected sex are not related to the major causes of morbidity and mortality among adolescents. So, although these topics may impact this population, they should not be the priority for the nurse.

5. A mother says, “My son wants me to let him buy a car. I must admit, I certainly get tired of driving him around to all his sports and

other activities. Do you think I should let him have a car?” Which of the following statements would be the best response by the nurse? a. “Absolutely, it will help him recognize the cost of gas and maintenance.” b. “Certainly, most young men want their own car, and peer pressure can be painful.” c. “It depends on whether you trust your son to drive safely.” d. “No, adolescent males cannot be trusted with an automobile.”

ANS: C

Motor vehicle-related injuries and violence are the leading causes of morbidity and mortality among adolescents. Males are more likely to take risks, and injury death rates for boys are twice as high as those for girls. Thus, the response by the nurse should take these factors into consideration in response and encourage the mother to individualize her decision for her son. The incorrect responses do not take into account the individual risk factors that the nurse should encourage the mother to consider. The nurse should encourage the mother to think about the risky behaviors specific to this population and how they apply to her son.

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6. Which of the following children is most at risk for being abused? a. A 1-year-old b. A 6-year-old c. A 9-year-old d. A teenager ANS: A

Children in their first year of life have the highest rate of victimization at 26.7 per 1000 children. A 6-year-old, 9-year-old, and teenager are not at high risk for being abused because they are older.

7. If underlying causes were listed on autopsy reports, which of the following would be the most common cause of unnecessary death

in the United States? a. Alcohol b. Guns c. Lack of exercise d. Unprotected sex ANS: C

Heart disease is the leading cause of death in the United States. Routine physical activity has been found to prevent early death and chronic diseases, including coronary artery disease, stroke, type 2 diabetes mellitus, depression, and some types of cancer. Alcohol, guns, and unprotected sex are not related to common causes of unnecessary death among adults in the United States.

8. A client has designated someone else to make health care decisions when he or she is unable to do so. Which of the following

methods is the client using to make health care decisions? a. An advance directive b. A living will c. A durable power of attorney d. A Do-Not-Resuscitate (DNR) order ANS: C

Durable power of attorney is the legal way for a client to designate someone else to make health care decisions when he or she is unable to do so. Advance directives is a broad category that includes both living wills and durable power of attorney. A living will allow the client to express wishes regarding the use of medical treatments in the event of a terminal illness. A DNR order is a specific order from a physician not to use cardiopulmonary resuscitation.

9. A woman needs to take some time off from work to care for her invalid mother. Which of the following health policies allows her

to take an extended leave from work to care for a family member? a. Patient Self-Determination Act b. Personal Responsibility and Work Opportunity Reconciliation Act c. Temporary Assistance for Needy Families (TANF) d. Family and Medical Leave Act (FMLA) ANS: D

The FMLA provides job protection and continuous health benefits where applicable for eligible employees who need extended leave for their own illness or to care for a family member. The Patient Self-Determination Act requires that providers receiving Medicare and Medicaid funds give clients written information regarding their legal options for treatment choices if they become incapacitated.

The Personal Responsibility and Work Opportunity Reconciliation Act is commonly known as “welfare reform.” This law created the TANF program. The Temporary Assistance for Needy Families program is a work program that mandates that women heads of households find employment to retain their benefits.

10. Which of the following situations would most likely indicate elder abuse? a. A daughter refuses to visit her mother due to work commitments. b. A child runs around a grandparent’s house breaking items. c. A young man repeatedly steals money from his grandmother. d. An elderly person demands that the family come for dinner.

ANS: C

Theft or mismanagement of money or resources is an element of abuse. A daughter refusing to visit, children breaking items, and an elderly person demanding that the family come for dinner are not situations that indicate elder abuse. None of these situations should cause alarm for the nurse as they all may normally occur within a family.

11. A nurse would like to learn more about the overall health of a population. Which of the following indicators would the nurse most

likely use? a. Life expectancy b. Mortality rate c. Morbidity rate d. Health status ANS: A

Life expectancy is a measure that is often used to gauge the overall health of a population. Health status indicators are the quantitative or qualitative measures used to describe the level of well-being or illness present in a defined population or to describe related attributes or risk factors. Morbidity rate is the frequency that a disease occurs within a population. Mortality rate is the number of deaths in a given area or period. Both morbidity and mortality rates are health status indicators.

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12. A nurse is new to the community but wants to begin planning immediately for health promotion programs. Even though the nurse

does not yet know the community, which of the following programs would be good to plan first? a. Alcohol and tobacco cessation programs b. Cancer screening programs c. Cardiac health education programs d. Exercise for life programs ANS: C

Heart disease is one of the most significant public health problems in the United States, responsible for premature mortality and disability. Cardiovascular disease is the leading cause of death in the United States. Good nutrition and exercise programs, while both good health promotion programs, are too narrow in focus to represent the greatest need in the community. Cancer is the second leading cause of death so may be the nurse’s second focus.

13. A nurse is caring for a child who has been diagnosed with a chronic health condition. Which of the following conditions would the

child most likely have? a. Heart disease b. Down syndrome c. Emphysema d. Arthritis ANS: B

Common chronic conditions seen in children are Down syndrome, spina bifida, cerebral palsy, asthma, ADHD, diabetes, congenital heart disease, cancer, hemophilia, brochopulmonary dysplagia, and AIDS. Heart disease, emphysema, and arthritis are common chronic health conditions of adults, not children.

14. A nurse has just met the parents of a 10-year-old child who has been diagnosed with a congenital heart defect. When interviewing

the parents, which of the following would be a priority question for the nurse to ask? a. What are the learning needs of your child? b. What does your child eat on a typical day? c. Does your child have a good peer support network? d. Does your child have a medical home?

ANS: D

The use of a medical home, in which one provider or clinic has all of the child’s records, is important for this population.

Communication among all providers who are working with this child is essential in order for the child to achieve optimal health and functioning. Learning needs, nutritional needs, and peer relationships are important for a 10-year-old child. However, without having the coordination and consistency of a medical home to coordinate medical care, these other things may be insignificant.

15. Which statement about eating disorders is correct? a. Individuals with anorexia frequently complain about weight loss. b. Purging is associated with anorexia. c. Most women with bulimia are concerned with the shape and weight of their body. d. Bulimia is considered to have more medical complications than anorexia.

ANS: C

Those with bulimia are usually concerned with the shape and weight of their body. Those with anorexia view themselves as normal or overweight; purging is associated with bulimia; and anorexia is considered to have more complications than bulimia.

16. A nurse is providing contraceptive counseling to a female client. Which of the following is the most appropriate outcome of this

counseling? a. Encourage the individual to choose abstinence. b. Ensure the individual is educated to make an informed choice about reproduction. c. Advocate for increased funding for reproductive services. d. Reduce the health risks of the individual.

ANS: B

The goal of contraceptive counseling is to ensure that women have appropriate instruction to make informed choices about reproduction. The nurse should provide a nonjudgmental approach during counseling and allow the woman to choose the appropriate contraceptive method. Nurses do advocate for reproductive services for women, but that is not a goal of contraceptive counseling. Reduction in the health risks of the individual is a goal of preconceptual counseling.

17. A nurse is providing preconceptual counseling to a young woman. Which of the following supplements would the nurse most likely

recommend? a. Iron b. Calcium c. Folic acid d. Vitamin C ANS: C

Research has shown that intake of folic acid can significantly reduce the occurrence of serious and often fatal neural tube defects. A recommendation was made that women capable of or planning a pregnancy take 400 mcg of folic acid daily (USDHHS, 2010). Iron, calcium, and vitamin C are not used as routine prenatal supplements.

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18. Which of the following best describes the current research findings related to the use of hormone replacement therapy (HRT)? a. HRT does not prevent heart disease. b. Use of HRT is recommended to prevent osteoporosis. c. When used with complementary therapies, HRT is most effective. d. HRT is a contributing cause of breast cancer.

ANS: A

HRT does not prevent heart disease. To prevent heart disease, women should avoid smoking, reduce fat and cholesterol intake, limit salt and alcohol, maintain a healthy weight, and be physically active. HRT is not recommended to promote osteoporosis. HRT is not a contributing cause of breast cancer. There is no evidence that HRT is most effective when used with complementary therapies.

19. Which of the following best describes where health care dollars in the United States be focused to improve breast cancer cure rates? a. Education for women about breast cancer b. Early detection programs with referral to ongoing access to a care provider c. Primary prevention programs d. Tertiary care through long-term follow-up ANS: B

Early detection can promote a cure, whereas late detection typically ensures a poor prognosis. The differences in the outcomes between women of color and white women point to issues associated with early detection, access to health care, and follow-up by a regular care provider. Education for women about breast cancer is not as effective as early detection programs. Screening must be completed which is accomplished through secondary, not primary prevention. Tertiary care does not occur until after diagnosis has occurred, and this is too late.

20. Which of the following behaviors results in men being less healthy than women? a. Concentration on sports, hunting, and other dangerous recreational choices b. Employment in stressful positions more so than women c. Preference to spend money on priorities other than health care d. Reluctance to visit health care providers ANS: D

A major obstacle to improving men’s health is their apparent reluctance to consult their primary care provider. Men are not well connected to the health care system. Men do not participate in health care at the same level as women, apparently because of the traditional masculine gender role learned through socialization (Bonhomme, 2007). Only 57% of US men see a doctor, nurse practitioner, or physician assistant compared with 74% of women (AHRQ, 2010). Hobbies, employment, and preference on how to spend money may influence a man’s decision to seek medical care. However, these have not been identified as major obstacles in comparison to overall reluctance to seek care.

21. Which of the following characteristics indicates a man is at a higher risk for developing prostate cancer? a. Being of Caucasian descent b. Has not had a PSA test c. Has a father or brother who has had prostate cancer d. Has benign prostatic hypertrophy ANS: C

Having a father or brother who has had prostate cancer places a man at higher risk for developing prostate cancer.

African-American males have a mortality rate from prostate cancer that is nearly twice as high as any other group. The PSA test is not accurate in terms of sensitivity or specificity. This blood test produces many false-positive results because many factors can elevate the PSA. There is no relationship between benign prostatic hypertrophy and the development of prostate cancer.

22. Which of the following factors has the largest impact on health disparities among all populations? a. Ethnicity b. Education level c. Lifestyle choices d. Poverty ANS: D

Poverty is a strong and underlying current factor that affects all special groups. Ethnicity, education level, and lifestyle choices do not have as large of an impact on health disparities than income level related to poverty.

23. A nurse is conducting a screening for type 2 diabetes for children attending a local school. In addition to an elevated BMI, which of

the following risk factors should the nurse consider? a. Caucasian descent b. Family history of type 2 diabetes c. Birthweight greater than 9 pounds d. Poverty ANS: B

Screening for type 2 diabetes mellitus is recommended for children with a BMI from the 85th to 95th percentile with two or more for the following risk factors: family history of type 2 diabetes in a first- or second-degree relative; Native American, African American, Latino, Asian American, or Pacific Islander descent; signs of insulin resistance or conditions associated with insulin resistance; or maternal history of diabetes or GDM during the child’s gestation. Native American, African American, Latino, Asian American, or Pacific Islander descent is a risk factor, not Caucasian descent. Elevated birthweight and poverty have not been identified by the American Diabetes Association as significant risk factors that indicate the need for additional screening.

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24. A nurse is providing nutrition counseling to the parents of a 4-year-old. Which of the following recommendations is the nurse most

likely to provide? a. It is recommended that the child consume approximately 10 ounces of grains on a daily basis. b. It is recommended that the child consume approximately four cups of dairy on a daily basis. c. It is recommended that the child consume approximately four cups of fruits and vegetables daily. d. It is recommended that the child consume approximately 10 ounces of protein on a daily basis.

ANS: C

It is recommended that children of 4 to 8 years consume 1-1.5 cups of vegetables and 1-1.5 cups of fruits on a daily basis. It is recommended that children of 4 to 8 years consume 5 ounces of grains on a daily basis. It is recommended that children of 4 to 8 years consume 2-2.5 cups of dairy on a daily basis. It is recommended that children of 4 to 8 years consume 4 ounces of proteins on a daily basis.

25. A nurse is considering implementing interventions to address an increased interest in health and wellness promotion in the

community’s older adult population. What intervention should the nurse consider as the priority? Which of the following actions would the nurse most likely take? a. Educate a community group about hypertension control. b. Create a social group for those who have lost a life partner. c. Administer immunizations to community members. d. Conduct depression screenings in the community.

ANS: A

While all options are appropriate interventions, educating the community about hypertension control is the priority since it contributes to the deterioration of health. Administering immunizations, promoting socialization, and conducting depression screenings do not address the management of the most common and costly chronic diseases: heart disease, diabetes, stroke, cancer, and arthritis.

26. Toward whom is the TLC model targeted? a. Caregivers of older persons with health problems b. Community organizations that offer services for the elderly c. Elderly clients with health problems d. Nurses who care for older clients ANS: A

The TLC model is focused toward caregivers (primarily families) in an effort to relieve caregiver burden. Components are T = training in care techniques, safe medication use, recognition of abnormalities, available resources; L = leaving the care situation periodically to obtain respite and relaxation and maintain their normal living needs; and C = care for themselves (the caregiver) through adequate sleep, rest, exercise, nutrition, socialization, solitude, support, financial aid, and health management. The TLC model is not focused on community organizations, elderly clients, or nurses, rather it focuses on caregivers and relieving caregiver burden.

27. A client explains to the nurse that it is just impossible for her and her husband to continue to have his mother in the home alone

during the day while they work because the woman becomes confused and has fallen twice. Which of the following community resources should the nurse recommend? a. Adult day health b. Home health c. Long-term care d. Senior center ANS: A

Adult day health is for individuals whose mental and/or physical function requires additional health care and supervision.

Typically, individuals return home to their caregivers at night. Adult day health serves as more of a medical model than the senior center. Long-term care would take the client out of the home. Home health would leave the patient for periods of unsupervised time in which the patient could have problems, and help would not be available.

28. An elderly person is in the last stages of dying. Which type of care would be the best for him? a. Home health b. Assisted living c. Nursing home d. Hospice ANS: D

Hospice would be the best form of care for a person in the last stages of dying. The other options are not specifically designed for persons in the last stages of dying. Home health provides care in the home, but is not specific to meet the needs of the dying patient and his or her family. Assisted living relates to a living situation where the client receives different amenities depending on the level of care needed. This type of living arrangement is not specific to care for the dying patient. Nursing homes provide long-term care and are not specific to care needed for a dying patient.

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29. Which of the following is the best way to ensure good nutrition in newborn infants? a. Breastfeeding only b. Feed them brand-name baby foods c. Feed them only homemade cereals d. Supplement breastfeeding with brand-name formulas ANS: A

Breastfeeding is the preferred method of infant feeding. Breast milk provides appropriate nutrients and antibodies for the infant.

Breastfed infants have fewer illnesses and allergies. Breastfeeding is associated with a lower risk in developing childhood obesity.

Feeding brand-name foods, homemade cereals, and supplementing with formula are not the best ways to ensure good nutrition in infants. Breastfeeding is the best option to ensure good nutrition.

30. A nurse is implementing a tertiary prevention program to promote health among middle-aged women with diabetes. Which of the

following best describes the intervention being implemented by the nurse? a. Developing lifestyle improvement programs for women at risk for diabetes b. Presenting lifestyle management presentations at women’s conferences c. Monitoring blood glucose levels closely and modifying diet accordingly d. Screening glucose levels of women at risk for development of diabetes ANS: C

Tertiary prevention includes activities that are aimed to reduce the complications of the disease process. Only monitoring blood glucose levels is directed toward preventing problems in women who already are diagnosed with diabetes. Developing lifestyle improvement programs for women at risk for diabetes is an example of secondary prevention as this group is at risk for developing the problem. Presenting lifestyle management at women’s conferences is an example of primary prevention, preventing the disease before it occurs. Screening glucose levels is an example of secondary prevention, as all screening tests are secondary prevention.

31. A nurse advises a client diagnosed with HIV not to donate blood, plasma, or organs. Which of the following levels of prevention is

being used? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion ANS: C

Tertiary prevention includes those interventions aimed at disability limitations and rehabilitation from disease, injury, or disability.

Primary prevention and health promotion both address the use of interventions before the disease occurs and to reduce the risk of developing the disease. Secondary prevention is aimed at detecting the disease early through screening programs and early intervention for at-risk individuals.

32. A nurse wants to promote improved health for obese children in the community. Which of the following best describes a tertiary

prevention measure that the nurse would implement? a. Establish lifestyle improvement programs through local youth organizations. b. Evaluate the food intake of a group of children for a 48-hour period. c. Provide education programs to overweight expectant parents. d. Evaluate the body mass index of children at regularly scheduled well-child examinations.

ANS: A

Tertiary prevention includes activities aimed to reduce the complications of the disease process. Only lifestyle improvement programs are directed toward preventing problems in children who are already obese. Evaluating food intake and evaluating BMI are types of screening programs (secondary prevention). Providing education programs to overweight expectant parents does not involve children.

MULTIPLE RESPONSE 1. Which of the following adolescent(s) would receive care from the advanced practice nurse without parental consent? (Select all

that apply.) a. A 16-year-old who is legally emancipated b. A pregnant adolescent c. An adolescent requiring an emergency appendectomy d. An adolescent whose diagnosis of cancer has a serious prognosis e. A 15-year-old who overdosed on cocaine ANS: A, B, C, E

Most states have enacted laws allowing health care providers to treat adolescents in certain situations without parental consent.

These situations include emergency care, substance abuse, pregnancy, and birth control. All 50 states recognize the “mature minor doctrine.” This allows youths of 15 years and older to give informed medical consent if it is apparent that they are capable of understanding the risks and benefits and if the procedure is medically indicated. If an adolescent has a diagnosis that has a serious prognosis, parental consent will be needed as this is not a situation that involves emergency care, substance abuse, pregnancy, and birth control.

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2. Which of the following interventions would the nurse most likely implement when addressing the problem of asthma among

school-aged children? (Select all that apply.) a. Assess schools and day care centers for environmental “friendliness.” b. Share nutritional information with all students in the school. c. Develop home and environmental assessment guides. d. Teach all school personnel how to use rescue inhalers. e. Work with community developing clear air policies.

ANS: A, C, E

Population-focused strategies for asthma management include education programs for families of children and adolescents who have asthma, development of home and environmental assessment guides to identify triggers, education and outreach efforts in high-risk populations to aid in case finding (e.g., in areas with low income, high unemployment, and substandard housing, where there is exposure to secondhand smoke), development of community clean air policies (e.g., no burning of leaves, use of smoke-free zones), improved access to care for asthmatic patients (e.g., developing clinic services with consistent health care providers to decrease emergency department use), and assessment of schools and day care centers for lack of asthma triggers.

Sharing nutritional information is not related to the care of asthma patients. It is not necessary that all school personnel know how to use rescue inhalers, rather those who are in direct contact with the child with asthma.

3. A health care provider is working with elderly clients who have ongoing chronic disease. Which of the following strategies can best

assist the client with healing? (Select all that apply.) a. Advocating for increased support for elderly persons b. Eliminating signs and symptoms of disease c. Managing any chronic diseases to prevent complications and delay deterioration d. Maximizing self-care capacity e. Focusing on achieving quality of life ANS: C, D, E

With chronic illness, the focus is on healing (a unique process resulting in a shift in the body/mind/spirit system) rather than curing (elimination of the signs and symptoms of disease). Appropriate goals include maximizing self-care capacity, managing chronic diseases effectively, preventing complications, delaying deterioration and decline, and achieving the highest possible quality of life before dying with comfort, peace, and dignity. It is probably impossible to eliminate signs and symptoms of the disease with a client who has a chronic disease. Advocating for increased support for elderly persons is not related to assisting the client with healing from the chronic disease.

4. After seeing a public education program on the need for screening colonoscopy and the dangers of colorectal cancer, an older

friend asks the nurse, “I’m really scared of getting cancer. What can I do to avoid that kind of cancer?” Which of the following recommendations should be made by the nurse? (Select all that apply.) a. Avoid smoking or much alcohol. b. Choose poultry or fish as a protein source. c. Eat lots of fruits, vegetables, and fiber every day. d. Try to get at least 8 hours of sleep a night. e. Limit intake of red or processed meat.

ANS: A, B, C, E

Obesity, physical inactivity, smoking, heavy alcohol consumption, a diet high in red or processed meats, and insufficient intake of fruits and vegetables are risk factors for colorectal cancer. Getting an adequate amount of sleep will not avoid any risk factors for the development of colorectal cancer.

5. A nurse’s mother leans forward and says, “My best friend fell the other day and now she’s in the hospital. I’m really worried about

getting osteoporosis. What do you think I should do?” What should the nurse recommend? (Select all that apply.) a. Ask your doctor for hormone replacement therapy. b. Continue to abstain from alcohol. c. Eat foods high in calcium such as fortified skim milk. d. Eat lots of green leafy vegetables. e. Avoid tobacco products.

ANS: B, C, E

It is estimated that one of every two American women older than 50 years will experience an osteoporosis-related fracture in her lifetime. Primary prevention activities include a diet rich in calcium and vitamin D; exposure to sunlight for 20 minutes a day; exercise, especially weight-bearing activities such as walking, running, stair climbing, and weight lifting, to improve bone density; limit in alcohol consumption; and avoidance of smoking. Use of hormone replacement therapy and consumption of green leafy vegetables are not related to decreasing the risk of developing osteoporosis.

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Chapter 23: Health Equity and Care of Vulnerable Populations Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following is the primary cause of vulnerability to health problems? a. Breakdown of family structures b. Poverty c. Prejudice d. Social isolation ANS: B

People with lower incomes and less education tend to be at higher risk for health problems. Poverty is a primary cause of vulnerability. Breakdown of family structures, prejudice, and social isolation may all influence vulnerability to health problems but have not been identified as a primary cause.

2. Which of the following terms is used to describe aggregates who are at high risk for having poor health outcomes because of

limited resources? a. Disadvantaged families b. Multi-problem families c. Resilient populations d. Vulnerable populations ANS: D

Vulnerable populations are groups (aggregates) with an increased risk to develop adverse health outcomes. Families are a subgroup of populations and do not appropriately fit the definition of “aggregates.” Resilience refers to the ability to resist poor health outcomes, not to succumb to them.

3. A community health nurse would like to implement an intervention to increase lasting resilience among new immigrants. Which of

the following actions should be taken by the nurse? a. Direct clients to English-as-second-language courses. b. Give immigrant clients money to help them get settled. c. Identify areas in the city where housing is less expensive. d. Solicit donations for food, clothing, and other needs.

ANS: A

Vulnerability can be reversed by obtaining resources to increase resilience. Learning the basic language of the country of residence will give immigrants the ability to communicate and navigate through systems and thus remove barriers that promote disenfranchisement and disadvantaged status. Although money, food, and clothing meet needs for the short term, they do not help the immigrant develop the power and control to improve health risks over the long term or contribute to lasting resilience.

4. Which of the following factors predisposes many migrant farm workers to disenfranchisement? a. Being a minority group member b. Inability to attend religious services because of work requirements c. Previous experiences of physical abuse d. Short length of time in the community ANS: D

Disenfranchisement refers to a feeling of separation from mainstream society. The person does not seem to have an emotional connection with any group in particular or the larger society. For migrant workers who are frequently moving, the short length of time they stay in the community does not allow for the development of social ties. Being a minority group member would not by itself cause disenfranchisement if the minority group member lived in a community with persons from similar ethnic and cultural backgrounds. A person’s inability to attend religious services or to have had experienced previous physical abuse are not specifically related to disenfranchisement of the population of migrant farmworkers.

5. A large financial grant was being offered to whichever health facility wanted to accept the responsibility for giving care to local

vulnerable populations. Which of the following actions would most likely be taken by the local medical centers? a. Agree to collaboratively apply for the funds in a cooperative proposal. b. Individually compete eagerly for the additional funds now available. c. Reach out enthusiastically to this previously underserved population group. d. Strongly consider not applying, because this population will be expensive to treat.

ANS: D

Many agencies do not wish to provide services to vulnerable populations. Vulnerable populations are more expensive to treat because they have multiple, cumulative risks and require special service delivery considerations (e.g., to help overcome transportation problems or provide culturally competent care). Because of the major costs associated with providing care to this population and risks related to reimbursement, it would not be in the best interest of the agency to want to eagerly apply to provide care to this group.

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6. Which individual has the greatest risk for becoming a member of the vulnerable population of the local community? a. A male diagnosed with a cardiac issue who recently moved in with his adult child b. A single mother who is studying for a law degree at the local university c. A 50-year-old married female who has worked as a server in local restaurants for

her entire adult life d. A single male who has a history that includes a learning disability and a parent diagnosed with type 2 diabetes ANS: D

The WHO, consistent with Healthy People 2030, describes three overall determinants of health to be (1) the social and economic environment, (2) the physical environment, and (3) the person’s individual characteristics and behaviors. The WHO also notes that individuals are unlikely to be able to directly control many of the determinants of health, and this is directly related to vulnerability.

The seven WHO factors are as follows (WHO, 2015, pp. 1-2): 1. Income and social status: Higher income and social status are associated with better health.

2. Education: Low education is linked with poor health, more stress, and lower self-confidence.

3. Physical environment: Safe water and clean air; healthy workplaces; safer homes, communities, and roads; and good employment and working conditions, especially when the person has more control, all contribute to good health.

4. Social support networks: Family, friends, and community as well as culture, customs, traditions, and beliefs affect health.

5. Genetics, as well as personal behavior and coping skills, affect health.

6. Health services: Access and use of services affect health.

7. Gender: Men and women suffer from different types of diseases at different ages The single male with a history of learning disabilities and a family history of type 2 diabetes has several potential risk factors including those related to his social support network (being single); learning disabilities (effecting education and pos sible low self-esteem); and a first degree family history of a chronic disease (type 2 diabetes). While the life stories in the remaining options present the individual with risks, none have multiple risks like the male depicted in the correct option.

7. A homeless family brought their father to the public health clinic after he reported bleeding when he went to the bathroom. Which

of the following nursing actions would be most appropriate? a. Begin tests to determine the cause of the bleeding while asking about other family concerns from nutrition to shelter for the night. b. Refer the man to a urologist to address the urinary bleeding. c. Suggest that the family take him to an urgent care center immediately. d. Treat the urinary infection and give the man medication to take to prevent the recurrence of infection.

ANS: A

It is important to provide comprehensive, family-centered, “one-stop” services. Providing multiple services during a single clinic visit is an example of one-stop services. If social assistance and economic assistance are provided and included in interdisciplinary treatment plans, services can be more responsive to the combined effects of social and economic stressors on the health of special population groups. If the family is referred to a different provider or agency, it is likely that this follow-up will never occur. Only addressing the urinary infection, and not the homeless status of this family, does not provide the comprehensive services that are expected from a public health clinic.

8. Nursing students have been assigned to set up a health fair for the homeless population in a large urban setting. Without any funds

to pay for space, where should the health fair be located, assuming that all of the following sites are available at no cost? a. At the city’s homeless shelter, which is, by policy, vacant during the day b. At a large medical center, where the students could get permission to use an empty clinic in the evening c. At the largest inner city police station, where there was a large empty space available d. At the local community college, where there are plenty of tables and chairs ANS: A

The most convenient place for the clients would be the homeless shelter, where transportation and lack of comfort in an unfamiliar place would not be issues. It is helpful to provide comprehensive services in locations where people live and work, including schools, churches, neighborhoods, and workplaces. Thus, for the homeless population, the homeless shelter would be an appropriate location. Homeless persons would probably avoid the police station, and many may not wish to go to the medical center—also, there would be transportation issues. Depending on the location of the community college, there may also be transportation issues.

9. Which of the following bills would the nurse lobbyist, who believes strongly in social justice, encourage legislators to support? a. A bill that establishes policies requiring all persons to pay the same cost for

services regardless of income b. A bill that promotes universal health insurance coverage c. A bill that requires all health care providers to give care to uninsured persons without charge d. A bill that requires health care workers to report undocumented immigrants who present for treatment ANS: B

Social justice refers to providing humane care and social support to the most disadvantaged members of society. Nurses can be advocates for policy changes to improve social, economic, and environmental factors that predispose vulnerable populations to poor health. Many people do not have health insurance, particularly those who work in jobs where insurance is not offered, or costs are too high. Promoting universal health insurance for all would be a step toward providing humane care for those who might not otherwise be able to receive care. Requiring health care professionals to give care to uninsured persons without charge would quickly bankrupt hospitals, and health professionals could not afford to continue in those roles. Such a law is unfeasible. A bill requiring all persons to pay the same cost for services regardless of income is not feasible. Multiple factors, including the benefits provided by individual health insurance, influence the amount of money individuals pay to receive health care services. A bill for universal health insurance could potentially influence this inequality. Health care providers are obligated to provide c are to individuals in an emergency regardless of citizenship in the United States; thus, this bill would not be feasible given current standards. These options would also not support the philosophy of social justice.

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10. A nurse who is providing diabetes screening at a community clinic discovers that a new client has type 2 diabetes mellitus. The

nurse provides counseling, refers the client to an endocrinologist for initial assessment and treatment, arranges for the client to see someone regarding financial assistance, contacts the mobile van to arrange transportation, and sets up a follow-up appointment.

Which of the following types of service does these actions represent? a. Case management b. Client advocacy c. Holistic care d. Wrap-around services ANS: A

Nurses often function as case managers for vulnerable clients, making referrals and linking them with community services. Case management services are especially important for vulnerable persons because they often do not have the ability or resources to make their own arrangements. Linking clients with health services is accomplished by making appropriate referrals and by following up with clients to ensure that the desired outcomes from the referral were achieved. Client advocacy refers to actions taken on behalf of another. Because of the variety of actions being taken by the nurse, the nurse is functioning in a larger role than simply advocating for the client. Holistic care addresses providing care for physical as well as emotional and spiritual needs. The nurse is not addressing all of these aspects of care through this coordination. Wrap-around services refer to when comprehensive health services are available and social and economic services are “wrapped around” these services. These services are n ot being necessarily all being provided by the same clinic.

11. A nurse offers homeless clients yearly tuberculosis (TB) screening and free treatment for those who test positive for TB. Which of

the following levels of prevention is being used?

Primary prevention Secondary prevention Tertiary prevention Secondary and tertiary prevention

a. b. c. d.

ANS: B

Screening homeless adults and providing medications to those who test positive for TB are examples of secondary prevention. The TB screening identifies infection in early stages. Medications work to prevent infection from developing into disease. Primary prevention refers to actions taken to prevent the disease from occurring. Tertiary prevention refers to actions taken after the disease has already occurred. A screening test cannot be both secondary and tertiary preventions.

12. A community health nurse is implementing a tertiary prevention activity related to tuberculosis. Which of the following

interventions is the nurse most likely completing? a. Administration of skin tests to identify persons who have been infected with tubercle bacilli b. Assessing for signs and symptoms of active tuberculosis c. Directly observing clients with active tuberculosis as they take their antitubercular medications d. Interpretation of tuberculosis skin test findings ANS: C

Tertiary prevention is exemplified when nurses provide directly observed medication therapy for people with active TB. Administering skin tests, assessing for signs and symptoms, and interpreting tuberculosis skin test findings are all examples of secondary prevention as these interventions are all focused on screening or the follow-up on a screening test.

13. A staff member is orienting a new nurse to a health clinic that serves primarily vulnerable populations. Which of the following

statements indicates a need for additional staff education? a. “If a client who does not speak English comes in, you must obtain an interpreter right away.” b. “We try to take care of as many problems as possible in one visit, so when you interview the client, ask about additional concerns.” c. “You will like working with Hispanic immigrants because they all have close-knit family structures.” d. “You will need to assist the client by scheduling any referral or follow-up appointments around their work schedules.”

ANS: C

Assumptions are not helpful. Each person and family should be assessed individually. No two people or groups are alike. Any stereotype, positive or negative, can be problematic. Even though Hispanic groups, as a whole, do have close-knit family structures, by assuming that all Hispanics are this way, staff members are less likely to be open to the possibility of issues such as family violence. It is important for the staff member to obtain an interpreter after learning that a client does not speak English, so this statement does not indicate the need for additional education. Addressing multiple concerns within one visit is also appropriate and does not indicate the need for additional staff education. Also, it is important for the staff member to recognize the importance of working around work schedules; thus, this action is appropriate and does not indicate the need for additional staff education.

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14. Nurses at a homeless clinic are concerned that homeless clients rarely return to have the nurses assess the findings of their

tuberculosis (TB) skin tests. Which of the following is the most appropriate policy for the clinic to have regarding the screening test findings? a. Call all homeless clients 48 hours after TB skin testing to remind them to return to the clinic for test interpretation. b. Have homeless individuals read their TB skin test, if necessary, and mail in results on a postage-paid card coded to protect privacy. c. Readminister the TB skin test if the client returns later than scheduled for test interpretation. d. Routinely refer all homeless clients for chest X-rays.

ANS: B

Nurses should develop a way for homeless individuals to read their TB skin test, if necessary, and give them a self-addressed, stamped card they can return by mail with the results. Homeless people often do not have a way to receive telephone calls.

Additionally, they usually face numerous barriers to return to the clinic. These issues often require deviation from strict policies, especially strict policies that are not working.

15. A nurse is working as a case manager with a vulnerable population. Which of the following actions should the nurse do when

providing care? a. Be willing to enter into a long-term relationship with families. b. Direct and control the client’s care because the nurse knows what is most needed. c. Encourage families to become self-sufficient and less dependent on nursing personnel for advice and referrals. d. Rotate assignments periodically to prevent attachment and codependency.

ANS: A

Case management is a process that enhances continuity and appropriateness of care. When using case management with vulnerable populations, the nurse can be of greatest benefit if he or she is willing to develop long-term relationships with the families served.

This increases trust as well as continuity of care. Care involves a partnership between nurse and client. Nurses who direct and control the client’s care cannot establish a trusting relationship and may inadvertently foster a cycle of dependency and lack of personal health control.

MULTIPLE RESPONSE 1. Which statements by a nurse demonstrate understanding of the unique needs of vulnerable groups? (Select all that apply.) a. “I always address the problem that the client believes is the most important.” b. “I avoid asking clients for income or financial information, because this is an

invasion of privacy.” c. “I try to observe the client’s cultural traditions as I complete my assessment.” d. “I make sure to do a complete assessment, since we often don’t know when the person will return to the clinic.” e. “Understanding an individual’s cultural experience is an important factor in meeting their needs.”

ANS: A, C

The nurse should focus on what data are needed to help the client that day with the problem the client believes is most important. It is important to keep the client’s cultural traditions in mind when completing an assessment so that the nurse is able to provide culturally competent care. Because poverty is a primary cause of vulnerability, the nurse should include questions about the client’s financial status. Nurses should not provide financial or legal advice; however, they should make sure to connect clients with someone who can and will help them. Although an assessment must be done, a nurse should only collect data that will actually be used.

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Chapter 24: Rural Health and Migrant Health Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A 13-year-old resident in a rural community has been diagnosed with asthma. Which of the following providers will most likely

provide care to this client? a. Advanced nurse practitioner b. Allergist c. Pediatrician d. Pulmonologist ANS: A

The providers most often seen by rural adults are general practitioners and advanced practice registered nurses (APRNs). Most urban adults are more likely to seek care from a medical specialist (allergist or pulmonologist). A pediatrician would provide care specific to children which may or may not be appropriate depending on the age of the resident.

2. Which of the following best describes a health professional shortage area (HPSA)? a. An area with inadequate health care facilities for residents b. An isolated area of underserved populations within an urban region c. A region with insufficient numbers of health care providers d. A rural region of the United States with a population density of less than 10,000 ANS: C

An HPSA is a geographical area that has insufficient numbers of health professionals according to criteria established by the federal government. Often, rural areas have a physician, nurse practitioner, or nurse in community health who provides services to residents who live in several counties. The incorrect responses do not fit the definition of a HPSA. 3. A migrant farmworker has been injured while working on the farm. Which of the following would provide assistance to care for

this injury? a. Emergency department for immediate care b. Migrant Health Act clinics c. OSHA, because the man was injured by farm machinery d. Workers’ Compensation, because injury was at work ANS: A

The only source the nurse can count on using is sending injured workers to emergency departments for immediate care. Farming and ranching do not often fall under OSHA guidelines, because they are considered small enterprises. Therefore, safety standards are not enforceable, nor is Workers’ Compensation insurance usually available for the agricultural industry. Although there are migrant health clinics, they are not always geographically convenient.

4. A nurse is caring for a migrant farm worker who has been working in the agricultural industry for the past 10 years. When

questioned about environmental hazards, the client reports regular exposure to pesticides. Which of the following disorders is the client most at risk to develop? a. Cancer b. Memory loss c. Skin rashes d. Headaches ANS: A

Chronic exposure to pesticides and chemicals may lead to cancer. Memory loss, skin rashes, and headaches are all potential side effects of short-term exposure to pesticides and chemicals.

5. A migrant farmworker presents to the clinic reporting an acute onset dizziness, intense thirst, vomiting, fatigue, and headache with

difficulty concentrating. Which of the following conditions would cause such symptoms? a. Appendicitis b. Bacterial gastroenteritis c. Pesticide poisoning d. Viral illness ANS: C

Because a migrant farmworker is employed in agriculture, the most probable cause is pesticide poisoning. Acute health effects of pesticide exposure include mild symptoms of pesticide poisoning including headache, fatigue, dizziness, nervousness, perspiration, loss of appetite, thirst, eye irritation, and irritation of the nose and throat. Severe poisoning symptoms include fever, intense thirst, vomiting, muscle twitches, convulsions, inability to breathe, and unconsciousness. The work setting of a migrant farmer would lead the nurse to first consider pesticide poisoning as a potential underlying cause of these symptoms. However, some of these symptoms could potentially be present with appendicitis, bacterial gastroenteritis, or a viral illness.

6. In addition to those barriers faced by many residents in rural areas, what additional barrier to health care is a Hispan ic migrant

farmworker likely to encounter? a. Absence of culturally competent care b. Availability of specialists c. Distance of health care facilities from the place of residence d. High cost of health care ANS: A

For migrant workers, a language barrier and cultural differences often exist between them and other area residents, including health care providers. This is an additional barrier that is not faced by other rural residents. Barriers to health care in gen eral affecting all populations include whether services and professionals are available, affordable, or accessible to rural consumers, not just migrant workers.

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7. Which of the following is the most accurate description of a migrant farmworker? a. A person who does farm work as the primary means of employment, although

other work may be done when the seasonal work ends b. A person who immigrates to the United States to “follow the crops” in performing seasonal farm work c. A person who moves from place to place to earn money performing seasonal agricultural work d. A person who specializes in the development of rural land for the purpose of farming ANS: C

The Office of Migrant Health of the US Public Health Service defines a migrant farmworker as a person “whose principal employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months and who establishes for the purpose of such employment a temporary abode.” The emphasis in the definition of migrant farmworkers is on moving (temporary abode), farm work, and seasonal basis. Not all migrant farmworkers are immigrants.

8. An employer provides a migrant farm family the day off to visit the health clinic in a nearby community and tells them to take all

of the time they need. However, the family arrives at the clinic appearing very stressed. In addition to the health issue, which of the following would most likely be a fear experienced by the family? a. Their personal belongings may be stolen while they are at the clinic. b. Immigration officials will send them back to their home country. c. The clinic personnel will look down on them and be biased against them. d. They weren’t getting paid for that day, and continued employment is never certain.

ANS: D

Migrant farmworkers often have an unpredictable and difficult lifestyle. Many must leave home each year and travel to distant locations to work. They may be uncertain about their work and housing as they go from one possible job to another. An employer telling them to “take all the time they want” could be interpreted as meaning they may no longer be needed, and their next job may be very uncertain. Most migrant farmworkers are legal residents or US citizens, not illegal immigrants. If the clinic personnel provide culturally competent care, they should not be biased or look down on this family when providing care. They should not be at any greater risk to have their belongings be stolen than on any other day when they leave their home.

9. A migrant farmworker brings his daughter to the clinic with severe heat stroke from being out in the sun. The nurse explains the

danger signs and stresses staying cool and drinking lots of water. The man seems to know this already. Which of the following best describes the most likely reason that this happened? a. It was a rare occurrence, which probably won’t be repeated. b. The daughter either disobeyed her father and went out to play in the sun or just did not realize how hot she was. c. Children may work on small farms because the family may need the additional income. d. The parents were busy working and didn’t realize the child was outside so long.

ANS: C

Children 12 to 13 years of age can work on a farm with the parents’ consent or if the parent works on the same farm. Children younger than 12 years can work on a farm with fewer than 7 full-time workers. Children may need to work for the family’s economic survival. This child may be at risk for this occurring again because the family needs the income that is generated by the child’s employment. The child is most likely working and not going outside to play. In order for this child to work, the parents also were working on the same farm with them but again need this child’s income for survival.

10. A nurse is working with Mexican immigrants. Which of the following behaviors would most likely lead to a positive interaction for

the nurse? a. Avoiding touching the client except when necessary as part of the physical examination b. Calling the client by name, socializing before addressing the problem, and being very respectful c. Keeping all interactions direct, to the point, and targeted on the reason for presentation d. Maintaining a nonconfrontational relationship by avoiding any disagreement even if the nurse does disagree with what the client is saying ANS: B

The nurse is considered an authority figure who should respect (respeto) the individual, be able to relate to the indivi dual (personalismo), and maintain the individual’s dignity (dignidad). Such an approach would be expected for any client, not just with immigrants. Mexican individuals, like those of many cultures, expect to establish some rapport through talking about personal matters (chit-chat) for the first few minutes of an encounter before addressing any problems. Touching as a caring gesture is usually seen as a positive behavior. When interacting with Mexican immigrants, as well as some other cultures, establishing general rapport through conversation is expected rather than a direct, focused approach. It would be appropriate for a nurse to develop a therapeutic relationship with the client, not a nonconfrontational one.

11. A Mexican immigrant mother tells the nurse she is concerned that people in the community will give her daughter mal de ojo. To

which of the following folk illnesses is the nurse referring? a. Evil eye b. Fallen fontanel c. Fright d. Indigestion ANS: A

A common folk illness that a nurse may encounter with the Mexican client is mal de ojo, or evil eye. Caida de mollera is known as fallen fontanel, empacho is known as indigestion, and susto is known as fright.

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12. Which of the following conditions of the rural environment provides increased opportunities for teaching? a. Increased interaction among residents due to neighbors visiting neighbors on the

family farms b. Involvement in rural community activities provides more contact with community residents than in urban areas c. Nursing responsibilities in these areas stress the importance of primary, secondary, and tertiary preventions d. Increased illnesses and injuries of rural residents require that they see nurses more often ANS: B

Rural areas have fewer churches, stores, and schools. Thus, nurses may go to the same church, shop at the same stores, and/or have children in the same schools as their clients. There are also fewer organizations, so it is easier to become involved and meet everyone while participating. Visiting neighbors does not increase opportunities for teaching. The fact that nursing responsibilities include all levels of prevention is true of both urban and rural areas. The statement about increased illness and injuries in rural residents is wrong, because although illnesses and injuries are increased, rural residents often do not seek care for th ese conditions.

13. A nurse is implementing a tertiary prevention strategy related to pesticide exposure. Which of the following activities would the

nurse complete? a. Observe farmworkers for evidence of unsafe handling of pesticides. b. Provide teaching on how to handle pesticides to avoid or decrease exposure. c. Teach farmworkers how to recognize signs and symptoms of pesticide poisoning. d. Treat a client who has pesticide exposure to prevent complications.

ANS: D

Tertiary prevention involves actions taken when a person already has a condition so that complications and worsening of the condition are avoided. Thus, treating a client with exposure is tertiary prevention. Observing farmers for evidence of unsafe handling of pesticides is an example of secondary prevention as the nurse is assessing to detect a problem at the earliest stage possible. Primary prevention occurs when the nurse aims to prevent the problem from occurring which is accomplished when the nurse teaches about safe handling of pesticides and recognition of signs and symptoms of pesticide poisoning.

MULTIPLE RESPONSE 1. Which of the following best describes why health professionals would be particularly concerned about the health needs of residents

in rural areas? (Select all that apply.) a. 40% of rural children live in poverty. b. People in rural areas are especially susceptible to acute illnesses rather than chronic diseases. c. Diagnoses in rural areas are usually for physical injuries, not mental health concerns. d. The cost of healthcare is strain on rural families. e. Accessibility to healthcare is limited.

ANS: A, D, E

Nearly 40% of all rural children are impoverished. Poverty and inaccessibility to health care is a major problem for rural communities. Nearly one half of all rural adults suffer from at least one chronic condition. Stress, stress-related conditions, and mental illness are prevalent among populations that have economic difficulties, including rural populations.

2. A nurse is caring for Mexican migrant farmworkers. Which of the following conditions are of greatest importance for the nurse to

assess? (Select all that apply.) a. Tuberculosis b. Hepatitis c. High blood level of lead d. Malaria e. Diabetes ANS: B, C, E

Poor quality and crowded housing can contribute to such health problems as tuberculosis (TB) and hepatitis, as well as exposure to high levels of lead from pesticides. Diabetes is common among this population as well. Malaria is not an illness associated with the migrant farmer population.

3. A nurse tells her nursing supervisor that her family is moving from the urban area where they both live in a rural area to be near her

spouse’s parents, who are becoming less independent. Which of the following suggestions would the nursing supervisor provide to the nurse? (Select all that apply.) a. “Community members will probably hold you in higher regard and will look up to you.” b. “Expect to have less autonomy in a small town than you have working as a nurse in a medical center.” c. “You may feel like an isolated outsider, because the community may not immediately accept you.” d. “You will have to be very sensitive about the differences in the rural lifestyle.” e. “The church and school will be the centers for socialization.”

ANS: A, C, D, E

Nurses working in rural areas usually have a prestigious status in the community and are viewed as role models. They will be experiencing a different lifestyle in the rural area and should be sensitive to these differences. Churches and schools are seen as the socialization centers for the community. Also, moving into a community does require the community to be accepting of the outsider which may or may not occur quickly. Nurses working in rural areas typically have more autonomy because of the larger geographic area that is being served.

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4. A nurse’s family has moved to a rural area to be near her spouse’s aging parents. Which of the following would the nurse most

likely notice about the family’s new environment? (Select all that apply.) a. It is very difficult to obtain continuing education, except for online programs. b. Neighbors seem to expect the nurse to know everything about all health care and illness conditions. c. Neighbors ask questions about health concerns any time they see the nurse, regardless of where they are. d. People come to the health clinic before their situation becomes relatively serious. e. Boundaries between personal and professional lives are blurred.

ANS: A, B, C, E

The boundaries between home and work blur because clients are also neighbors and friends of immediate family members. Nurses are highly regarded by the community and viewed as experts on health and illness. Residents may ask health-related questions and request recommendations whenever they see the nurse. Nurses in rural areas may also be expected to, in general, know something about everything, and this can be a demanding expectation. Some of the challenges are professional isolation, limited opportunities for continuing education, lack of other health personnel or professionals with whom the nurse can interact, heavy workloads, the need to function well in several clinical areas, lack of anonymity, and for some, a restricted social life. Rural people often develop independent and creative ways to cope because of the distance, isolation, and sparse resources they encounter. Because of the sparse resources, rural residents may seek limited preventive care and may only come to the health clinic if their situation is severe.

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Chapter 25: Poverty, Homelessness, Teen Pregnancy, and Mental Illness Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. A nurse was shocked when late one night she saw a former high school friend going through a trash bin outside a fast-food

restaurant and pulling out half-eaten food. Which of the following is the most likely explanation for a healthy young adult engaging in such behavior? a. He ate his meal but wanted more and had no more money. b. He had full-time employment, but with such a low salary it was inadequate to meet basic expenses. c. A friend had thrown his meal away, and he thought he could find his friend’s untouched food. d. He was doing this to fulfill an obligation of fraternity initiation at the college.

ANS: B

The causes of poverty are complex and include decreased earnings, increased unemployment rates, and inadequate education and job skills. Thus, it is most likely that he was unable to meet his basic needs through his current employer. If he had already eaten his meal, it would be unusual to get additional food out of garbage, rather he should be able to afford to purchase additional food if he was able to purchase his meal. The young adult would most likely not be pulling out half-eaten food if he was looking specifically for a friend’s meal. There is no reason to assume that he was part of a fraternity.

2. Which of the following clients is most likely to experience a high incidence of poverty? a. A 65-year-old woman b. A 14-year-old male c. A 79-year-old male d. A 19-year-old female ANS: B

While gender is not relevant, the poverty rate for children under 18 years of age was 16.2 percent, and the poverty rate for people aged 65 and older was 9.7 percent.

3. A school nurse was talking to the teacher of an 8-year-old child who was living with her mother in their car. Which of the

following concerns would lead the nurse to talk to the teacher concerning the child’s academic progress? a. Protentional abuse risk b. Possible developmental delays c. Food insecurity d. Susceptibility to infections ANS: B

Poverty increases the likelihood of all the options but developmental delays will impact academic progress most severely.

4. Which of the following is the most rapidly growing group experiencing poverty? a. Hispanic families b. Women older than 65 c. African-American families d. Single men of all ages ANS: B

Under the official poverty measure, in 2017, 4.7 million adults ages 65 and older lived in poverty. The rate of increase among seniors increases with age and is higher among women, African Americans, and Hispanics.

5. Which of the following statements best describes why health care of the homeless is so expensive to the community? a. Health conditions of the homeless require increased preventive services. b. Homeless clients typically make more clinic visits for multiple health problems. c. Homeless people are a major source of spread for contagious diseases. d. Most care to homeless people takes place in hospital emergency departments.

ANS: D

Homeless persons have the same problems accessing care as do others in poverty (e.g., lack of money, lack of insurance, lack of transportation). Therefore, health care of homeless persons is usually crisis oriented and sought in emergency departments, where the cost of service is high but is not refused as it often is in clinics. It is likely that most homeless people do not seek preventive care, thus, it is not that they require increased services, but they are less likely to seek these preventive services. Homeless clients are likely to not be seen in the clinic setting. Homeless people may spread contagious diseases, but this does not explain why providing health care to this population is expensive.

6. The nurse who works at a homeless clinic wants to improve healing of chronic wounds in clients living on the streets. Which of the

following would be the best action to take to improve client outcomes? a. Provide antibiotics to all homeless persons with chronic, nonhealing wounds. b. Offer daily access to a room with soap, water, and bandages. c. Hand out free bandaging supplies following each clinic visit. d. Perform regular monitoring of the client’s wound condition.

ANS: B

Health problems faced by the homeless often are related directly to poor access to preventive health care services. Proper wound care relies on cleanliness; however, those living on the streets do not typically have ready access to soap and water. T he nurse can help by designating a wound room, in which clients can safely carry out wound care activities taught during clinic visits. If the wound is not kept clean, it is unlikely that antibiotics will be able to prevent an infection, and the antibiotics will not promote wound healing. Handing out bandaging supplies does not address being able to wash the wound on a regular basis. Monitoring of the wound will not assist in wound healing.

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7. A nurse is assessing a young, single pregnant woman. Which of the following findings would be of most concern to both mother

and fetus? a. Elevated blood pressure b. First prenatal visit at 5 months’ gestation c. Homelessness d. Positive STD test ANS: C

Pregnant homeless women present several challenges. They have higher rates of sexually transmitted diseases, higher incidences of addiction to drugs and alcohol, poorer nutritional status, and higher incidences of poor birth outcomes. Thus, being homeless is the most dangerous sign of those listed. Elevated blood pressure, positive STD test, and seeking prenatal care late in the pregnancy are all concerns for the nurse. However, most concerning would be homelessness, as homelessness presents many challenges for the women during and after the pregnancy.

8. A nurse is working to ensure long-term positive health outcomes of poor pregnant teens and their children. Which of the following

actions would the nurse most likely take? a. Assist teen mothers to learn about their body changes during pregnancy. b. Develop programs that allow teen mothers to complete their education. c. Offer courses in proper care of babies and how to be a parent. d. Monitor pregnant teens to detect early problems with pregnancy.

ANS: B

A direct correlation exists between poverty and poor health outcomes. Poor teens are nearly three times more likely to drop out of school as their nonpoor counterparts. When programs that assist the mother to complete her education are instituted, chances are increased for a better future, which improves health care over the long term across the life span. It is important to keep the pregnant adolescent in school during the pregnancy and have her return as soon as possible after the birth. Teaching about body changes a proper care of babies and parenting would address short-term health outcomes. Monitoring teens to detect early problems in pregnancy addresses short-term health outcomes as well.

9. A school health nurse presents a program on preventing teen pregnancy to a group of parents. Following the presentation, which of

the following comments by a parent would cause concern? a. “I do not know if my son is sexually active; however, I have decided I’m going to talk to him about it.” b. “My daughter is too intelligent to get involved with boys, even if her friends do sleep around.” c. “My daughter and I have often discussed sexuality, and when she’s ready, I’ll pay for her birth control pills.” d. “I have spoken to my son about birth control. He says he’s not ready to be a father and support a baby. He wants to go to college.”

ANS: B

Teens who are knowledgeable and want to be responsible often find it difficult to access birth control. Parents who do not talk about sexuality with their teens may find them more at risk for sexual permissiveness and pregnancy. Teens are often ignorant concerning sexuality and pregnancy and often very embarrassed to discuss such topics. Further, they often believe myths such as they cannot get pregnant the first time they have sex. The earlier their sexual debut, the less likely a birth control method will be used, because younger teens have less knowledge. Teens are more likely to be sexually active if their friends are sexually active.

Confidential reproductive health care services may be available for teens, but problems are still associated with transportation, school absences, and costs of care.

10. A nurse is providing care to a pregnant teenager. Which of the following principles is the most important for the nurse to consider

when providing care? a. All teen pregnancies are considered high risk. b. Limited self-care knowledge can lead to pregnancy complications. c. Pregnant teens are likely to receive prenatal care late in the pregnancy. d. Pregnant teens may have limited financial resources to pay for care.

ANS: A

It is crucial to consider all pregnant teenagers as high-risk obstetric clients. A number of problems (e.g., poverty, late entry into prenatal care, and limited self-care knowledge) can lead to complications of pregnancy, so it is important to treat every teen pregnancy as a special high-risk pregnancy. All of these statements are true; however, it is crucial to consider all pregnant teenagers as high-risk obstetric clients. Limited self-care, lack of prenatal care, and limited financial resources are all contributors to the potential for all teen pregnancies to be considered high risk.

11. The nurse is making a postpartum visit to a teenage mother and her month-old infant. Which of the following assessments would be

most important? a. Assessing for mother’s ability to fulfill her own growth and development tasks b. Assessing for mother’s knowledge about normal infant growth and development c. Assessing how much the teenage mother’s own mother is helping her cope with childcare d. Assessing whether the baby’s father is being helpful to the mother ANS: B

The primary goal would be to assess how much the mother knows and understands about the needs of infants and their development. Such knowledge helps avoid unrealistic expectations and frustrations, which could lead to child abuse. Although the nurse might assess for any and all of these options, however, the primary goal of a postpartum visit would be to assess knowledge regarding normal growth and development. A teenager mother’s knowledge about her own growth and development and how much assistance she is receiving from her own mother and the baby’s father would be secondary concerns.

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12. A mother and her son are in the emergency department seeking care after the son had become so angry that he put his hand through

a glass window and had to have stitches. The emergency care provider suggested a psychiatric consult. Now the mother asks, “Do you think my son is crazy?” Which of the following is the most appropriate response by the nurse? a. “Absolutely not. But a psychiatrist can help your son realize more appropriate ways of displaying anger.” b. “Have you had other reasons to think your son is crazy? Perhaps the psychiatrist can reassure you that your son is just an adolescent coping with hormones.” c. “Your son is having problems coping with anger. And naturally you’re upset. Let the psychiatrist determine whether your son is crazy or not.” d. “Your son is having problems with behavior, which is distressing all of you. A psychiatrist may be able to help your son cope with life in a more acceptable way.”

ANS: D

Mental health is defined as being able to engage in productive activities and fulfilling relationships with other people , to adapt to change, and to cope with adversity. Mental disorders are conditions characterized by alterations in thinking, mood, or behavior, resulting in distress and/or impaired functioning. Most persons do not get so angry that they become self-destructive (e.g., putting their hand through a glass window and requiring medical attention). The nurse can help the mother accept appropriate assessment and intervention by using positive language and giving hope. In order to respond therapeutically to the mother, the nurse should not use the words absolutely (which implies that there may not be a problem with the son at all) or crazy (which is not a positive word to describe the son’s behavior).

13. Which of the following is the leading cause of disability for adult Americans? a. Accidents b. Arthritis c. Anxiety disorders d. Workplace injuries ANS: C

Anxiety disorders are common both in the United States and elsewhere. An alarming 31.1 percent of the adult population will experience an anxiety disorder at some time in their lives (NIMH, 2018). Anxiety disorders may have an early onset and are characterized by recurrent episodes of illness and periods of disability. While the other options can contribute to disability, none are as impactful as anxiety.

14. A community mental health nurse is working within the community to help prevent youth violence. Which of the following

interventions would most likely be implemented by the nurse? a. Distributing literature that associates violence with a lack of intelligence b. Explaining to youth why youth violence is detrimental to society c. Partnering with associations to provide alternative activities that improve social skills d. Recommending increased funding to prosecute and jail teens associated with violent activity ANS: C

Community mental health providers can help prevent a culture of youth violence by creating coalitions and partnerships and providing activities to increase social skills by helping children learn to stop, think, and act. Distributing literatur e is an ineffective intervention as community members would need to read the literature that has been provided. Based on the growth and development of youth, they are unlikely to be able to truly understand the larger scope of youth violence. Recommending increased funding for prosecution and jail does not provide any measure to prevent the problem from occurring.

15. Which of the following clients is most at risk for suicide involving firearms? a. A 15-year-old female b. A 20-year-old male c. A 56-year-old female d. A 36-year-old male ANS: B

Suicide was the second leading cause of death for youth ages 10-24. Males take their lives about four times more often than do females, yet females are more likely to have suicidal thoughts than males are. Firearms are the most common method of suicide among males and poisoning among females.

16. A nurse is trying to identify the risk for mental health problems among older adults. Which of the following interventions should

the nurse implement initially? a. Provide information on mental health resources in the community. b. Teach the elderly to self-monitor for signs and symptoms of depression. c. Organize screening programs offered at senior centers. d. Teach older clients to focus on their strengths rather than their weaknesses.

ANS: C

Early detection and intervention for mental health problems can be increased if persons seeking primary care are assessed for mental health problems. Nurses are in an ideal position to assess and detect mental health problems. They conduct comprehensive biopsychosocial assessments as part of screening programs. While the other options are not inappropriate, they do not help identify mental illness in the older adult population.

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17. A nurse is concerned about stress related to the heavy caregiving burden assumed by adult children of older clients. Which of the

following actions by the nurse demonstrates the use of secondary prevention to limit caregiver stress? a. Asking caregivers how they are doing and suggesting coping strategies b. Encouraging caregivers to periodically leave the house for a couple of hours c. Establishing support groups for caregivers of older parents d. Referring some activities to neighbors and friends ANS: A

Secondary prevention activities involve screening activities that allow for early recognition of problems so that prompt interventions can limit disability. By asking caregivers how they are coping (thus screening), the nurse identifies problems early so that interventions can be employed to limit the extent of stress, thus paving the way for improvement. The other options are either primary or tertiary activities depending on whether the intervention takes place before or after caregiving stress has d eveloped.

Also, encouraging caregivers to periodically leave the house for a couple of hours could result in negative outcomes for the person needing care (unless a competent substitute is filling in for the primary caregiver).

18. A nurse would like to increase the accessibility to health care services for mentally ill homeless clients in the community. Which of

the following actions should be taken by the nurse? a. Apply for a grant to fund a mobile clinic to take health care to the clients. b. Distribute flyers to the homeless that detail the location of various types of health care services. c. Refer homeless clients to areas that provide temporary housing. d. Solicit donations for food and clothing to be distributed to the homeless.

ANS: A

Accessibility refers to the ability of clients to obtain needed health care services. Only applying for a grant for a mobile clinic can potentially improve accessibility to a health care clinic. Neighborhood clinics, mobile vans, and home visits can bring health care to people otherwise unable to access care. Coordinating services at a central location often improves client compliance because it reduces the stress of getting to multiple places. All of these options lead to opportunities for improvement in health, either directly or indirectly, but distributing flyers, referring homeless clients, and soliciting donations do not address the issue of accessibility.

19. According to the Federal Register, which of the following is the minimum income needed by a family of four to meet the basic

needs for healthy living (that is, an income below this amount is considered insufficient to provide the food, shelter, and clothing needed to preserve health)? a. $16,020 b. $26,200 c. $36,580 d. $40,890 ANS: B

As of 2020 for a family of four, the poverty level—defined as the threshold below which families or individuals are considered to be lacking the resources to meet the basic needs for healthy living—is $26,200.

20. A nurse is working to improve personal self-awareness in order to provide better client-centered care to clients living in poverty.

Which of the following questions should the nurse self-reflect upon?

What would I do if I lived in poverty?

What can be done to get poor people motivated to work?

How have the media images of poor persons shaped my image of poverty?

How can community resources assist those living in poverty?

a. b. c. d.

ANS: C

Self-awareness is a key component of providing authentic, genuine client-centered care. To clarify their own values and perspectives about poverty, nurses should ask themselves questions about poverty and persons living in poverty. These questions should cause the nurse to reflect on how his or her ideas of poverty have been developed. The only question that relates to the nurse reflecting on how personal values and perspectives have been developed is, “How have the media images of poor persons shaped my image of poverty?” The incorrect responses address how to address the issue of poverty or concerns of the nurse but do not address increasing the nurse’s self-awareness.

MULTIPLE RESPONSE 1. A teenager who has just come in for her prenatal visit appears to be about 6 months pregnant. Which of the following best describes

why the teenage girl has waited so long to come in for prenatal care? (Select all that apply.) a. Her friends were suggesting ways to make the problem go away. b. She knew she could not be pregnant because her boyfriend said he used a condom. c. She was afraid her parents would pressure her to terminate the pregnancy. d. She kept hoping the pregnancy would just go away. e. She dreads the gynecological examination.

ANS: C, D, E

Most young women suspect pregnancy as soon as a period is late. These young women may still delay seeking care, because they falsely hope that the pregnancy will just go away. A teen also may delay seeking care because she wants to keep the pregnancy a secret from her parents, who may pressure her to terminate the pregnancy, or because she does not want to have a gynecological examination. Barriers to care early in the pregnancy also include the real or perceived costs of care, lack of transportation, dislike or fear of the needed exams, and apprehension about the attitude of care providers toward her. Having friends suggest that the pregnancy will just go away is not a common reason why pregnant teens do not seek prenatal care; it is more likely that the teen herself is thinking that the pregnancy will just go away. Being told that a condom was used doesn’t make it so. The girl should know whether a condom was used or not without relying on verbal statements.

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2. A nurse is concerned about a teenage mother who does not seem to know how to play with an infant. Which of the following

behaviors would the nurse want to role-model as good parenting behaviors? (Select all that apply.) a. Allow the baby to cry for 10 or 15 minutes before reacting so that the infant can

learn to self-soothe. b. Cuddle the baby often. c. Teach the mother to keep her face about 4 or 5 inches from the baby and to gently

blow on the infant’s face. d. Sing to baby with different melodies until baby seems to listen and shows a preference for certain tunes. e. During the assessment, smile and gaze into the baby’s eyes.

ANS: B, D, E

Suggestions for promoting interaction between an adult and a baby include smiling and making eye contact. Singing may also help soothe a baby when fussy (try different melodies to see what the baby prefers). The mother should be taught to use a distance of 8 to 10 inches from the infant and should not blow on the infant’s face. The mother should soothe the baby and try to provide comfort before trying to let the infant “cry it out.”

3. A school nurse was caring for an 8-year-old child who had been hurt on the school playground. During the nurse’s assessment, the

child admitted that her mother was working but didn’t make much money, so the girl and her mother were living in their car. Based on this information, which of the following would the nurse most likely suspect? (Select all that apply.) a. Food insecurity b. Target of peer bullying c. Increased school absences d. Vision problems e. Depression ANS: A, C, E

The health problems of homeless children, although similar to those of poor children, often have more serious consequences and are at greatest risk for poor health as a result of poor nutrition, inconsistent health care, high levels of anxiety, an d an inability to practice good health behaviors. Homeless children also experience higher rates of school absenteeism, academic failure, depression, and emotional and behavioral maladjustments. It is possible that this child could be bullied; however, there are also children who do not live in poverty who experience bullying as well. Vision issues are generally no more a risk than for the general child population.

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Chapter 26: Alcohol, Tobacco, and Other Drug Problems in the Community Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following approaches has research suggested is the most effective way to approach drug addiction? a. Criminal justice system b. Harm reduction c. Punishment approach d. Substance abuse education ANS: B

The harm reduction model is a public health approach that recognizes addiction as a health problem and focuses on pragmatic interventions, especially education, to reduce the adverse consequences of drug use and treatment for addicts. Substance abuse education is only one part of the harm reduction model. Using an approach of punishment and the criminal justice system has not been found to be effective based on research.

2. A woman has just delivered a baby and is lamenting that the baby’s father is not with her. She shares with you that he became

involved with drugs and is now in prison for theft. The new mother says, “It’s so sad. He’s clearly no good.” Which of the following would be the best response by the nurse while demonstrating empathy? a. “I’m so sorry to hear that. Is your mother able to be with you?” b. “It’s good that you and the baby are safe from him.” c. “Is there anyone to help you with the baby until the baby’s father can be released and encouraged to get treatment for his addiction?” d. “You must hate him for leaving you alone with a new baby!”

ANS: C

The nurse must express concern and empathy and hold out hope for future improvement. To be therapeutic, the nurse must realize that any drug can be abused, that anyone may develop drug dependence, and that drug addiction can be successfully treated. It is inappropriate to assume that the woman wants assistance from her mother. There is no evidence to suggest that the woman or her baby were in danger before he went to prison. Saying “you must hate him” is not appropriate, as it is not the nurse’s role to tell the client how she should be feeling.

3. A man who takes a prescribed narcotic for pain on a regular basis reports that he does not like the way the medicine makes him

feel. He has tried to change to an alternate analgesic but experienced withdrawal symptoms when he stopped taking the narcotic.

Which of the following problems is the man experiencing? a. Drug abuse b. Drug addiction c. Drug dependence d. Substance abuse ANS: C

Drug dependence is a state of neuroadaptation (a physiological change in the central nervous system) and alterations in other systems caused by the long-term, regular administration of a drug. People who are dependent on drugs must continue using them to prevent withdrawal symptoms. Drug addiction is a pattern of abuse characterized by an overwhelming preoccupation with the compulsive use of a drug and securing its supply and a high tendency to relapse if the drug is removed. Substance abuse does not apply in this case, because the man is taking a prescribed medication for a legitimate purpose. The term drug abuse is no longer meaningful.

4. A school health nurse is asked by a parent group to explain risk factors for alcoholism. Which of the following information should

the nurse include? a. Alcoholism is determined primarily by the family environment. b. Alcoholism is determined partly by genetic factors. c. Persons who are alcoholics are usually women. d. Persons born with fetal alcohol syndrome are alcoholics from birth.

ANS: B

Research demonstrates that genes are responsible for about half of the risk for abuse of alcohol. Multiple genes play a role in a person’s risk for the development of alcoholism. Research has not shown that the family environment is the main risk factor for alcoholism. Alcoholism is more common among men than women. Persons who are born with fetal alcohol syndrome are not alcoholics from birth and are likely to have metabolic or other disturbances.

5. A movie shows a woman and a man having a contest to see who can drink more shots of whiskey. Who is more likely to “win” the

drinking contest when and one is unable to continue drinking? a. If their alcohol consumption is the same size, they’ll both pass out about the same time. b. Whoever has food in their stomach will probably vomit and be unable to continue drinking. c. The man will likely win because of an inborn tendency to greater alcohol tolerance. d. The woman will likely win due to the tendency to have more adipose tissue.

ANS: C

Women are more affected by alcohol than men, because women have less alcohol dehydrogenase activity than men; thus men have an increased tolerance for alcohol. It is also unlikely that they will both “win” at the same time because the alcohol will likely affect the woman factor than the man. The adipose tissue ratio is not a factor in alcohol tolerance. While vomiting may occur, it will not necessarily affect the ability to continue to consume alcohol.

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6. Students at first-day orientation at the local community college are discussing alcohol and drug abuse with their freshmen advisor.

During a break, some students go outside for soft drinks and snacks. Soon after, the advisor walks by and notices several of these students smoking cigarettes. Based on this, which of the following topics of the drug and alcohol orientation would be most important for the advisor to reemphasize after the break? a. A discussion of which drugs are commonly used on campus b. How students can learn to “just say no” when offered drugs or drinks c. How to recognize and overcome peer pressure to continue bad habits d. The fact that tobacco smoking causes more premature deaths than any other behavior ANS: D

The most relevant action in this case is making it clear to students that tobacco is a drug—and that smoking cigarettes accounts for one in five deaths in the United States. Smoking is the foremost preventable cause of death in the United States. Because the students are engaging in tobacco use, this is the most important topic to address with them at this time. If the students were not engaging in this behavior, the other topics of commonly used drugs on campus, just “saying no”, and overcoming peer pressure may have been just as appropriate.

7. A nurse sees the father of a newborn baby push his wife in a wheelchair out onto the patio. The man and woman each smoke a

cigarette while the baby sleeps in the mother’s arms. Which of the following information should the nurse share with the parents? a. Fetal nicotine syndrome may cause complications in the newborn. b. The sidestream smoke that the baby is exposed to is more dangerous than the mainstream smoke that the parents are inhaling themselves. c. The baby will eventually develop tolerance to tobacco smoke. d. The parents should switch to chewing tobacco as long as the child lives in the home.

ANS: B

Sidestream smoke contains higher concentrations of toxic and carcinogenic compounds than mainstream smoke. Sidestream smoke contains higher concentrations of toxic and carcinogenic compounds than mainstream smoke. Fetal alcohol syndrome is a cause of newborn congenital dysfunctions. There is not known tolerance to tobacco smoke. While chewing tobacco doesn’t produce smoke, the parents would still be at a considerable health risk from the nicotine.

8. Which of the following addictive drugs is both legal and culturally acceptable throughout almost all of the United States? a. Beer b. Caffeine c. Cigarettes (nicotine) d. Mixed alcoholic beverages ANS: B

Caffeine is in commonly served beverages such as coffee, tea, and soft drinks, as well as in some commonly used pain medications.

Beer, cigarettes, and mixed alcoholic beverages are not as culturally acceptable as caffeine, as there are regulations t hat limit the age that these products can be used.

9. A school nurse stops a student in the hall and expresses concern that, “Your eyes look rather red and dry.” The student yawns and

denies eye problems but does mention having gained 15 pounds since smoking “special cigarettes.” Which of the following is the student most likely smoking? a. Tobacco b. Crack cocaine c. Ice methamphetamine d. Marijuana ANS: D

Side effects of marijuana include increased appetite, dry and reddened eyes, and drowsiness. Side effects of crack cocaine and ice methamphetamine are similar and include increased breathing, rapid heart rate, high blood pressure, and increased body temperature. Tobacco use is associated with many chronic diseases but a person smoking tobacco would not necessarily display the student’s symptoms.

10. Which of the following is an accurate concern about the marijuana? a. Strength of most available marijuana is weaker than in the past. b. Paranoia is a known side effect of marijuana use. c. Marijuana has no effect on a fetus. d. Psychological and physiological dependence are seldom experience with

marijuana use.

ANS: B

Marijuana’s diverse reactions include anxiety, disorientation, and paranoia. The risks of marijuana are not being discussed as much as in the past. Today’s marijuana is stronger than ever before, and people can become addicted. The Substance Abuse and Mental Health Services Administration (SAMHSA) says “approximately 1 in 10 people who use marijuana will become addicted.” The rate increases to 1 in 6 if the youth is under age 18. Marijuana use has known effects on fetal development.

11. Which client may be able to safely detoxify and manage their withdrawal symptoms with only minimal medical supervision? a. A 50-year-old who uses diazepam to “manage my anxiety” b. The 30-year-old reporting a “weekend cocaine habit” c. A 60-year-old who takes a secobarbital “most nights to help me sleep” d. A 70-year-old who usually drinks “3-4 beers in the evening” ANS: B

Stimulants, e.g., cocaine or opiates, may produce withdrawal symptoms that are uncomfortable but not life threatening.

Detoxification from these drugs does not require direct medical supervision, but medical management of the withdrawal symptoms increases the comfort level. On the other hand, drugs such as alcohol, benzodiazepines, e.g., diazepam, and barbiturates, e.g., secobarbital, can produce life-threatening withdrawal symptoms. These clients should be under close medical supervision during detoxification and should receive medical management of the withdrawal symptoms to ensure a safe withdrawal.

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12. Research as shown that vaping increases an individual’s risk of contracting what disease five-fold? a. Gingivitis b. Mouth cancer c. Oral herpes d. COVID-19 ANS: D

Vaping increases the risk of contracting COVID-19. This is due to the fact that e-cigarettes affect the lungs and immune system, and that makes the user more susceptible to the virus. The seriousness is increased when teens or other uses share the e-cigarettes.

Research has found that people who vaped and smoked were five times more likely to develop COVID-19. The other options are potential risks but have not been shown to be so directly associated with vaping.

13. Three female clients were brought to the emergency department by ambulance after a two-car accident at a busy intersection.

Which of the following tests should automatically be done under such circumstances? a. Alcohol blood level b. Cardiac workup c. Pregnancy test d. STI tests ANS: A

Approximately 40% to 50% of people seen in trauma centers were drinking at the time of their injuries. Hence, blood alcohol testing should be routinely done for patients admitted to the emergency department for traumatic injuries. Because of the high rate of alcohol involvement in injuries seen in trauma centers, an alcohol blood level would be most important. A cardiac workup, pregnancy test, or STI test would not be the priority.

14. An IV drug abuser admits to the nurse he has no desire to stop using drugs, so rather than lecture the individual on the dangers of

drug addiction, the nurse provides information how to sterilize his needles. Which of the following prevention efforts is the nurse attempting to achieve? a. Primary prevention by educating about safe injections b. Primary prevention by avoidance of future legal complications c. Secondary prevention to reduce the risk for infection or other complications d. Tertiary prevention to reduce the transmission of blood-borne diseases ANS: D

Tertiary prevention is for people who already have a disease or problem (in this instance, someone already abusing IV drugs) to prevent complications (harm reduction). In this instance, because the client does not plan to stop taking drugs, the nurse is trying to prevent complications related to use of contaminated needles and reduce the transmission of disease through sharing contaminated needles with others. Using the harm reduction model, the nurse should provide education on cleaning needles with bleach between uses and inform the addict about needle exchange programs to decrease the spread of the blood-borne pathogens. This client is already using IV drugs, thus, the nurse will be intervening at the tertiary level of prevention. Secondary and primary prevention strategies would not be appropriate when working with this client who already has a known problem.

15. In which of the following scenarios is a family member enabling an individual to continue to abuse alcohol? a. The husband asks the nurse to explain why his wife’s continued drinking is

dangerous. b. The son threatens to leave home because he finds the father’s behavior embarrassing. c. The teenage daughter of an alcoholic turns to a favorite teacher for emotional support. d. The wife tells her husband’s boss that her husband is sick when he is actually inebriated.

ANS: D

Enabling is the act of shielding or preventing the addict from experiencing the consequences of the addiction. When someone lies for the abuser, the individual is enabling the abusing behavior to continue. The other options do not demonstrate the behavior of enabling, since none are shielding the abuser from experiencing the consequences of the addiction.

16. Which of the following statements accurately describes why methadone is used to treat heroin addiction? a. Addicts come to prefer methadone instead of heroin. b. Methadone blocks the effects of heroin and reduces the craving. c. Methadone prevents further dependence on drugs. d. Methadone gives an enjoyable high, so addicts continue treatment.

ANS: B

Methadone, when administered in moderate or high daily doses, produces a cross-tolerance to other narcotics, thereby blocking their effects and decreasing the craving for heroin. The advantages of methadone are that it is long acting and effective when taken orally, it does not produce a “high,” it is inexpensive, and it has few known side effects. The main effect of this medication is that it decreases the craving for heroin; it is not a drug that clients come to prefer nor does it prevent further dependence on drugs.

17. A client requests help to stop smoking. Which of the following methods would be the best for the nurse to suggest to the client? a. A combination of interventions, beginning with changing the environment b. Acupuncture to reduce the nicotine cravings c. Behavior modification through hypnosis d. Nicotine replacement products ANS: A

The most effective way to get people to stop smoking and prevent relapse involves multiple interventions and continuous reinforcement, and most smokers require several attempts at cessation before they are successful. Making changes to the smoker’s environment helps by eliminating cues to smoking, such as ash trays, lighters, and cigarette cases. Acupuncture, behavior modification, and nicotine replacement products may all assist the client in stopping smoking. However, it has been demonstrated that the most effective method involves a combination of strategies.

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18. A nurse is reviewing with a client the importance of the diabetic diet to maintaining control of blood glucose levels. The client

states, “I went to the classes and learned how to count carbohydrates. I have even started to write down what I eat for each meal.”

Which of the following would be most appropriate response from the nurse? a. “I’m so glad you’re beginning to recognize the need to control your blood sugar.” b. “Now you just have to make sure you don’t give that habit up!” c. “Sounds like you’re not ready to really plan your eating yet.” d. “That is great. You’ve started to take action and make changes.”

ANS: D

There are five stages of change: (1) precontemplation—or resisting that there is a problem, (2) contemplation—or thinking about the problem, (3) preparation—preparing for action and taking some initial steps, (4) action—or making modification in behavior and environment, and (5) maintenance—or preventing relapse. The client prepares for action by learning to recognize the importance of eating and needed changes. Therefore, the nurse should encourage and recognize that the client has begun serious change. This comment by the client demonstrates readiness to take action and needs to be encouraged by the nurse. The incorrect responses are not encouraging replies that would promote the client to continue to move forward with these actions.

19. At a county board meeting, a nurse reports statistics related to the increasing problem of substance abuse in the county. The nurse

then requests funding for an after-school recreation program that promotes age-appropriate fun activities and sports. Which of the following objectives is the nurse attempting to meet through this action? a. Help prevent obesity and boredom. b. Offer alternatives to being “on the streets.” c. Prevent children from getting in trouble before their parents get home from work. d. Promote healthy lifestyles with physical activity.

ANS: D

The nurse is engaging in primary prevention efforts against substance abuse by helping to promote healthy lifestyles and resiliency factors. The purpose of the nurse requesting this funding is to address the problem of substance abuse, not obesity. This program may offer an alternative to children and keep them safe and off the streets; however, the primary objective is to address the overall healthy lifestyle of these youth.

20. A school health nurse is conducting drug screening to detect drug use by students before serious problems develop. Which of the

following levels of prevention does this action represent? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Primary and secondary prevention ANS: B

One means of secondary prevention is to institute early detection (screening) programs in schools, workplace, and other areas in which people gather to determine the presence of substance abuse. Primary prevention involves education before a problem occurs.

Tertiary prevention occurs after the problem has occurred and aims to assist the client to the highest level of functioning. It is not likely for a single intervention to be both primary and secondary in prevention foci.

MULTIPLE RESPONSE 1. A mother is concerned that her daughter may be considering experimentation with drugs and alcohol. Which of the following

strategies would the nurse suggest the mother implement? (Select all that apply.) a. Provide opportunities for her daughter to develop her talents. b. Provide realistic feedback to the daughter about her performance at school. c. Encourage her daughter to become involved in extracurricular activities. d. Encourage her daughter to develop new friendships. e. Encourage her to discuss her dreams for the future.

ANS: A, B, C, E

Prevention guidelines to teach parents and teachers how to increase resiliency in youths include the following strategie s: help them develop an increased sense of responsibility for their own success; help them identify their talents; motivate them to dedicate their lives to helping society rather than believing that their only purpose in life is to be consumers; provide realistic app raisals and feedback, stress multicultural competence, and encourage and value education and skills training; and increase cooperative solutions to problems rather than competitive or aggressive solutions. Based on the information provided, there is no reason to suggest the child needs to develop new friendships. Keeping consistent friendships may provide the support the child needs to avoid engaging in these behaviors.

2. A nurse is helping a client’s family prepare to have an intervention that hopefully will encourage the alcoholic father to realize the

need for change. Which of the following instructions by the nurse to the client’s family members would be most effective? (Select all that apply.) a. “Express your belief in him and his ability to change.” b. “Point out that his behavior is his choice and his responsibility.” c. “Let him know that you understand how much he loves being with his drinking pals.” d. “Remind him that entering treatment is better than going to prison.” e. “Let him know that he is loved by his family and friends.”

ANS: A, B, E

Using FRAMES as a guideline, the nurse would provide Feedback about problems with using drugs, emphasize the person’s own personal Responsibility for any changes made, and give Advice on how to change behaviors, including a Menu of options from which to choose while expressing Empathy. Finally, the nurse would provide encouragement and belief that the person can change, hence increasing feelings of self-efficacy. Having the client’s family members tell the father that they understand his behavior does not encourage him to realize the need for change. Threatening a future possibility of prison would not provide encouragement to the father and may even challenge him to continue his behavior.

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3. A nurse is developing a community-based activity aimed at preventing substance abuse in the community. Which of the following

interventions would the nurse most likely implement? (Select all that apply.) a. Supporting an increase in the availability of recreational facilities b. Lobbying to state legislators to approve a higher cigarette tax c. Educating all middle school students about the long-term side effects of drugs and alcohol d. Providing general screenings for substance abuse e. Identifying community-based resources that deal with substance abuse issues ANS: A, C, D, E

Supporting an increase in additional recreational facilities would engage the community members in healthy activities rather than having them potentially turn to substances for relaxation. Providing screenings for substance abuse in the community may assist community members in recognizing the problem sooner. It would be appropriate to educate middle-school students about the long-term side effects of drugs and alcohol since they would be able to understand the information. Early intervention with education is a proven deterrent to substance abuse. Lobbying state legislators for increase in a higher cigarette tax may be beneficial, but this intervention is focused on the state rather than the community where the nurse is working. Identifying local resources where assistance and addition information about substance abuse issues can be found is an appropriate community-based intervention.

4. A home health client has been prescribed acetaminophen with codeine every 4 hours for pain following a hip arthroplasty. Which

of the following statements made by a nurse to the client’s primary health care provider indicates a need for further education on narcotics related to the goals of safe pain management? (Select all that apply.) a. “Please consider decreasing the time interval between doses to every 3 hours so that my client will maintain pain relief.” b. “I’m really concerned my client will become addicted to the codeine.” c. “Consider prescribing a different medication so that my client will achieve adequate pain relief.” d. “My client needs a prescription for PRN medication for ‘breakthrough’ pain.” e. “This medication is expensive; please prescribe something less costly.”

ANS: A, B, D

It would not be appropriate to ask to decrease the time interval in between doses as the increased use of acetaminophen may be damaging to the client’s liver and kidneys. There is no evidence that this client is at risk for developing an addiction. Thus, demanding that this medication be discontinued may be a premature action by the nurse. However, the nurse should monitor the patient closely for signs and symptoms of potential addiction. It would be appropriate to ask the primary care provider for an additional medication in the form of a PRN prescription to possibly assist with the client achieving optimal pain relief rather than changing medications entirely. Although it is a factor, the cost of pain medication isn’t a consideration when addressing safe pain management interventions.

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Chapter 27: Violence and Human Abuse Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following statements is the best explanation as to why some countries are more violent than others? a. Civilized societies are less violent than primitive societies. b. Geographical differences are the primary factor. c. Population differences are the main determinant—for example, having more

males than females. d. Violence is a learned behavior controlled or allowed by social norms.

ANS: D

Some societies are basically nonviolent, and for them violence is not a significant health problem. Violence is a learned behavior, and social norms can keep violence at low levels or even eliminate it. The learned culture of the society is the best indicator for violence, not the differentiation between civilized or primitive, geographic location, or population differences among males and females.

2. Which of the following statements best explains the primary reason why violence is so high among young male parents? a. Men tend to be more violent than women. b. They are young and thus lack maturity. c. Unemployment is higher in this population. d. Violent tendencies are transferred genetically along racial lines.

ANS: C

Most analyses conclude that the differential rates of violence in the United States have more to do with economic realities, such as poverty, unemployment, and overcrowding, than with race. Although violence among men may be higher than among women, this question specifically addresses “young men.” Economic realities are more indicative of this rate of violence than age and maturity.

Violence is a learned behavior; it is not transferred genetically along racial lines.

3. Which of the following is the top risk factor for intimate partner homicide? a. There is a gun in the house. b. The husband has made threats against wife before. c. The wife has previously reported being physically abused. d. The woman’s young daughter also lives with them.

ANS: C

The top risk factor for intimate partner homicide (IPH) is previous domestic violence. Other risk factors are access to guns, estrangement, threats to kill or threats with a weapon, nonfatal strangulation, and a stepchild in the home if the victim is a female; however, these are not the top risk factor.

4. Which of the following persons is most likely to be assaulted? a. A young man b. A young woman c. An older man d. An older woman ANS: A

Men are far more likely to be assaulted or killed than are women. The greatest risk factor for an individual’s victimization by violence is age; youths are at significantly higher risk.

5. Which of the following is the most likely reason for a man to rape a woman? a. Because the woman was asking for it b. For power and control c. Provoked by the woman’s dress and behavior d. Sexual pleasure and release ANS: B

The underlying issues of rape are hostility, power, and control. Sexual desire is not an underlying issue of rape, nor is provocative dress and behavior. Rape occurs because of power and control, not because the woman is asking for it.

6. A nurse is counseling a woman following a rape. Which of the following feelings is the woman most likely to state she felt while

being raped? a. Confusion b. Satisfaction c. Sexual release d. Victimization ANS: D

During the act of rape, survivors are often hit, kicked, stabbed, and severely beaten. It is this violence, as well as the violation of the sense of self, that most traumatizes the person because of the fear for her life and her feelings of helplessness, lack of control, victimization, and vulnerability. Because of the violence associated with rape, it is highly unlikely that the victim will report satisfaction or sexual release. The woman may be confused about what to do next, but it is more likely that the trauma will cause feelings of helplessness which could contribute to the confusion.

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7. A nurse is concerned about the possibility of suicide in a teenage boy. Which of the following characteristics has the boy most

likely displayed? a. He has threatened harm to his school peers. b. He is between the ages 15 and 19. c. He is depressed and has a history of being sexually abused. d. He has been accused of abusing an animal.

ANS: C

Leading risk factors for suicide are depression and other mental disorders or substance-abuse disorders. Other risk factors (that are not as common as the leading risk factors) include prior suicide attempt, family history of suicide, mental disorder, substance abuse or violence, firearms in the home, incarceration, and exposure to the suicidal behavior of others (family, peers, or figures in the media). Children who threaten to harm others or who abuse an animal are more likely to hurt others than themselves.

8. Which of the following is a common factor typically found in those who abuse others? a. Fear and belief that others are “out to get them” b. Poor self-esteem and unawareness of alternatives c. Previous observations of violent behaviors to manage conflict d. Difficulty keeping commitments ANS: C

People who become involved in violence typically had previous exposure to some form of violence. Abusers were often beaten when they were children, or they witnessed siblings or one of their parents being beaten. They learned that violence is a way to manage conflict. The incorrect responses are not commonly found among those who typically abuse others.

9. A public health nurse is hosting an informational meeting for young parents about how to balance their multiple responsibilities.

Which of the following parents in attendance would be most at risk for abusing his or her own child? a. A new mother who has joined a parents’ support group b. A father who is overwhelmed and exhausted by overtime work c. A depressed father who was laid off from work and is missing his work colleagues d. A mother who is missing her career challenges and friends but enjoying being home with her baby ANS: C

Parents with low social support, a tendency toward depression, multiple stress factors, and a history of abuse are at risk for abusing their own children. Abusive parents often have unrealistic expectations of a child’s developmental abilities. A new mother who has joined a parents’ support group is displaying positive coping behaviors. Although a mother is missing her career challenges, she is finding enjoyment in being home with her child which displays that she has a positive emotional health. A father who is overwhelmed and exhausted is at risk for abusing his children; however, he is not displaying as many risk factors and stressors as the father who is depressed, laid off from work, and missing his colleagues.

10. A teacher asks the school health nurse to assess a child for neglect. Which of the following assessment findings could indicate

neglect? a. Bruises in various stages of healing b. Failure of parent to attend parent-teacher conferences or return teacher phone calls c. Lack of weight gain and wearing dirty clothes d. Lice in the hair ANS: C

Physical neglect refers to failure to provide adequate food, clothing, shelter, hygiene, or necessary medical care; emotional neglect refers to the omission of basic nurturing, acceptance, and caring essential for health development. Lice are a common problem among schoolchildren, and the presence of lice does not indicate neglect. Failure to attend parent-teacher conferences should not be construed as neglect, because various reasons, such as employment requirements, may prevent parents who care from attending.

Bruising is a sign of physical abuse rather than neglect.

11. Which of the following statements by a parent indicates a need for increased learning regarding appropriate (nonabusive) discipline

of a child? a. “I have stopped using a switch on my child, and I am learning to count to 10 before reacting.” b. “I never spank or hit; I yell at them to stop being stupid, and if they don’t, I tell them no one is ever going to love them if they act like that.” c. “I use time-outs when my child acts out or is naughty. Sometimes my child doesn’t cope well with this, but I am persistent.” d. “When my child misbehaves, I distract him and focus his attention on other things. If he throws a tantrum, I have been known to just pick him up and leave from wherever we are.”

ANS: B

Emotional abuse involves extreme debasement of feelings and may result in the child feeling inadequate, inept, uncared for, and worthless. Yelling at a child and threatening loss of love are devastating. Counting to 10 before reacting, using time-outs, and distraction all display positive methods of discipline.

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12. A mother cannot understand why her daughter ran away from home. When the police locate the daughter, she complains of a severe

headache, so the police take both of them to the emergency department for assessment. Which of the following potential problems should be assessed by the nurse? a. The daughter’s inability to do well in school b. Intimacy problems with the daughter’s boyfriend c. The mother’s abuse of the daughter over a long period of time d. Sexual abuse by the father ANS: D

Nurses must be aware of the incidence, signs and symptoms, and psychological and physical trauma of incest. Symptoms include headaches, as well as other physiological problems. Children often try to avoid or escape the abusive behavior. Intimacy problems with her boyfriend, abuse by the mother, and the daughter’s inability to do well in school could all be potential reasons why the daughter ran away. However, the nurse’s primary concern should be the potential for sexual abuse because of the behaviors that are being displayed by the daughter.

13. The wife of an abusive husband reports to the nurse that her husband has been increasingly more abusive over the past year. Which

of the following should be the first action that is taken by the nurse? a. Arrange for the couple to attend marital counseling. b. Develop a plan for the wife’s escape if the violence starts again. c. Teach the client how to avoid initiating her husband’s anger. d. Work with the client on development of self-esteem.

ANS: B

Unfortunately, abuse tends to escalate in frequency and severity over time, and the man’s remorse tends to lessen. A nurse encountering severe abuse needs to consider the safety of the woman and her children as the priority. The woman will need an order of protection and help in getting to a safe place. At the very least, the woman must design a carefully thought-out plan for escape and arrange for someone to call the police if another violent episode occurs. Although marital counseling may be useful at an early stage of abuse, it is generally contraindicated at all other stages because of the risk to the woman’s safety. After first developing an escape plan, it may be beneficial for the nurse to speak with the woman more about potential triggers for the husband’s abuse as well as her own self-esteem and how that may be influencing the continuation of the relationship.

14. During a group counseling session for perpetrators of intimate partner violence, which of the following statements made by a client

indicates a lack of insight into his violent behavior? a. “I have been taking out my frustrations with work on my girlfriend.” b. “I love my girlfriend and didn’t want to hurt her; it was an accident.” c. “It might be a good idea for me to temporarily leave the house when I feel myself becoming angry.” d. “When I drink alcohol, I become more abusive toward my girlfriend.”

ANS: B

Violence is defined as those nonaccidental acts that result in physical or psychological injury. Although this client may now be feeling remorse, at the time the violent act was committed against the girlfriend, the intent was to inflict harm and maintain control. It was not an accident. The incorrect statements indicate an admission of a problem—at least on the surface.

15. Which of the following statements, made by a caregiver of an older client, should alert the nurse to assess for evidence of elder

abuse? a. “Mom is always into something and can’t seem to stay still, so I’ve been giving her half a Valium to get her to relax so I can get some rest.” b. “Mom wanted to stay at her home, but we were scared for her safety, so we moved some of her personal things into our home and brought her to live with us.” c. “She has not been having incontinence problems since we have been taking her to the toilet every 2 to 3 hours when she is awake.” d. “We have to feed Mom baby food now because she has trouble chewing and swallowing regular food.”

ANS: A

Giving medication to induce confusion or drowsiness so that the elders will be less troublesome or will need less care is considered a form of elder abuse. Such medication may also make it easier for adult children to control the elder’s assets. The incorrect responses are all examples of proper care.

16. A nurse is implementing a primary prevention strategy to address abuse in the community. Which of the following actions is the

nurse most likely taking? a. Encouraging others to interfere when they see children hit or hurt in a public place b. Referring caregivers to community respite centers if abuse is beginning to occur c. Lobbying for passage of legislation to outlaw physical punishment in schools d. Screening each pregnant woman privately for intimate partner abuse ANS: C

Primary prevention involves action before damage has occurred. The other options are all screening for abuse or reactions to abuse that has already taken place. Encouraging others to interfere when they see children hit or hurt in a public place and r eferring caregivers to community respite if abuse is beginning to occur are examples of tertiary prevention because the abuse is already occurring. Screening pregnant women for intimate partner abuse is secondary prevention as it is a screening aimed at early detection of the problem.

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17. A nurse is working with a family to reduce the incidence of home violence. Which of the following actions by the nurse would

most likely have a positive effect? a. Being assertive and taking control of decisions because family members cannot be expected to have this ability b. Focusing attention on family weaknesses that need to be fixed before healing can begin c. Pointing out things that victims should do differently to avoid antagonizing the abuser d. Soliciting ideas from the family regarding what they feel will improve their situation ANS: D

To empower the family, the nurse needs to recognize and capitalize on the violent family’s strengths and to guide the family in recognizing and dealing with its problems. The nurse must use a nurse-family partnership rather than a paternalistic or authoritarian approach. Families often can generate many of their own solutions—in fact, the family’s own solutions tend to be more culturally suitable and individualized than those the nurse generates.

18. Which of the following best describes a principle of care that the nurse should abide by when working with abusive families? a. Confront the abuser and shame him into penitence and a desire to change. b. Demonstrate respect for all family members, including the abuser. c. Exclude the abuser from family meetings because the abuser is the one creating d.

problems.

Notify the abuser’s clergyman, boss, and others who can exert pressure for change.

ANS: B

Principles of giving care to families who are experiencing violence include the following: intolerance for violence; respect and caring for all family members; safety as the first priority; absolute honesty; and empowerment. Confrontation and exclusion would not be therapeutic techniques for the nurse to implement. Notification of others would violate HIPAA laws, as the nurse should be keeping this information confidential.

19. A mother confides to the nurse that her live-in boyfriend knocked down her 2-year-old child because he was crying too much. She

begs the nurse not to tell anyone because her boyfriend has agreed to take anger management classes. Which of the following actions should be taken by the nurse? a. Abide by the mother’s wishes because this information was provided in confidence. b. Arrange for counseling for the boyfriend at the earliest possible availability. c. Encourage the mother to take the child and find alternate housing right away. d. Report the incident to child protective services or other appropriate legal authority.

ANS: D

Nurses are mandatory reporters of child abuse, even when only suspected, in all states. The incorrect options put the child’s welfare at risk, including encouraging the mother to seek alternatives, since encouraging an action will not ensure that it will happen.

MULTIPLE RESPONSE 1. Which of the following factors may lead to increased violence? (Select all that apply.) a. Minimal social support b. Feelings of powerlessness c. Violence shown in the media d. Living in a crowded environment e. A history of depression ANS: A, B, C, D

Factors that increase violence include seeing violence in daily life or in the media, living in poverty with few opportunities for employment, and feelings of powerlessness. Crowded environments can be a factor but can also lead to banding together for the common good. While social support is a positive factor, an insufficient amount may lead to increased violence. Depression is not necessarily a trigger for violence.

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Chapter 28: Nursing Practice at the Local, State, and National Levels in Public Health Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following is the underlying science or area of study on which public health is based? a. Biostatistics b. Epidemiology c. Medicine d. Social sciences ANS: B

It works across many disciplines and is based on the scientific core of epidemiology. Public health uses biostatistics in its practice. It is not a branch of medicine; it is an organized community approach designed to prevent disease, promote health, and protect populations. Public health is not based on the social sciences, which is the study of society and relationships.

2. A nurse is employed at the state department of public health. Which of the following is a fundamental principle guiding his or her

practice? a. Decisions are made at the federal level, disseminated at the state level, and carried out at the community level. b. Health of populations is only as good as the health of individuals that live and work in the community. c. Oversight of community health departments is the most important function. d. The interaction of the local-state-federal partnership is critical to success.

ANS: D

In the United States, the local-state-federal partnership includes federal agencies, the state and territorial public he alth agencies, and the local public health agencies. Their effective interaction is critical to the effective use of both financial and personnel resources to address the health of populations. Nurses working in all of these agencies work together to identify, develop, and implement interventions that will improve and maintain the nation’s health. Decisions can be made and implemented at the federal, state, and local levels. The health of individuals and populations is influenced by the health policies that are in plac e. The state agency may provide some oversight of local health departments, but that is not its primary purpose.

3. The public health administrator is in the process of hiring a new public health nurse. Which of the following statements made by an

applicant would most likely result in the applicant not being hired? a. “I like to be the only person working on a project because individuals in teams have their own ideas and plans and the resulting debate slows progress.” b. “I prefer to work in teams because no single person has too much responsibility because the burden is shared.” c. “Teamwork is better than work done by individuals because teamwork incorporates different perspectives.” d. “Whether teamwork is better than work done by individuals depends on the nature of the work being performed.”

ANS: A

An applicant who does not like to work in and with teams would not be appropriate to fill this position. Teamwork is a necessary skill when working as a public health nurse. Working in collaborative partnerships is an essential role of public health nursing.

Partnerships and collaboration among groups are much more powerful in making change than the individual client and nurse working alone. Part of the reason is that multiple perspectives are examined in the process of coming to the best solution.

4. Which of the following federal agencies is most influential in public health activities? a. The Agency for Healthcare, Research, and Quality b. Centers for Disease Control and Prevention c. Department of Health and Human Services d. Food and Drug Administration ANS: C

The US Department of Health and Human Services (USDHHS) and the Environmental Protection Agency (EPA) are the federal agencies that most influence public health activities at the state and local levels. The Agency for Healthcare, Research, and Quality, the Centers for Disease Control and Prevention, and the Food and Drug Administration are all pieces of the broader USDHHS. 5. Which of the following agencies are responsible for implementing and enforcing local, state, and federal public health codes and

ordinances and providing essential public health programs to a community? a. Community health clinics b. Federal health agencies c. Local health agencies d. State health agencies ANS: C

Local public health agencies are the agencies responsible for implementing and enforcing local, state, and federal public health codes and ordinances and providing essential public health programs to a community. State public health agencies are responsible for monitoring health status and enforcing laws and regulations that protect and improve the public’s health; they do not provide essential public health programs to the community. Federal health agencies develop regulations that implement policies formulated

by Congress. Community health clinics may provide essential public health programs to the community but are not responsible for implementing and enforcing local, state, and federal public health codes and ordinances.

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6. A nurse at a migrant clinic assists clients with completing the application process to receive supplemental food assistance. Which

of the following roles is the nurse preforming? a. Advocate b. Case manager c. Outreach worker d. Primary caregiver ANS: A

As an advocate, the nurse collects, monitors, and analyzes data and discusses with the client which services are needed and whether the client is an individual, a family, or a group. When using the role of case manager, the nurse assists in providing equal access to health care by identifying and alerting the community to gaps in services available. As an outreach worker, the nurse addresses the multiple needs of high-risk populations. Nurses provide direct client care when using the role of primary caregiver.

7. Which of the following best describes the primary reason life spans have notably lengthened over the past 100 years? a. Advances in hospital care and procedures b. Advances in medicine and medical research c. Advances in nursing practice d. Advances in public health ANS: D

A person born today can expect to live 30 years longer than someone born in 1900. Medical care accounts for 5 years of that increase, but public health is responsible for the additional 25 years, through prevention efforts brought about by changes in social policies, community actions, and individual and group behavior changes. Advances in medical care only accounts for 5 of the additional 30 years that longevity has increased. Hospital and nursing care are not specifically noted when discussing the increase in life span.

8. Which of the following best describes how public health nurses (PHNs) differed from other health care professions in the early 20th

century? a. PHNs contributed without receiving any salary for doing so. b. PHNs created new settings where health care could be given. c. PHNs gave care to powerless groups. d. PHNs worked outside any organized health care system.

ANS: C

During this period, public health nurses worked with populations and in settings that were not of interest to other health care disciplines or groups. Much public health service was delivered to the poor and to women and children, who did not have political power or voice. Public health nurses were employed by agencies and received pay for the work that they did. In the early 20th century, new settings where health care could be delivered were not developed. Public health nurses worked with a variety of partners to begin to include reproductive health, chronic disease prevention, and injury prevention activities.

9. Which of the following best describes the role of nursing in community health? a. Application of nursing and public health theory in promoting, preserving, and

maintaining health of individuals, families, or communities b. Health care provision offered in primary and secondary institutions or in the client’s home c. Provision of health care services in institutions located in the community but outside the hospital d. Use of the nursing process and evidence-based practice to meet Healthy People 2020 objectives for community health improvement ANS: A

Nursing practice in community health is the synthesis of nursing theory and public health theory applied to promoting, preserving, and maintaining the health of populations through the delivery of personal health care services to individuals, families, and groups.

The focus of practice is health of individuals, families, and groups. Care is provided within the context of preventing disease and disability and promoting and protecting the health of the community as a whole. Healthy People 2020 addresses the role of multiple disciplines in improving the health of the population; thus, it does not use the nursing process or is specific for the nursing profession.

10. A community health nurse is trying to decrease the incidence of emerging infections caused by drug-resistant organisms. Which of

the following actions would be most appropriate for the nurse to implement?

Lobby for increased use of antibiotics in the treatment and prevention of communicable diseases. b. Notify the Centers for Disease Control regarding any unusual signs and symptoms related to a communicable illness. c. Reinforce the importance of receiving vaccinations according to recommended schedules. d. Teach parents that antibiotics should not be used for treatment of viral infections or for prevention of bacterial infections. a.

ANS: D

The widespread, often inappropriate, use of antimicrobial drugs has resulted in loss of effectiveness for some infections. Clients and health care providers are responsible for the inappropriate use of antibiotics. The nurse can influence this trend by objecting to inappropriate use of antibiotics by providers and by educating individuals, families, health care providers, and the community about the dangers of misuse and overuse of antibiotics. Lobbying for increased use of antibiotics would not assist in decreasing the number of drug-resistant organisms. Notifying the Centers for Disease Control or increasing the percentage of children who are vaccinated will not affect the increased development of drug-resistant organisms.

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11. A nurse is applying for a public health nurse position at a local health department. Which of the following minimum levels of

educational preparation should the nurse have obtained? a. Associate degree in nursing b. Baccalaureate degree in nursing c. Master of science degree in nursing d. Training as a licensed practical nurse ANS: B

Educational preparation of nurses in community health should be at least a baccalaureate degree. Nurses need this level of education because of the increasing complexity of better care delivery in public health. A licensed practice nurse would need supervision for a registered nurse and would not be able to practice autonomously in this setting. Those registered nurses who have associate degrees are encouraged to seek further degrees because of the increasing complexity of better care delivery in public health. A master’s degree would be even more useful, but for many, advanced education may not be feasible.

12. Which of the following should be the focus for programming in the community related to communicable diseases proposed by

Healthy People 2030? a. Encouraging community members to engage in healthy behaviors b. Identifying high-risk sexual behaviors among community members c. Monitoring the sexual activity of adolescents d. Providing information about the hazards of multiple sexual partners ANS: D

Healthy People 2030 lists communicable disease as an area of focus including levels of human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), and sexually transmitted infections. One method to reduce the risk of acquiring a communicable disease is by the public health nurse providing information on the hazards of multiple sexual partners and street drug use. Encouraging “healthy behaviors” is not specific to the prevention of communicable diseases. Monitoring the sexual activity of adolescents only addresses one segment of the population, and monitoring does not provide an active intervention for the nurse to complete to influence the problem. Identification of high-risk behaviors is part of the assessment of the community and may assist the nurse in knowing what programs to develop, but this would not assist in decreasing the rates of communicable disease.

13. Which of the following is a core competency required of public health nurses? a. Knowledge in the use of high-technology diagnostics b. Knowledge of the implementation of electronic medical records c. Skill in the physical assessment of complex clients d. Skill in developing policy and planning programs ANS: D

The core public health competencies are divided into the following eight domains: (1) analytic assessment skills; (2) basic public health sciences skills; (3) cultural competency skills; (4) communication skills; (5) community dimensions of practice skills; (6) financial planning and management skills; (7) leadership and systems thinking skills; (8) policy development/program planning skills. The incorrect competencies are better suited for tertiary facilities such as hospitals.

14. Which of the following factors is causing nursing to change so quickly? a. Economic issues b. Increases in medical and nursing knowledge c. Legislative issues d. Technology changes ANS: A

More than any other single factor, the driving force behind nursing changes is the economy and the increase in managed care to decrease or control health care costs in the United States. Changes in technology and knowledge are not influencing the rapid change in nursing knowledge. Legislative issues are not influencing nursing practice.

15. A nurse is implementing a primary prevention activity to decrease the incidence of communicable disease. Which of the following

actions is the nurse most likely taking? a. Identifying and treating clients in a sexually transmitted disease clinic b. Partnering with schoolteachers to teach and observe handwashing techniques in elementary school children c. Providing case management services that link clients with communicable diseases to health care and community support services d. Performing directly observed therapy (DOT) for clients with active tuberculosis ANS: B

An example of primary prevention is to educate day care centers, schools, and the general community about the importance of hand hygiene to prevent transmission of communicable diseases. The goal of primary prevention is to prevent the disease from occurring. Identifying and treating clients are part of secondary prevention, as screening is being completed to determine at the earliest stage possible who has the disease. Providing case management services for those with communicable disease and performing DOT therapy with clients are both examples of tertiary prevention as the populations that the nurse is working with both already have the disease. Through tertiary prevention, the nurse is working to restore their health to the highest level possible.

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16. A public health nurse traces sexual contacts of clients with sexually transmitted diseases for screening and treatment. Which of the

following levels of prevention is being implemented? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Secondary and tertiary preventions ANS: B

Tracing individuals exposed to a client with a sexually transmitted disease is secondary prevention because the nurse is attempting to find those exposed and screen them. Once the exposed persons have been located, screening is another secondary prevention activity.

Through tertiary prevention, the nurse is working to restore their health to the highest level possible. If th e nurse were to provide direct care to the clients with sexually transmitted diseases, this would be an example of tertiary prevention. The goal of primary prevention is to prevent the disease from occurring. Thus, when providing primary prevention, the nurse could provide free condoms for sexually active persons or provide education about ways to prevent the transmission of these diseases.

17. A community mental health nurse is implementing a tertiary prevention activity. Which of the following interventions is most

likely being completed? a. Disseminating information about mental health to community organizations b. Partnering with school health nurses for early identification of children who have evidence of mental health problems c. Providing case management services that link clients with serious mental illnesses to mental health and community support services d. Screening high-risk clients for the presence of mental disorders ANS: C

An example of tertiary prevention is the provision of case management services that link clients identified with serious mental illnesses to mental health and community support services. Tertiary prevention aims to restore those with the disease to the highest level of functioning possible. Disseminating information about mental health is an example of primary prevention as the nurse is aiming to prevent a problem before it occurs. Partnering for early identification of children and screening high-risk clients are examples of secondary prevention. Secondary prevention occurs when the nurse conducts screenings and tries to identify diseases at the earliest possible stage.

18. A nurse is working at a local health department. Which of the following would most likely be completed by this agency? a. Enforcement of laws and regulations related to public health nationwide b. Provide leadership in planning community health screenings c. Providing experts in various specialties to answer questions and respond as

needed d. Surveying the state’s public health needs ANS: B

Local public health agencies provide and disseminate health information, provide leadership in health planning, provide essential public health and environmental services, analyze statistics on births to monitor community health status, and file a certificate for every birth or death in the community. Enforcing laws and regulations related to public health nationwide, providing experts in various specialties, and surveying the state’s public health needs would all occur at the state level.

MULTIPLE RESPONSE 1. A nurse is employed by a state public health department. Which of the following functions would most likely be completed by this

agency? (Select all that apply.) a. Delegating power to engage in certain activities such as quarantine b. Enforcing laws and regulations that protect public health c. Filing birth and death certificates whenever these occur within the state d. Monitoring health status of citizens within its geographic boundaries e. Fund and conduct a school eye screening ANS: A, B, D, E

State public health agencies are responsible for monitoring health status and enforcing laws and regulations that protect and improve the public’s health. These agencies receive funding from federal agencies for the implementation of public health interventions such as the maternal and child health programs. State agencies distribute federal and state funds to the local public health agencies to implement programs and provide oversight and consultation for local public health agencies. State health agencies also delegate some public health powers, such as the power to quarantine, to local health officers. Local departments file birth and death certificates and often ask for volunteers to assist.

2. Which of the following activities are addressed by most public health departments on the federal, state, and local levels? (Select all

that apply.) a. Collecting and analyzing various health statistics b. Fining any facility that engages in unsafe commercial practices c. Identifying and planning for high-risk populations d. Planning for and responding to emergencies e. Providing health assessments to older adults after a hurricane ANS: A, C, D, E

The majority of local, state, and federal public health agencies engage in collecting and analyzing vital statistics, pr oviding health education and information, receiving reports about and investigating and controlling communicable diseases, protecting the environment to reduce the risk to health, providing some health services to particular populations at risk, planning for and responding to natural and human-made disasters and emergencies, identifying public health problems for at-risk and high-risk populations, conducting community assessments to identify community assets and gaps, and partnering with other organizations to develop and implement responses to identified public health concerns. Public health departments do not regulate the practices of businesses; thus, they would not be responsible for fining or terminating businesses.

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3. What did events after September 11, 2001, clearly demonstrate? (Select all that apply.) a. A strong public health structure ready to respond effectively to a crisis b. Public health’s need for additional funding and resources c. The unrecognized importance of nurses in lowering health care costs d. Lack of adequate vaccines to meet community’s needs e. The need for public education regarding bioterrorism attacks ANS: B, C, D, E

The anthrax exposures after 9/11 alerted policymakers to the weakening public health infrastructure required to respond to bioterrorism events. Unprecedented influenza, tetanus, and childhood vaccine shortages and emerging infections competed with bioterrorism activities for resources. The general public was not informed about how immunizations by nurses improved health and lowered health care cost. For public health services to receive adequate funding, it is necessary for the public and the government to be aware of the benefits provided to a community by nurses. These events showed that the public health system needed to be strengthened in order to operate effectively to keep the public safe.

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Chapter 29: The Faith Community Nurse Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following best describes the primary difference between parish nursing and all other nursing positions? a. Affiliation with a church or congregation b. Incorporation of spiritual aspects into nursing care c. Provision of holistic nursing care d. Residence within the community of service ANS: A

In 1998, the American Nurses Association accepted parish nursing as the most recognized term for the practice of nurses working with congregations or faith communities. All nurses may choose to incorporate spiritual aspects into holistic nursing care.

2. To help congregation members better meet their nutritional needs, the parish nurse organized members to participate in activities

that focused on fellowship while providing healthy meals to homebound members and serving “healthy heart” church suppers.

Which of the following activities is being completed? a. Holistic care b. Health ministries c. Partnerships d. Pastoral care practices ANS: B

Health ministries are those activities and programs in faith communities organized around health and healing to promote wholeness in health across the life span. These services include activities such as visiting the homebound, providing meals for families in crisis or when returning home after hospitalization, organizing prayer circles, serving “healthy heart” church suppers, and holding regular grief support groups. Holistic care is concerned with the relationship of body, mind, and spirit in a constantly changing environment. Providing a healthy meal does not address these multiple components. Partnerships may be among individuals, groups, and health care professionals within the congregation. It may involve partnerships to provide these meals; however, the focus is on the overall health ministry provided by this activity, not the partnerships which may be necessary to develop the program. Pastoral care practices involve stressing the spiritual dimension of nursing, lending support during times of joy and sorrow, guiding the person through health and illness throughout life, and helping identify the spiritual strengths that assist in coping with particular events. These practices related to pastoral care are not provided through this meal.

3. Which of the following best describes why it is helpful to be a member of a faith community? a. Belief and traditions help with coping. b. Members can ask others in the group for help. c. It is a social outlet. d. Members are able to get others to contribute to the causes they support.

ANS: A

Persons who encounter assaults with physical and emotional illness and brokenness and who are able to call upon their faith beliefs and religious traditions are able to increase coping skills and realize spiritual growth even during adversity. Family c ommunities do allow for a social outlet, asking others for help, and getting others to contribute to causes the support. However, the common connect of faith and traditions is what connects the members together and allows them to accomplish these other things.

4. Which of the following principles is central to the role of the parish nurse? a. Advanced nursing practice education and skills b. Faith consistent with the community and its leadership c. Spiritual dimension of care d. Willingness to serve anyone in need ANS: C

The spiritual dimension of health care is central to the practice of parish nursing. Advanced nursing practice education and skills, although helpful, is not necessary for a nurse to become a parish nurse. Having a faith that is consistent with those who the nurse is working with is helpful, but not essential to the role of the parish nurse. Willingness to serve others is not specific to the role of the parish nurse, but rather a role that all nurses should embrace.

5. A young woman had been away from home several years before she returned home sick and disheartened. Her mother called a

nurse to help. Which of the following behaviors would suggest that the caregiver who arrived was a parish nurse? a. Advanced nursing practice education and skills b. Compassionate, skilled, dedicated touch c. Offered a prayer with the daughter and mother d. Willingness to do whatever was needed by mother or daughter ANS: C

The spiritual dimension of health care is central to the practice of parish nursing. Both nursing functions and pastoral care functions are performed by parish nurses, whose visits often involve prayer and reference to scripture, symbols, sacraments, and liturgy of the faith community. Advanced nursing practice is not required for a parish nurse, so this would not suggest that the nurse was a parish nurse. All nurses should demonstrate compassionate, skilled, and dedicated touch; thus, this would not be specific to the role of the parish nurse. Nurses should be willing to complete tasks that are within the scope of their practice, and this does not specifically describe what that scope of practice would be for a parish nurse.

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6. Which of the following statements best describes how clients and parish nurses typically perceive spiritual health? a. It exists at the point that cure is attained. b. It has a tangential relation to well-being. c. It is part of an ongoing dynamic process. d. It is usually unchanging across the life span.

ANS: C

Health, spiritual health, and healing are considered parts of an ongoing, dynamic process. Because spiritual health is central to well-being, influences are evident in the total individual and noted in a healthy congregation. Well-being and illness may occur simultaneously; spiritual healing or well-being can exist in the absence of cure. Spiritual health and its definition is an ongoing and dynamic process; thus, it changes across the life span.

7. Which of the following statements suggests that faith community nursing is a nationally recognized specialty of nursing? a. Academic programs now offer a clinical specialty in parish nursing. b. Faith community nurses are increasingly receiving salaries for their efforts. c. Faith community nursing is being adapted in other countries and to non-Christian

faiths. d. Scope and standards of faith community practice have been developed and revised.

ANS: D

The 2005 Faith Community Nursing: Scope and Standards of Practice revised the original 1998 document in describing the who, what, where, when, why, and how of the practice of faith community nursing. Specialty areas within professional nursing achieve a major milestone when the standards and scope common to that practice are recognized. Academic programs do not offer a clinical specialty in parish nursing; however, there may be ways to obtain specialty certification in the practice after becoming a registered nurse. Many faith community nurses work as volunteers. The majority of parish nurses are found in Protestant congregations, but they can be found around the world and in other faiths; however, there is nothing to suggest that the practice needs to be adapted when working with these other populations.

8. A group of parish nurses affiliated with a number of faith-based communities located in different regions across the state are

attending a quarterly meeting. Which of the following statements made by one of them indicates a lack of understanding of parish nursing? a. “I always make sure to have new clients sign a release of information form to obtain their health record from their previous parish nurse.” b. “Because I work for and within the church, I am immune from civil laws.” c. “The pastor and I work together for the spiritual health of the community.” d. “Yes, I am happy to pray with my clients and help them worship.”

ANS: B

A nurse stating immunity to civil laws does not understand the role of the parish nurse. Parish nurses must abide by all of the parameters of the nurse practice act of the state just as other registered nurses. The nurse must personally and professionally abide by the parameters of the nurse practice act of the jurisdiction and maintain an active license of that state.

9. A nurse is considering accepting the parish nursing position within their congregation. Which of the following educational

preparation is crucial for the nurse to have received? a. Baccalaureate education including community health nursing experience b. Graduate education in community health nursing c. Passing the national certifying examination for parish health nursing d. Worship experiences for the process of ministry ANS: A

Current educational preparation for the parish nurse includes the successful completion of extensive continuing education contact hours or designated coursework in parish nurse preparation at the baccalaureate or graduate level, as well as a thorough grasp of the scope and standards of the practice. These basic programs provide an orientation to the role and functions of the parish nurse, as well as worship experiences for the process of ministry. Graduate education is not necessary to be employed as a parish nurse. A national certification examination for parish health nurses does not exist at this time. The parish nurse must be a member of the faith community and be comfortable with worship practices and traditions to function; however, the main function of the parish nurse is not ministry.

10. A family shared their concerns, including sexual issues, in strictest confidence with a faith community nurse. When the nurse

returned to the church office, the pastor asked why the family wanted to see the nurse. Which of the following statements would be the best response by the nurse? a. “Because you are my supervisor, I will summarize what was said for you.” b. “I will include that information in my report to our church’s wellness committee.” c. “They just wanted me to assess their health needs and make some suggestions.” d. “The family had some issues they wanted to discuss in confidence, which I will keep in confidence.”

ANS: D

Issues of privacy and confidentiality as well as record management should be discussed upon accepting a position. Regardless, if the nurse agreed to keep the information confidential, the nurse is morally obligated to do so. If the practice is to share all information with the pastor, then the family must be told this before they choose to share any information with the nurse. In order to keep this information confidential, the nurse should not disclose to the pastor that the nurse spoke with them about their health needs, as this may lead to further questions by the pastor. Additionally, because of confidentiality, the nurse would not share this information with the church’s wellness committee.

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11. A father confides to the parish nurse that his wife has been hurting their 3-year-old daughter. The nurse examines the daughter and

finds evidence of physical abuse. In the parish nurse role, which of the following actions should the nurse take first? a. Contact the pastor for guidance in handling this situation. b. Recommend that the family be removed from the faith community. c. Refer the family to pastoral services for counseling. d. Report the findings to child protective services.

ANS: D

As an advocate of client and group rights, the nurse identifies and reports neglect, abuse, and illegal behaviors to the appropriate legal sources. This is necessary regardless of the feelings of the pastor or the father because the nurse is bound legally to report abuse to a child, confirmed or suspected. Referral for counseling is appropriate; however, the child’s present state of well-being is paramount. Parish nurses must obey the nurse practice act and laws of the state. The nurse should not need to contact the pastor, as it is within the scope of nursing practice to report suspected abuse.

12. A faith community nurse is partnering with a local public health department to develop programs for primary, secondary, and

tertiary prevention activities. Which of the following should be used as the primary guide for development? a. Contemporary articles in nursing journals b. Evidence-based practice guidelines for treatment of disease c. Healthy People 2030 goals and objectives d. Preferences of partners who are funding the programs ANS: C

Healthy People 2030 guidelines are basic to the planning of health care. Contemporary nursing articles may be limited in scope and it may be very time consuming for the nurse to search multiple articles to find examples of these various levels of prevention.

Evidence-based practice is for treatment, not for program development. Preferences of partners should not be used as the primary guide for development, rather after reviewing Healthy People 2030, the nurse may want to decide on which community partners would be appropriate for program development.

13. A parish nurse is evaluating health programs that provide holistic care across the life span. Which of the following methods would

be the most appropriate approach? a. Bringing families together to plan programs to meet the needs of individuals b. Establishing a wellness committee to assist in the evaluation process c. Matching financial resources with program objectives and goals d. Revisiting assessment data to be certain that planning reflects actual problems observed ANS: B

The nurse and members of the congregation assess, plan, implement, and evaluate programs. The process of providing holistic care is enhanced by an active wellness committee or health cabinet. These incorrect options deal with factors other than program evaluation.

14. Which of the following statements by a parish nurse exhibits a lack of understanding of the concept of pastoral care? a. “By working with my clients to help them identify their spiritual strengths, I am

drawing on pastoral care aspects of practice.”

“To incorporate pastoral care, I should involve the pastor in ministering to the members of the congregation.” c. “I use pastoral care when I emphasize the spiritual dimension of nursing when providing care.” d. “When I lend support to my clients during times of joy, as well as during their times of sorrow, it illustrates an important aspect of pastoral care.” b.

ANS: B

Pastoral care is a service ministry formalized by a church or faith community, not necessarily involving the pastor. The nurse fulfills the role of pastoral care through stressing the spiritual dimension of nursing, lending support during times of joy and sorrow, guiding the person through health and illness throughout life, and helping identify the spiritual strengths that assist in coping with particular events.

15. A parish nurse is using the institution-based model to plan care for a client with a chronic illness. Which of the following activities

would the nurse most likely implement? a. Bringing in family members to work with the client and nurse in decision making b. Partnering with outlying health care centers for coordinating optimal care c. Pulling from the collective strengths of faith-based community members for social support for the client d. Relying on congregational prayer as a component of healing ANS: B

The institution-based model includes greater collaboration and partnerships. The nurse may be in a contractual relationship with hospitals, medical centers, long-term care establishments, or educational institutions. Thus, based on the institution-based model, partnering with outlying health care centers is appropriate. The other options are better examples of the nurse implementing the congregation-based model. In this practice, the nurse usually practices autonomously and is accountable to the congregation and its governing body. There are not specific partnerships in this model.

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16. A nurse would like to maximize autonomy in their parish nursing practice. Which of the following models would most likely be

preferred by the nurse? a. Congregation-based model b. Institution-based model c. Teamwork model d. Partnership model ANS: A

In the congregation-based model, the nurse is usually autonomous. The development of a parish nurse/health ministry program arises from the individual community of faith. The nurse is accountable to the congregation and its governing body. The institution-based model includes greater collaboration and partnerships. The nurse may be in a contractual relationship with hospitals, medical centers, long-term care establishments, or educational institutions. The teamwork and partnership models are not models of parish nursing.

17. A parish nurse organizes the annual health fair for the congregation, inviting community agencies to attend the event and display

the health resources that are available in the community. What function of the parish nurse is being demonstrated? a. Health advocate b. Referral agent c. Health educator d. Coordinator of volunteers ANS: D

As the coordinator of volunteers, the parish nurse recruits, trains, and supervises volunteers to expand ministry and outreach; organizes a health ministry team to guide and direct faith and health initiatives; and utilizes the gifts and talents of congregation and community members. As a health advocate, the parish nurse empowers congregation members to obtain needed health care services. Using the function of referral agent, the parish nurse provides information for referrals to appropriate agencies and services. As a health educator, the parish nurse focuses on the teaching role of the nurse; organizing a health fair enables others to complete that health teaching, not the parish nurse.

18. A parish nurse is implementing a primary prevention measure related to obesity among the school-age members of the church.

Which of the following activities is most likely being used by the nurse? a. Establishing a walking program that is sufficiently challenging yet not too strenuous for those who are obese b. Partnering with youth camp cooks to ensure that food is nutritious c. Supervising height and weight measurements taken by clinic assistants d. Working with parents of obese children to implement family lifestyle changes ANS: B

An example of primary prevention is encouraging healthy snacks and meals for youth outings and at educational hour and parenting sessions. The incorrect options all deal with secondary prevention activities, which are focused on decreasing obesity.

MULTIPLE RESPONSE 1. The parish nurse is working with the wellness committee to develop health programming for the congregation. Which of the

following activities would the nurse most likely include? (Select all that apply.) a. Provide regular blood pressure screening for members of the congregation. b. Create a bulletin board to display information about the signs and symptoms of stroke. c. Implement a program to speak with adolescents about stress management. d. Research evidence-based approaches for chronic wound healing. e. Provide healthy recipes for holiday baking.

ANS: A, B, C, E

As a member of the wellness committee, the parish nurse is concerned with reducing the risk of development of disease or disorder among all of the members of the congregation. Thus, implementing strategies that are related to health promotion would be appropriate for the nurse to implement. These would include blood pressure screenings, creation of bulletin board about stroke, healthy eating-related information, and implementation of stress management program for adolescents. Researching evidence-based guidelines for chronic wound healing would not address health promotion strategies within the congregation. Also, it is unlikely that the parish nurse is providing direct care services, such as caring for chronic wounds, for members of the congregation.

2. A parish nurse has been using pastoral activities when providing care to clients. Which of the following interventions is the nurse

most likely using? (Select all that apply.) a. Helping families plan healthy nutritious meals and get plenty of rest b. Giving health education classes to the congregation c. Using hymns and scripture as a source of guidance and comfort d. Helping identify spiritual strengths that may assist in coping e. Visiting home-bound parishioners ANS: C, D, E

When the nurse fulfills pastoral care, the nurse stresses the spiritual dimension, lends support during times of joy and sorrow, guides the person through health and illness, and helps identify the spiritual strengths that assist in coping with part icular events.

The incorrect responses represent nursing functions, not functions of pastoral care.

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Chapter 30: The Nurse in Public Health, Home Health, Palliative Care, and Hospice Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following statements best describes the most essential difference between home health care and acute client care? a. Acute client care is individualized for the client and family. b. Home health care is provided in the client’s environment. c. Reimbursement for home health care varies from that of care provided in

institutions. d. The focus of acute client care is on community health.

ANS: B

Home health differs from other areas of health care in that health care providers practice in the client’s environment. All nurses give individualized care to clients. Reimbursement for home health care is different than that provided in an acute care setting; however, this is not the most essential difference. The focus of acute client care is typically on care provided in a hospital setting, not in the community.

2. A nurse has just received word that Medicaid will reimburse for care provided to a homeless man with schizophrenia who is afraid

to come to the clinic to receive health care. Which of the following best describes this type of nursing? a. Community-oriented nursing b. Home health nursing c. Hospice nursing d. Private duty nursing ANS: B

Home health nursing is provided in the client’s environment, regardless of where that may be. “Home” may be a house, apartment, trailer, boarding house, shelter, car, makeshift shelter under a bridge, or cardboard box. Community-oriented nursing refers to any care that is provided in a community setting. Hospice nursing is care that is provided to a client and his or her family who has a terminal illness. Private duty nursing is care that is primary care that is paid for by an individual who is requesting the care.

3. A hospital nurse wants to know why home health nurses often take more time with assessment than nurses do in the hospital.

Which of the following is the best explanation for this? a. Home care assessment includes not only the client but also the supplies and equipment the family may have available for use. b. The home environment is less organized and equipped for the nurse’s use. c. Family members must also be assessed for possible problems that could interfere with the primary client’s recovery. d. To be effective, the home health nurse must earn the family’s trust and work in partnership with them.

ANS: D

The primary reason that assessment may take longer for the home health nurse is because when working in a client’s home, the nurse is a guest. To be effective, the nurse must earn the trust of the family and establish a partnership with client and family. The home care assessment includes many aspects which are broader in scope than only the client, supplies, and equipment. The home environment varies and may or may not be organized for the nurses’ use. The primary focus of home care is the care of the individual, not the care of other family members.

4. Which of the following events led to the emphasis on home care nurses caring for acutely ill clients and the increased demands for

extensive documentation? a. Advances in medical technology and pharmacology b. Increased number of lawsuits for substandard care c. Introduction of Medicare d. Social Security Act of the 1930s ANS: C

The combination of preventive services and illness care followed the introduction of Medicare in 1966. The Medicare program emphasized care for more acutely ill people rather than illness prevention and health promotion. Medicare was a provision of the Social Security Act that was implemented in 1965. It was not part of the original legislation of the 1930s. There have not been an increased number of lawsuits based on substandard care. Advances in medical technology have been available to the population to extend their longevity, but this has not changed the need for homecare or extensive documentation.

5. In the agency, one of the nurses spent all available time visiting a group of persons with mental health problems who were trying to

remain functional in the community. Which of the following types of assignments did the nurse most likely have? a. Home-based primary care b. Population-focused home care c. Proprietary home care d. Transitional care ANS: B

Population-focused home care is directed toward the needs of specific groups of people, including those with high-risk health needs such as mental health problems, cardiovascular disease, or diabetes; families with infants or young children; and older adults. Such care commonly includes structured regular visits with assessment protocols, focused health education, counseling, and health-related support and coaching. Home-based primary care emphasizes delivering primary care in the homes of people who have difficulty going to a primary care clinic because of functional or other health problems. Proprietary agencies are ones that are profit making; it does not describe the care model that is being implemented. Transitional care programs are designed for populations who have complex or high-risk health problems and are making a transition from one level of care to another.

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6. A new client has just been released from the hospital after intensive treatment for multiple injuries following a motorcycle accident.

Which of the following types of care will the client most likely receive? a. Home-based primary care b. Population-focused home care c. Proprietary home care d. Transitional care ANS: D

Transitional care programs in the home are designed for populations who have complex or high-risk health problems and are making a transition from one level of care to another. Assessing, planning, teaching, making referrals, and following up on referrals foster independence and self-care. Besides intensive teaching about self-care, telephone calls help ensure that the clie nt understands and is able to implement instruction. Home-based primary care emphasizes delivering primary care in the homes of people who have difficulty going to a primary care clinic because of functional or other health problems. Population-focused home care is directed toward the needs of specific groups of people, including those with high-risk health needs such as mental health problems, cardiovascular disease, or diabetes; families with infants or young children; and older adults. Proprietary agencies are ones that are profit making; it does not describe the care model that is being implemented.

7. Which of the following types of home health agencies emphasizes health promotion and illness prevention? a. Combination agencies b. Hospital-based agencies c. Official agencies d. Proprietary agencies ANS: C

Official or public agencies include those agencies operated by the state, county, city, or other local government units, such as health departments. Nurses employed in these settings provide well-child clinics, immunizations, health education programs, and home visits for preventive health care. Consequently, they include a focus on health promotion and illness prevention as well as giving direct care. The merging of official and voluntary home health agencies has led to the development of combination agencies. One of the main purposes of hospital-based agencies is to provide for the continuity of care from the acute to the home care setting as all care is provided by the same organization. Proprietary agencies are home care agencies that are for profit.

8. Which of the following is a potential advantage of hospital-based home health agencies over other types of home care agencies? a. Administration and management benefits are gained from the expertise of two

boards of experts. b. Continuity of care is enhanced. c. Health promotion and illness prevention concerns take precedence over acute care and rehabilitation. d. They are eligible for tax exemptions through affiliated agencies.

ANS: B

Hospital-based agencies emerged in response to the recognized need for continuity of care from the acute care setting. Having two boards of experts relates to care that is provided by a combination agency (combining an official and voluntary agency). Health promotion and illness prevention are typically the focus of official agencies. Non-proprietary agencies are eligible for tax exemptions because they do not make a profit.

9. Which of the following is the primary focus of hospice care? a. Curing or controlling the client’s chronic disease b. Decreasing the waste of acute care (hospital) resources c. Providing palliative care to maintain comfort until death d. Teaching the client and family how to care for themselves ANS: C

The primary goal of hospice care is to help maintain the client’s dignity and comfort. Alleviating pain: encouraging the client, family, and friends to communicate with each other about essential sensitive issues and coordinating care to ensure a comfortable, peaceful death all contribute to palliative care. Curing the disease is not part of hospice care; patients who have begu n hospice care are no longer seeking a cure for their disease or illness. Hospice care focuses on providing safe and effective care so that the client is able to maintain dignity and comfort during the dying process; it does not relate to decreasing the use of hospital resources. The purpose of hospice care is not to teach self-care.

10. Which of the following best describes why it is more challenging for most nurses to meet the needs of a dying child and his or her

family than to meet the needs of a dying adult? a. Children don’t understand what it means to die. b. A child’s death is harder for anyone to accept. c. Society does not expect death to occur in children. d. Families are not prepared to deal with death.

ANS: C

The needs of the dying child and family are unique because society does not expect death to occur to the young or to have the child die before the parent. Because society does not expect death to occur in children, death among children is not discussed. Thus, families are then unprepared to deal with the death; it becomes harder to cope with because it is a subject that is not openly discussed. It is true that children have a limited understanding of dying; however, this can be related back to society’s view on death in children as well as the growth and development stage of the child.

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11. When meeting with a client and family, the home health nurse says, “We have discussed your health problems and limitations. Now

tell me what level of health and function you hope to achieve.” In which of the following phases of the nursing process is the nurse engaging? a. Assessment b. Diagnosis c. Outcome identification d. Planning ANS: C

By steering the conversation toward goals, the nurse is now able to work with the client to mutually identify outcomes. When discussing health problems and limitations, the nurse was gathering a history as part of the assessment phase. This allowed formulation of a nursing diagnosis. The planning would occur after the outcomes have been identified so that a plan can be established as to how the outcomes will be met.

12. A home health nurse asks a client diagnosed with arthritis to attend a demonstration in which an assistive device is used to put on

shoes. Which phase of the nursing process is the nurse’s current focus? a. Outcome identification b. Planning c. Implementation d. Evaluation ANS: C

Implementation is the phase in which the home health nurse implements the interventions identified in the plan of care. When the nurse discusses the development of goals with the client, they are identifying outcomes. The planning phase occurs after outcomes have been identified, as a plan to reach those outcomes is created. If the client is able to use the device, the process can progress to evaluation, in which the nurse will assess the usefulness of the device when incorporated into the client’s activities of daily living.

13. A home health nurse is caring for a client who has right-sided paresis secondary to a stroke. Which of the following would be the

best approach for the nurse to take? a. Arrange for private duty nurses to assist the client with daily needs. b. Assist the client with activities of daily living. c. Teach the client to participate in self-care activities. d. Teach the family how to care for the client.

ANS: C

Because home health care is often intermittent, and because a reliance on others is not always possible over the long term, a primary objective for the nurse is to facilitate self-care so that clients may remain in their home. This allows clients to have some control over their life and can help prevent hopelessness and a loss of self-esteem. Although assistance may be needed, such as from a private duty nurse, the home care nurse, or family members, this assistance should come after helping clients to help themselves.

14. Which of the following do community-based nurses typically use to organize, sort, and document pertinent client data? a. NANDA b. NIC & NOC c. Nursing Diagnosis Taxonomy d. The Omaha System ANS: D

Although all four are recognized nursing taxonomies, in community health, especially home nursing, the Omaha System is typically used. This system was developed by a visiting nurses’ association in Omaha and based on home nursing documentation needs. The Omaha System is most relevant to home health nursing and is most typically used by home health nurses. NANDA is a standardized nursing language, but it is not known for its usage specific to the home health setting. NIC & NOC are standardized languages for the development of interventions and outcomes for clients but are not well known for being used in the home care setting. The Nursing Diagnosis Taxonomy refers to the use of nursing diagnoses.

15. Which of the following should be the minimum requirement for a nurse to be prepared for home health nursing? a. An RN license and a baccalaureate degree in a health-related field b. A baccalaureate degree in nursing and RN licensure c. An associate degree in nursing and RN licensure d. Eligibility for certification as a home health nurse ANS: B

A baccalaureate degree in nursing should be the minimum requirement for entry into professional practice in any community health setting. The baccalaureate degree should be in nursing, not in a health-related field. Additional education, beyond an associate degree, is necessary for a home health nurse. Certification as a home care nurse is not available until after working in this setting, so this would not be an option.

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16. A nurse orienting to the home health role states, “I don’t understand why we have to collaborate with so many other disciplines;

this conflicts with the concept of nurses providing all direct care to the client in the home?” Which of the following would be the best response? a. The nurse still provides direct care for the client; however, interdisciplinary collaboration is necessary to prevent fragmentation of care. b. Direct nursing care is a concept applied to care in tertiary facilities, such as hospitals, where materials are centrally located in one facility. In home health, this is not possible. c. Even though home health nursing does not provide as much direct care as other nursing specialties in the community, each discipline contributes to client needs from its special knowledge base. d. Yes, it does create conflict, but Medicare mandates interdisciplinary collaboration.

ANS: A

The responsibilities and functions of other health professions in home care are dictated by Medicare regulations, professional organizations, and state licensing boards. Many of these services can be provided on a consulting basis. The plan of care should be implemented and reinforced by all involved disciplines. Therefore, interdisciplinary collaboration is required in the home health setting. Interdisciplinary collaboration does not conflict with the concept of providing direct care services. Direct ca re refers to the actual physical aspects of nursing care anything requiring physical contact and face-to-face interactions. In home care, direct care activities include performing a physical assessment on the client, changing a dressing on a wound, giving medication by injection, inserting an indwelling catheter, or providing intravenous therapy. Direct care also involves teaching clients and famil y caregivers how to perform a certain procedure or task.

17. A nurse completes a self-assessment of performance as part of the home health nurse’s annual evaluation. Which of the following

terms best describes this activity? a. Collaboration b. Quality of care c. Performance appraisal d. Resource utilization ANS: C

As part of a performance appraisal, the home health nurse evaluates his or her own nursing practice in relation to professional practice standards, scientific evidence, and relevant statutes, rules, and regulations. Collaboration means working with others to achieve a common goal; completing a self-assessment does not require collaboration. Using the Standards of Care is a way that the nurse can provide quality care, but a self-assessment does not guarantee that quality care is being provided. Resource utilization refers to using a variety of resources effectively to provide safe and quality care; this is not demonstrated by completing a self-assessment.

18. Which of the following best describes when the home health nurse must document required Outcome and Assessment Information

Set (OASIS-C2) data? a. Before any episode of hospitalization b. After each home health visit c. For all incidences of error or mistake in care d. On first admission to home health care ANS: D

OASIS-C2 data are measured and reported to CMS (1) on admission to home health care, (2) after an episode of hospitalization, (3) at the time of recertification, and (4) on discharge from care or death at home. Data are submitted by each agency to a national databank, and agencies receive both results and comparisons with similar agencies to determine areas needing improvement. The data reported from OASIS determine the payment received by the home health agency for the client’s total episode of care.

OASIS-C2 data are measured and reported to CMS after each episode of hospitalization, not before, and at the time of recertification, not after each home health visit. The submission of OASIS-C2 data is not required when an error or mistake is made.

19. The board of directors is examining various submitted reports concerning its home health agency. Which of the following reports

represents an example of benchmarking? a. A report by the administrator regarding how the home health agency’s performance compares with that of other local and national home health agencies b. A report by the chief financial officer regarding a cost-benefit analysis related to technological advances c. A report by the chief nursing officer regarding client outcomes d. A report by the medical director regarding implementation of evidence-based practice into standards of care ANS: A

Performance improvement programs are based on measurable data, including benchmarking, which means comparing oneself with national standards and guidelines and with other agencies. A cost-benefit analysis relates to the use of technology and its impact on the home care agency and is not related to benchmarking. A client outcomes report would need to be compared to other data in order for benchmarking to occur. The implementation of evidence-based practice does not demonstrate the use of benchmarking.

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20. Which of the following comments was most likely stated by a home health nurse? a. “Every time I see a client, it costs $80.” b. “Health care costs are killing our economy.” c. “I can’t believe how much clients are charged for things.” d. “Medicaid costs are such a large portion of our state’s budget.”

ANS: A

Nurses in many settings are not directly exposed to the financial aspects of health care, although as citizens they should be aware of the overall effects of high health care costs. In home health, nurses must be cost-conscious so that they can accurately explain to clients what Medicare will or will not cover and discuss other financial concerns. In addition, home care nurses must be knowledgeable about which medical supplies are covered. Health care costs are impacting the economy, but it is not only home care that is influencing these high costs. Both Medicare and Medicaid costs are a large portion of a state’s budget. The home care nurse probably not only recognizes the costs of supplies, but also realizes the need to be cost conscious to keep these costs at a minimum when possible.

21. Which of the following best describes one of the outcomes of the incentives and pressures for cost control and improved health

outcomes? a. Expansion in alternative health care agencies b. Improvements in client teaching materials c. Public pressure to improve health professionals’ education d. Development and increased use of telehealth technology ANS: D

The incentives and pressures for cost control and improved health outcomes have increased the development and use of telehealth technology in home care. Simultaneously, technologies have been simplified and their reliability increased, facilitating their safe use in the home. There has not been an expansion in alternative health care agencies, most likely because there is not adequate reimbursement available. Improved client teaching materials has not been influenced by the need to control costs. Improving health professionals’ education may improve health outcomes, but this may also drive up costs as the care is being provided by those who are more highly educated.

22. Which statement made by the nurse best confirms the achievement of goals related to the Omaha System conceptual model? a. The nurse confirms to the client that, “Your appointment can be rescheduled.” b. The occupational therapist emails the nurse confirming, “I got the client’s files.” c. The client thanks the nurse saying, “I appreciate knowing what the procedure will

cost.” d. The pharmacist calls the client to say, “Your prescription is going to be delayed by one day.”

ANS: A

The Omaha System was intended for use by nurses and all members of the health care delivery team. The goals of the research were to develop a structured and comprehensive system that could be both understood and used by members of various disciplines in order to foster collaborative practice. The correction option best demonstrates collaboration between team members.

23. What example of information sharing is most important when managing a client’s transition from acute care to home care? a. Working directly with the client’s insurance provider b. Arranging for emotional support for both client and caregivers. c. Communication between acute care and home health agency staff d. Providing the client with information regarding available community resources ANS: C

The sharing of information from one health care setting or provider to another is critical for community-based care, especially as clients make the transition between hospital and home. While the other options are valid, the sharing of information between acute and home care providers is most directly involved in the successful transition of care for the client.

24. Which interdisciplinary service member is most important to the achievement of autonomy for a client who experienced a lumbar

located spinal cord injury? a. Occupational therapist b. Physical therapist c. Home health aide d. Social worker ANS: A

An occupational therapist will focus on upper extremities to restore muscle strength and mobility for functional skills and performance of activities of daily living supporting autonomy. While the other options are relevant, they are not as directly focused on self-care and autonomy.

25. A family member asks a home health nurse to explain the concept of hospice care. Which of the following would the nurse need to

include as the fundamental underlying philosophy of hospice? a. Enabling the client to die at home b. Ensuring that the client’s living will is upheld c. Placing experts in the position of power of attorney d. Providing comfort measures before death ANS: D

The hospice philosophy of care means providing comfort measures to an individual before death. Death may occur in the individual’s home, in a hospital setting, or in an uncontrolled setting such as the community. The philosophy of hospice does not relate to what happens with the client’s living will or power of attorney, rather it focuses on providing a dignified death.

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MULTIPLE RESPONSE 1. Which of the following aspects of a home health agency would most likely be examined during the accreditation process? (Select

all that apply.) a. Cost of each service rendered b. Credentials of each employee c. Organizational structure d. Outcomes of care e. History of clients ANS: C, D

Both The Joint Commission (TJC) and the Community Health Accreditation Program (CHAP) of the National League for Nursing (NLN) look at the organizational structure through which care is delivered, the process of care through home visits, and the outcomes of client care, focusing on improved health status. Performance improvement must be ongoing in the agency. It is assumed the credentials of each employee were confirmed before employment. Accreditors are not as concerned with client history or with the costs of the services rendered as they are with the other quality indicators.

2. A family is concerned about the medical bills of their father, age 63, who is unemployed and has almost no savings. Which of the

following statements by the nurse accurately explain how Medicaid and Medicare would work in this family’s situation? (Select all that apply.) a. “All your father’s medical bills will be paid by whichever program is appropriate.” b. “Choose any physician and just show them your Medicare or Medicaid card.” c. “Your father must be homebound to qualify for Medicare assistance but less so for Medicaid.” d. “Medicare is a federally funded program, but Medicaid is administered by your state.” e. “Your father’s age disqualifies him from both programs.”

ANS: C, D

Medicare, for those age 65 and over or disabled, is a federal insurance program administered by the Social Security Administration, whereas Medicaid, based on a client’s lack of financial resources, is a federal and state assistance program administered by the state. Medicare will only pay for home health care by skilled professionals while the client is homebound, whereas Medicaid does not necessarily require homebound status and may reimburse for home health aides and other nonskilled supportive services. Many physicians will not accept a client on Medicare or Medicaid because of the low reimbursement rates. A deduction from Social Security is made for Medicare premiums, and clients are still responsible for deductibles and copays, so it is misleading to tell the family that all their father’s medical bills will be paid.

3. What are examples of telehealth applications? (Select all that apply.) a. A cardiac client’s heart function being monitored daily b. A client calling their provider’s office to make an appointment c. A client discussing a skin reaction with a telephone triage nurse d. A surgeon accessing a client’s electronic health record when a referral was made e. A “Zoom” meeting between an advanced practice nurse and mother regarding a

well-baby visit ANS: A, C, D, E

Telehealth supports long-distance health care, client and professional health-related education, and public health and h ealth administration using electronic information, medical devices, and telecommunication technologies. The technology used varies to include live videoconferencing, the Internet, store-and-forward imaging, streaming media, satellite, wireless communications, and plain old telephone systems. Telehealth equipment and program components include telephone triage and advice, and biometric telemonitoring equipment to measure vital signs, weight, cardiac function, and point-of-care diagnostics. The system may or may not include video technology for live interaction.

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Chapter 31: The Nurse in the Schools Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. Which of the following activities are expectations for a school health nurse? a. Ensuring that children with health problems are accepted by their peers b. Driving children home if parents can’t pick them up c. Giving emergency care in the school or during school events d. Giving medications as needed if children are ill ANS: C

School nursing responsibilities include making sure that children get the health care they need, including emergency care in the school; keeping track of the state-required vaccinations that children have received; carrying out the required screenin g of the children based on state law; and ensuring that children with health problems are able to learn in the classroom. The nurse cannot convince children to accept other children as peers, although certainly efforts should be made. HIPAA would not allow individual examples of health problems to be shared, other than providing group statistics. It would not be appropriate for the school nurse to provide transportation services to the students attending the school.

2. Which of the following statements best explains why many school nurses are not able to ensure that all children receive needed

health care in the schools? a. There is a shortage of baccalaureate-prepared nurses with national school health nurse certification. b. Most nurses prefer to be employed in hospitals giving direct care. c. Most school districts are unable to afford a nurse in every school. d. School districts and taxpayers see no need for nurses in schools.

ANS: C

The Healthy People 2030 Objective AH-R08 recommends an increase in the proportion of secondary schools with a full-time registered nurse (US Department of Health and Human Services, 2020). But such a recommendation is expensive and not a possibility for all school districts presently. School districts may see that the need for nurses is important but may have insufficient funds to be able to afford to pay for their services. There is not a national requirement that school nurses must have baccalaureate preparation or school nurse certification. Preference of employers by nurses does not impact why school nurses are unable to ensure that adequate care if provided.

3. A school health nurse is requested by the board of education to assist in choosing new playground equipment for an elementary

school that meets safety standards. Which of the following best describes the nurse’s role in this scenario? a. Case manager b. Consultant c. Counselor d. Health educator ANS: B

The school nurse is the person best able to provide health information to school administrators, teachers, and parent-teacher groups. As a consultant, the school nurse can provide professional information about proposed changes in the school environment and their effect on the health of the children. The nurse also can recommend changes in the school’s policies or ask community organizations to help make the children’s schools healthier places. As a case manager, the school nurse helps to coordinate the health care for children with complex health problems. As a counselor, the school nurse is considered a trustworthy person to whom the children can go if they are in trouble or when they need to talk. In the health educator role, the school nurse may be asked to teach children both individually and in the classroom.

4. At the annual community health fair, the school health nurse displays a science booth that examines the hazards of ineffective hand

washing. Which of the following best describes the nurse’s role in this scenario? a. Consultant b. Community outreach c. Counselor d. Researcher ANS: B

When participating in community outreach, nurses reach out to residents in the community. One common way this occurs is when nurses are involved in activities such as community health fairs or festivals in the schools. As a consultant, the school nurse can provide professional information about proposed changes in the school environment and their effect on the health of the children.

As a counselor, the school nurse is considered a trustworthy person to whom the children can go if they are in trouble or when they need to talk. As a researcher, the nurse can study outcomes related to school nursing services which may advance the practice of school nursing.

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5. Which of the following best explains why school nurses are involved in helping teachers with the task of teaching children how to

practice problem solving, communication, and other life skills? a. Teacher shortages have required nurses to be increasingly involved in teaching life skills. b. Because so many nurses want to be employed in schools, this responsibility was assumed to increase employment opportunities. c. States are requiring nurses to screen and to teach life skills. d. Nurses have been enlisted in this role to help reduce risk factors for future health problems in schoolchildren.

ANS: D

Nurses fulfilling the health educator role assist in teaching children both individually and in the classroom. This teaching should assist in helping reduce the risk factors among children in the future. Potential teacher shortages have not impacted the role of the school nurse as a health educator. Use of the role of health educator has not changed the need for school nurses in the school setting. There are not state requirements for required school screening or teaching life skills.

6. Which of the following best describes services that are offered at a school-based health center? a. Employee care at a discounted cost at the school b. Family-centered care for preK-12 grade students c. Sex education, birth control, family planning, and care throughout pregnancy d. Referral and networking with other health care services in the community ANS: B

These are family-centered, community-based clinics that are run within school, often in low-income populations. These centers provide primary care services to students of preK-12 and may offer expanded health services, including mental health and dental care. The intention of school-based health centers is to provide care specific to preK-12 grade students, not employees. These clinics provide a variety of services, depending on the clinic. Based on the size and services of the clinic, they may not provide family planning services, referral, or networking with other health care services.

7. The school health nurse has enlisted the assistance of high school role models in the areas of sports and scholarship to provide an

antidrug presentation to their peers. Which of the following levels of prevention is being implemented? a. Primary b. Secondary c. Tertiary d. Both primary and secondary ANS: A

Primary prevention interventions by the school nurse include educating children and adolescents about the effects of drugs. In preventing use, students are taught by the school nurse to stay away from drugs such as marijuana, cocaine, crack, heroin, and alcohol. Secondary prevention involves screening and intervening with at risk populations. Tertiary prevention aims for rehabilitation and returning to the highest functioning possible.

8. Which of the following best describes the primary reason that school health nurses spend so much time on educational programs

that teach children the importance of water and fire safety, using a seatbelt in the car and wearing a helmet when biking or skateboarding? a. Because children won’t know if someone doesn’t tell them b. Because injuries are the leading cause of death in children and most injuries are preventable c. Because it is a dangerous world and someone has to warn children about the dangers d. Because teaching is easy and more fun than passing out bandages and documenting care ANS: B

The school nurse, as the trusted person at school, is able to quickly give information to help prevent injuries from occurring, since most injuries are preventable. Injuries are the leading cause of death in children and teenagers. The nurse is a trustworthy person, but the children may likely have heard this information from someone else. The role of health educator is an appropriate and important role of the school nurse which is the same as the role of the direct caregiver in caring for injured children and documenting care.

9. A nurse would like to implement a primary prevention effort to decrease the leading cause of death among children and teenagers.

Which of the following actions would the nurse most likely take?

Educate students about injury prevention measures.

Provide free condoms to sexually active students.

Screen for signs and symptoms of cancer.

Invite a guest speaker to talk about living with HIV.

a. b. c. d.

ANS: A

Injuries are the leading cause of death in children and teenagers; therefore, preventive measures should focus on injury prevention.

Because the question asks for primary prevention efforts, the intervention must occur before injury. Common interventions by the school nurse include educational programs reminding children to use their seatbelts or bicycle helmets to prevent injuries. Other classes can be on crossing the street, water safety, and fire safety. Providing free condoms to sexually active students would be a secondary prevention intervention as these students are at risk to contract a sexually transmitted disease. Screening fo r signs and symptoms of cancer is an example of secondary prevention, aimed at early detection. Inviting a guest speaker to speak about HIV would address primary prevention, but it does not address the leading cause of death among children.

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10. The school nurse has arranged for volunteers to help assess each child’s hearing and vision. Any child that the volunteers feel did

not “pass” will be sent to the nurse for follow-up. The nurse will then send a note to the parents that a physician should be seen.

Which of the following levels of prevention is being implemented? a. Primary b. Secondary c. Tertiary d. Both primary and secondary ANS: B

Because secondary prevention involves caring for children when they need health care, this is the largest responsibility for the school nurse. This includes caring for ill or injured students and school employees. It also involves screening and assessing children and referral to appropriate health agencies or providers. Primary prevention involves providing education before a problem or disease occurs. Tertiary prevention aims at rehabilitation after the disease or problem has occurred and intends to get the client to the highest possible level of functioning.

11. Which of the following would be the best way for the school nurse to fulfill his or her responsibilities in an emergency situation? a. Tell all staff to call 911 if the nurse is not in the building. b. Arrange to always be available, even if only by phone. c. Create and share an emergency plan with all teachers and staff. d. Wear a pager so that the nurse can come as soon as humanly possible.

ANS: C

It is recommended that the school nurse create an emergency plan with at least two different staff members identified and responsible for implementing the plan if the nurse is not in the building at the time of the emergency. The plan would include when to call 911 and how to get a child to the hospital via ambulance if needed. Depending on the emergency, it may or may not be appropriate to call 911; thus, having an emergency plan in place is a more appropriate response. It is impossible for the nurse to be available at all times. Depending on where the nurse is and what other roles the nurse is fulfilling, it may not be possible for the nurse to respond quickly to an emergency.

12. A school nurse is administering medications at the school. Which of the following guidelines should be followed? a. A current drug reference should be available in case information is needed. b. The nurse should administer medications brought in from home by the child in a

plastic bag. c. Medications cannot be administered without a physician order. d. Narcotics and controlled substances should be kept in a locked cabinet.

ANS: A

A current drug reference should always be available so that it can be consulted for information. The nurse should develop a series of guidelines to help with the legal administration of medications in the school. The prescribed drugs should have the original prescription label on it and be in the original container. There should be a current, signed parental consent form for giving the medication, and the nurse should have a means of contacting a pharmacist to ask questions. A primary care provider’s order is not needed to administer the medications. All medications, including narcotics, should be kept in a locked container so that they are not accessible to others.

13. An upset mother calls the school nurse and says, “How dare you say my child has lice? My child is clean and I keep a clean house!

You’ve obviously made an error.” Which of the following would be the best response by the nurse?

“I’m sorry you’re upset, but your child cannot return to school until this problem is addressed.” b. “Most lice are found in clean hair. Children often share combs. Let me tell you how to fix the problem.” c. “You may have been traveling. Lice are often found in motels.” d. “I’m sure you’re correct; one of my volunteers probably made an error. I’ll recheck.” a.

ANS: B

The nurse must reassure the mother that no insult was intended; in fact, lice are most often found on middle-class children with clean hair. Lice travel easily when children share items such as combs or other property in school. Lice are not life threatening, and the necessary shampoo and other items to treat lice are widely available over the counter. Most school policies are more caring and less exclusionary and allow children with lice to attend school. It is more likely that the student contracted the lice from another student than from traveling to a motel. If the nurse has delegated the responsibility of assessing for lice to a volunteer, the nurse should reassess the findings of the volunteer to confirm that the child has lice before contacting the parent.

14. A school nurse listens as one student talks about another student being upset because his father frequently spanks him with a

leather belt that leaves big marks on the student’s back. But the student begs the nurse not to tell anyone because he promised the friend that the information would never be shared. Which of the following actions should be taken by the nurse? a. Ask the student if abuse has occurred. b. Call in the named student and ask him to remove his shirt. c. Discuss the conversation with the student’s parents. d. Notify the legal authorities.

ANS: D

When the nurse identifies a child, who may be abused or who receives information from someone else that a child may have been abused, the nurse must contact the appropriate legal authorities and the school’s principal. Asking the student about the abuse will not always elicit a truthful answer, because children will protect their parents. A confidential file should be made about the incident; however, the nurse should let the government authorities, usually the state or county child protection department, look into the suspected case. In all cases, the child should be protected from harm, and those who have no right to know that child abuse or neglect is suspected should not be given any information.

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15. A school nurse suggests to teachers that they have a session on coping strategies and stress management techniques. The nurse also

sets up a peer counseling program for teens. Which of the following is the school nurse most likely trying to prevent? a. Suicide b. Bullying c. Obesity d. Violence ANS: A

Among teenagers, more than 17 percent have considered suicide and more than 8 percent have actually attempted to take their own lives (Substance Abuse and Mental Health Services Administration). To reduce the incidence of suicide in teenagers, the nurse can emphasize coping strategies and stress management techniques and organize a peer assistance program to help teenagers cope with school stresses. Bullying may result in adolescents feeling that suicide is the only answer. However, the strategies that the nurse is completing would not necessarily promote a decrease in bullying. The strategies suggested would not impact the prevalence of obesity or the incidence of violence.

16. A disaster has occurred in the community. Which of the following actions should be taken by the school nurse? a. Continue activities as much as possible as if nothing had happened. b. Continue to assess for shock and stress. c. Help teachers discuss the disaster with their class. d. Maintain school routines and activities.

ANS: B

After a disaster, the school nurse has many responsibilities—for instance, continuing to assess the school community for the presence of shock and stress; encouraging parents to minimize how much their children view the disaster coverage on TV; providing grief counseling; continuing to communicate with the children, parents, and school personnel; and following up with assessment of children for anxiety, depression, regression, and posttraumatic stress disorder. It would not be appropriate for the nurse to ignore that a disaster has occurred or to assume that routines will remain the same; it is important for the nurse to assist the community to cope with the disaster. The nurse may use counselors in the community to assist the children to cope with the disaster as this may not be an appropriate role for the nurse or for the teacher to perform.

17. Which of the following is the leading cause of children being absent from school because of a chronic illness? a. Allergies b. Asthma c. Diabetes d. Upper respiratory infections ANS: B

Asthma is one of the leading causes of children being absent from school because of a chronic illness. Upper respiratory infections are an acute problem, not a chronic one. Diabetes and allergies are not leading causes of chronic disease that result in children being absent from school.

18. A school nurse is demonstrating the use of a peak flow meter to help children with chronic asthma recognize when they need to use

a rescue inhaler. Which of the following levels of prevention is being used by the nurse? a. Primary b. Secondary c. Tertiary d. Both primary and secondary ANS: C

Tertiary prevention includes caring for children with long-term health needs, including asthma and disabling conditions. The nurse is teaching disease management (i.e., when to use an inhaler). Primary prevention involves providing education before a problem or disease occurs. Secondary prevention addresses screening and early detection of the disease or problem.

19. A school nurse has developed a special class for pregnant teens to teach them everything from anticipated body changes to methods

for managing common pregnancy-associated problems. The classes also allow the nurse to be in close frequent contact with the students to monitor their health status. Which of the following levels of prevention is being used by the nurse? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Both primary and secondary prevention ANS: C

Many teenage girls who are pregnant attend school; therefore, the school nurse may provide ongoing care to the mother. Although this may appear to be secondary prevention, it is tertiary prevention because adolescent pregnancies are considered to b e high risk.

Primary prevention involves providing education before a problem or disease occurs. Secondary prevention addresses screening and early detection of the disease or problem. Because the teenager is already pregnant, the nurse is addressing how to assist the teen to achieve the highest level of functioning possible (tertiary prevention).

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20. A pregnant teen asks the school nurse to provide information on abortion and a list of health care providers who offer such services.

If the school nurse has very strong personal beliefs against abortion, which of the following actions should be taken by the nurse? a. Call in another nurse to care for this client. b. Explain, from the nurse’s perspective, all the reasons that abortion should be made illegal. c. Offer the student a combination of oral contraceptives to induce spontaneous abortion. d. Provide information on alternatives to abortion and give the client information on adoption agencies.

ANS: A

This creates an ethical dilemma for the nurse. If the nurse feels so strongly that he or she cannot work with the situation, another school nurse should be called for help or the student should be referred to other health providers who can provide the care the student needs. It is important that the nurse be able to keep an open mind when working with this teen, and if that is not possible, another nurse needs to be asked to care for this client. The incorrect options all address the nurse discussing his or her personal beliefs against abortion which may not be therapeutic for the teen.

21. Which of the following is most important for school nurses to master in order to prepare for health care delivery in the future? a. Complementary and alternative therapies b. Computer and technology use c. Psychoanalytical techniques d. Self-defense techniques ANS: B

In the future, school nursing will use telehealth and telecounseling to teach health education. School nurses will use the Internet to work with children and parents. Complementary and alternative therapies are already being widely used; most likely the nurse will not be the one providing such care, so it would not be necessary for the nurse to master these skills. Psychoanalytical techniques would not be necessary for the nurse to master as the nurse is able to refer students who require this type of care to appropriate providers. There would not be a need for school nurses to master self-defense techniques.

22. The principal of a school was upset over a rumor that one of the children had engaged in a violent activity that injured a younger

sibling. The principal asked the nurse who the children were so that the involved teachers could both support the injured child and guard other children from the violent child. Which of the following would be the best response by the nurse? a. “I’ll get the names to you and the involved teachers immediately.” b. “Let me get the parents’ consent, and then I’ll get you the names.” c. “Rumors are often inaccurate; let me follow up and see what happened and what needs to be done.” d. “Why don’t we coordinate a school-wide program on preventing accidents instead?”

ANS: C

The school nurse is responsible for maintaining school health office policies, including privacy and safety of health records. When a rumor is involved, it is always wise to check its accuracy. If a child was indeed hurt, the nurse needs to make sure both children involved receive (or have already received) appropriate care. The nurse must follow the HIPAA privacy rules while also ensuring the safety of children at school. The question about having a school-wide program may be appropriate, but this behavior was apparently purposeful, not accidental.

23. The mother of a high school student newly diagnosed with a condition that will require special health care services is concerned

that the student will be required to be homeschooled away from the friends he has developed. Which of the following would be the most appropriate response by the school nurse? a. “Federal legislation requires that the school make provisions for those with various challenges, so your child will be able to remain in school as long as he is able.” b. “I realize that this will be a difficult adjustment, but homeschooling has improved over recent decades and the Internet will allow your child to connect with friends.” c. “Whether your child can remain in school will depend on state funding for those with disabilities. You might want to contact your congressman on this issue.” d. “Your child may remain in school as long as he can manage the course requirements and doesn’t flunk out.”

ANS: A

Federal legislation specifies that children cannot be excluded from schools because of a disability. The school must provide health services that each child needs. Legislation further requires the school district’s committee on the disabled to develop individualized education plans (IEPs) for children. Federal legislation will support this child continuing in the current school; thus, it would not be necessary to counsel the parents about concerns related to the child needing to be homeschooled. Depending on the diagnosis, special educational needs may need to be addressed for the child through an IEP which may assist the child in being successful in the coursework.

24. A group of nursing students are scheduled to present a program on healthy hearts to various community groups, with a day care

center being the first location. What of the following advice should be given to them by their instructor? a. Base the program on the audience’s development and maturity. b. Bring (borrow if necessary) a model of the heart to help explain its functioning. c. Focus on entertaining the learners. d. Have lots of handouts to reinforce the lesson.

ANS: A

For younger learners, it is important to keep the lesson to no more than 20 minutes in length; to use plenty of examples, pictures, and stuffed animals in the talk; and to remember the developmental stage of the children when teaching them. It will be important for the nurse to assess the developmental level of the audience in order to determine if models or handouts are appropriate to be used. Keeping the presentation short should assist in keeping the learner’s attention.

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MULTIPLE RESPONSE 1. Which of the following activities are included in the Centers for Disease Control and Prevention’s school health program? (Select

all that apply.) a. Ensuring a healthy school environment b. Assisting teachers with education related to health c. Encouraging nutritious school meals d. Giving immunizations to students, staff, teachers, and their families e. Providing mental health counseling ANS: A, B, C, E

The federal government, through the coordination of the Centers for Disease Control and Prevention, developed a plan that school health programs should follow, including health education, physical education, health services, nutrition services, counseling, psychological and social services, healthy school environment, health promotion for staff, and family/community involvement.

Unfortunately, schools cannot afford to give immunizations to everyone who might want such a benefit.

2. Which of the following best explains why the federal government is beginning to fund school-based health centers? (Select all that

apply.) a. These centers help young children avoid becoming addicted to drugs while still in elementary school. b. Attendance and learning are higher in schools with health clinics. c. These centers help keep children in school longer by distributing birth control and thus avoiding pregnancies. d. Many children have no other source of health care services. e. To ensure parents are compliant with meeting the health needs of their children.

ANS: B, D

The US government began funding school-based health centers essentially because many schoolchildren may not receive health care services otherwise. These are family-centered, community-based clinics run within the schools. Certainly, avoiding pregnancy and drug addiction are among the goals of school-based health centers, but these are not reasons the government began funding them. Ensuring compliance is not a governmental responsibility in this situation since no federal laws apply.

3. A new student’s parents had not yet submitted an immunization record, although the nurse had sent a reminder home with the

student twice. Which of the following actions should be taken by the nurse to keep the child in school? (Select all that apply.) a. Call the parents or mail another reminder. b. Report the problem to the teacher and the principal. c. Send the child home with a note saying the child cannot return until the immunization record is received. d. Determine whether the family has health care insurance. e. Offer assistance in replacing a lost immunization record.

ANS: A, D, E

There are many problems with children not being immunized or having incomplete vaccination records, especially in families who have moved many times or who may not have a regular physician. The parents may have no idea whether the child has received the required shots. Families may also be without health care insurance to pay for the immunizations, or they may have insurance that does not pay for preventive care. In these cases, they may lack the resources to pay for the immunizations themselves. Therefore, the nurse’s role is to be sure parents are aware of the problem, to help them obtain the records if they have been misplaced, and to suggest ways to obtain the injections without charge, even if there is no obvious evidence that lack of funds is the problem. Telling the teacher or principal won’t resolve the problem. Sending home a note saying the child cannot return to school does not assist the family with obtaining the immunization for the child which may be a burden for the family or a potential underlying reason why the child has not received the immunization.

4. Which of the following emergency supplies or equipment should a nurse have available in the school health office? (Select all that

apply.) a. Cervical spine collars b. Complete emergency kit that fulfills American Hospital Association requirements c. Epinephrine autoinjector kit d. Material for splints e. Supplemental oxygen ANS: A, C, D, E

The school nurse needs much equipment to deal with emergencies in the school. Basic necessary equipment includes full oxygen tanks with oxygen masks of different kinds, splints, cervical spine collars, sterile dressings, and an epinephrine autoinjector kit in case a child goes into anaphylactic shock after exposure to an allergen. A hospital-oriented emergency kit would become quickly outdated (medications) and extremely expensive.

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5. A school nurse would like to improve the safety of everyone at the school by creating policies to decrease the likelihood that

violence will occur. Which of the following actions would the nurse likely take to minimize risk of school violence? (Select all that apply.) a. Engaging parents in school activities b. Creating a zero tolerance police for weapons on school property c. Encouraging children to participate in the after-school program at a local community center d. Developing mentoring programs for at-risk youth e. Initiating a student hot line for discussing possible violence risks ANS: A, B, D, E

Interventions that are aimed at preventing violence from occurring are: engaging parents in school activities that promote connections with their children; fostering communication, problem solving, limit setting, and monitoring of children; supporting/assisting with creating policies of zero tolerance for weapons on school property, including school grounds; and developing mentoring programs for at-risk youth and families. Encouraging students to attend the after-school program at a local community center may assist with the students having additional supervision, but it does not contribute to the students having an increased loyalty or connection to the school. It is important to facilitate student connectedness to the school community.

6. A child has multiple disabilities, and caring for the child has been both expensive and time consuming for the school. Once the

child turns 16, which of the following actions is the school responsible for? (Select all that apply.) a. None, since the child is no longer eligible for school services b. Continuing to provide needed appropriate education for the child c. Excluding the child from selected extracurricular activities d. Continuing to prepare an updated individualized education plan e. Arranging for reimbursement for services provided ANS: B, D

Educational services must be offered by the schools for all disabled children from birth through age 22 years. Children cannot be excluded from activities because of a disability. The school must always develop an individualized education plan for each child and update it at appropriate intervals. Turning 16 does not make a child an adult; thus, the child is still able to rece ive services of the school and participate in extracurricular activities.

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Chapter 32: The Nurse in Occupational Health Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition MULTIPLE CHOICE 1. An occupational health nurse sees the various injuries and diseases that persons can acquire from employment. Which of the

following recommendations would the nurse most likely provide about safety in the workplace? a. Find employment in physical labor; at least your body will be in good condition. b. Professional positions are the safest choice for employment. c. White collar positions provide the least risk for injury. d. There is no “safe” occupation or profession.

ANS: D

Most adults spend about one-third of their time at work. No work is completely risk free. Every single industry grapples with serious hazards related to work.

2. A nurse who works for a hospital in employee health notes that several nurses from one unit have missed work after contracting a

communicable disease from a patient. Which of the following best describes the host factor? a. Each sick nurse b. The communicable disease c. The hospital d. The patient ANS: A

Each worker represents a host within the worker population group. The communicable disease and the patient are considered the agent, the factor associated with the illness or injury. The hospital is part of the physical environment.

3. Which of the following groups should the occupational health nurse devote the most time to regarding education and follow-up

evaluation? a. New workers employed less than 1 year b. Older workers with chronic illnesses c. Older workers with diminished hearing d. Women in their childbearing years ANS: A

The population group at greatest risk for experiencing work-related accidents with subsequent injuries is new workers with less than 1 year of experience on the current job. Because of the inherent risks, the nurse should spend extra time with this group to decrease risk. Older workers with more experience are less likely to experience injury even if they have underlying issues of chronic disease. Women of childbearing age are not at any greater risk than the general population of employees.

4. An employee in a laboratory drops a flask, resulting in a chemical splash into the employee’s eyes, which in turn results in burns to

the eyes. Which of the following would be considered the agent? a. The chemical b. The employee c. The flask d. The laboratory ANS: A

Agents represent potential dangers or risks to the health and safety of workers. However, in the case given, the chemical itself caused the damage. If the flask had broken and glass got into the employee’s eye, then the flask would be an agent. However, in the case given, the chemical itself caused the damage. The employee is considered the host and the laboratory is considered part of the environment.

5. Which of the following hospital employees are most at risk for being exposed to and possibly developing active drug-resistant TB? a. Housekeeping staff b. Medical staff c. Nursing staff d. Ward clerks ANS: A

Transmission of tuberculosis (TB) within health care settings has reemerged as a major public health problem. Outbreaks of this type of TB have been reported in hospitals, and some workers have developed active drug-resistant TB. Many workers in these settings are employed as maintenance workers, security guards, aides, or cleaning people, who tend not to be well protected from inadvertent exposures, which include contaminated bed linen in the laundry, soiled equipment, and trash containing contaminated dressings or specimens. Ward clerks have limited contact with acutely ill patients. Medical and nursing staff are more likely to have the proper equipment and education to be well-protected from inadvertent exposures.

6. Which of the following is the most common disabling condition when measured by days away from work? a. Bruises b. Cuts and lacerations c. Mental illnesses d. Sprains and strains ANS: D

In 2014, sprains, strains, and tears were by far the most frequent disabling conditions, accounting for 420,870 days-away-from-work cases and an incidence rate of 38.9 cases per 10,000 full-time workers (Bureau of Labor Statistics, 2015d).

Bruises, cuts and lacerations, and mental illness are not among the most common disabling conditions that are reported.

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7. A nurse makes the suggestion that the 2-week shift rotations should be set up so that the next rotation in shifts is later rather than

earlier. Which of the following is the nurse attempting to prevent through this suggestion? a. Anxiety, depression, and exhaustion b. Family turmoil c. Physical illnesses d. Sleeping disorders ANS: A

An estimated 10% of Americans do some form of shift work that has the potential to lead to a variety of psychological and physical problems, including exhaustion, depression, anxiety, and gastrointestinal disturbance. Strategies to minimize the adverse effects of shift work, such as rotating shifts clockwise, are beneficial. Family turmoil, physical illnesses, and sleeping disorders all have the potential to occur. However, there is evidence that anxiety, depression, and exhaustion are the more prevalent physical and psychological problems that are reported.

8. In which of the following settings have nurses most often reported being the victims of violence, especially by patients and their

families? a. Acute care inpatient settings b. Community clinics and physicians’ offices c. Emergency departments and psychiatric units d. In homes during home health visits ANS: C

Nonfatal violence in the health care worker’s workplace is a serious problem that seems to be underreported. Much of the study of health care worker violence has been in psychiatric settings and emergency departments. Violence is not reported in as high of an incidence in acute care settings, community clinics, or in client homes in comparison to emergency departments and psychiatric units.

9. The occupational health nurse makes certain all employees have and know how to use personal protective equipment (PPE). Which

of the following factors will most likely determine how effective the PPE is in keeping employees safe? a. Comfort level of the PPE b. Effectiveness of the nurse’s teaching c. Knowledge level of the employee d. Psychosocial norms of the setting ANS: D

The employee will only be safe if the employee uses the PPE. If the employee doesn’t use the PPE or uses only part of the equipment, then the employee will be at risk. The primary determination of whether the PPE is used correctly and used all the time is the psychosocial norms of the setting. If others are careless in PPE use, then such carelessness is the norm. If everyone is extremely careful to use their PPE, then that is the norm in that setting. Through education, employees have the knowledge and skills available to correctly use PPE. The educational session should also make the employees comfortable with its use. The use of PPE does not depend on the effectiveness of the teaching, rather the employees’ choice to correctly put into practice the knowledge and skills that they have received.

10. Which of the following is the primary reason that large companies are becoming more involved in their employees’ personal health

and well-being? a. It is an ethical and moral responsibility. b. It improves public relations within the community. c. It allows managers to better understand their employees. d. It provides a cost savings to the company.

ANS: D

A significant increase in the number of health promotion and employee assistance programs offered has occurred. Health promotion programs focus on lifestyle choices that cause risks to health such as obesity or smoking. Employee assistance programs are designed to address personal problems (e.g., marital/family issues, substance abuse, financial difficulties) that affect the employee’s productivity. Such efforts are cost effective for businesses. Becoming more involved in employees’ health and well-being would most likely not change the relationship between the manager and the employee. This also would not change the public relations in the community. Becoming more involved is the right thing for companies to do; however, the main motive behind this shift is to save the company money.

11. The occupational health nurse continually reminds employees to wear their safety goggles and ear plugs. Which of the following

levels of prevention is being implemented? a. Both secondary and tertiary prevention b. Primary prevention c. Secondary prevention d. Tertiary prevention ANS: B

Delivery of primary prevention services to employees is directed toward promoting health and averting a problem. Primary prevention is attempting to avoid harm through protecting measures, in this case reducing ear damage due to high noise levels and eye damage from flying particles or fluids. Secondary prevention involves screening for the disease or detecting the disease at the earliest stage possible. Tertiary prevention aims at rehabilitation and restoring the client to the highest possible lev el of functioning.

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12. An occupational health nurse is removing a foreign body from a patient’s eye. Which of the following levels of prevention is being

implemented? a. Injury prevention b. Primary prevention c. Secondary prevention d. Tertiary prevention ANS: C

The nurse is engaging in secondary prevention when providing treatment for the injury. This does not meet the criteria for injury prevention because the injury has already occurred. Primary prevention would occur to prevent the injury from occurring, such as teaching the employee about use of protective eyewear. Tertiary prevention strategies would follow treatment to prevent recurrence and to prevent more serious problems related to the foreign body from developing.

13. An occupational health nurse periodically conducts spirometry testing of employees who work around hazardous gases. Which of

the following levels of prevention is being implemented? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Tertiary care prevention ANS: B

Secondary prevention involves health surveillance and periodic screening to identify an illness at the earliest possible moment in its course and elimination or modification of the hazard-producing situation. Primary prevention would occur to prevent the injury from occurring, such as teaching the employees about how to protect themselves from exposure to hazardous gases. Tertiary prevention strategies would follow treatment to prevent recurrence and to prevent more serious problems related to the exposure to the hazardous gas.

14. The occupational health nurse suggests that an employee work only half-days for three weeks and then return to full-time

employment. Which of the following best describes the rationale for this suggestion? a. To provide an example to other employees to ensure future cooperation with safety measures b. To enforce an economic penalty for not obeying nurse’s instructions regarding safety measures c. To ensure that all employees keep their positions during an economic downturn d. To continue employment and income with limited duty as a rehabilitation effort after an injury ANS: D

Rehabilitation strategies such as return-to-work programs after a heart attack or limited duty programs after a cumulative trauma injury are examples of tertiary prevention. Tertiary prevention is intended to restore health as fully as possible and assist individuals to achieve their maximum level of functioning. The method described is focusing on an effective method of rehabilitation. Rehabilitation strategies are not used as a form of punishment to employees or to ensure employment for all workers.

15. An occupational health nurse is working with the manager to change the assignment of an employee from working with heavy

metal to using machinery to assist with loading and unloading boxes at the truck dock. Which of the following best explains the rationale for this change? a. To prevent injury b. To limit disability c. To provide primary prevention d. To provide tertiary prevention ANS: B

Interventions aimed at disability limitation are intended to prevent further harm or deterioration, and they include referral for counseling and treatment of an employee with an emotional or mental health problem whose work performance has deteriorated and removal of workers from heavy metal exposure who manifest neurological symptoms. The repetitive work with handling heavy metal may have already caused harm or previous injury to this employee. Thus, the goal is to limit disability rather than to prevent injury. Primary prevention would occur to prevent the injury from occurring, such as teaching safe lifting or operation of the equipment. Tertiary prevention strategies would follow treatment to prevent recurrence and to prevent more serious problems related to any incident or injury.

16. A nurse is completing a health history on a client during a routine physical examination. Which of the following questions, which is

often omitted, should be asked by the nurse?

“How is your family doing?”

“What problems have you been having?”

“What health concerns do you have today?”

“Where do you work and what do you do there?”

a. b. c. d.

ANS: D

The question often omitted is, “Where do you work and what do you do there?” The occupational health history is an indispensable component of the health assessment of individuals. Because work is a part of life for most people, including an occupational health history in all routine nursing assessments is essential. All of these questions are appropriate during a routine physical examination.

However, it is likely that the nurse asks about family, current problems, and current health concerns to clients on a routine basis.

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17. A nurse is interviewing a person who has stated on their entry health form that they are retired. Which of the following is the most

crucial question for the nurse to ask? a. “Have you had any problems since leaving your employment?” b. “How do you spend your time now?” c. “What has retirement been like for you?” d. “Where were you previously employed and what did you do there?”

ANS: D

The most crucial question is, “Where were you previously employed and what did you do there?” The occupational health history is an indispensable component of the health assessment. All persons should be questioned about their employment history. To describe only a current status of “retired” may lead to the omission of needed data. Even for retired persons, the nurse must ask about employment history, because many problems take years to manifest in signs and symptoms. All of these questions are appropriate during a routine physical examination for a person who has retired because they relate to current problems, recreation, and mental health. However, they are not as crucial as asking for additional information about employment history. The client’s answer to this question may alert to potential problems that the nurse should focus on.

18. A nurse keeps ongoing documentation of all the clients seen at the community health clinic. The nurse enters the demographic data

and the primary diagnoses into the computer to have a comprehensive perspective of the clinic’s clients. Which of the following best explains why the nurse is collecting this data? a. This data will be useful in a research study the nurse is conducting. b. This data will provide evidence of clinic resources being wasted on minor health problems. c. This data will help identify patterns in the risk factors associated with a particular subgroup. d. This data can be used to show trends that can be included in the next grant proposal for further funding.

ANS: C

When health data are considered collectively, the nurse may determine some patterns in risk factors associated with the occurrence of particular injuries and illnesses in a total population of clients. There is no mention of consent, so the nurse should not be collating research data. Grants for funding typically require current client data rather than trends.

19. As the single occupational health employee at a company, a nurse is busy with safety programs and first aid when employees are

hurt. However, the nurse still finds time to walk through the entire facility once a day. Which of the following best explains the rationale for this action by the nurse? a. To document employee efficiency and effectiveness at their jobs b. To look for evidence of personal protective equipment being torn or destroyed c. To observe whether employees are taking their rest periods as scheduled and drinking adequate fluids during the day d. To observe effectiveness of safety education and equipment ANS: D

The nurse may conduct an assessment of the workplace itself, which is known as a worksite walk-through or survey. Direct observation allows the nurse to learn about the work processes and the materials; the requirements of various jobs; the presence of actual or potential hazards; and the work practices of employees. Such information is directly useful in planning programs, assessing their effectiveness, and reinforcing safety with individuals who have been seen behaving in a less than safe manner. It is not within the scope of the occupational health nurse’s role to document employee efficiency and effectiveness. The nurse may observe how PPE is being used or if employees are taking care of themselves while on the job; however, this is not the main purpose of a worksite walk-through assessment.

20. Which of the following interventions regarding worker safety would be the least effective? a. Using job rotation and workplace monitoring b. Designing equipment so that employee exposure to hazards is minimized c. Having employees use safety measures and personal protective equipment d. Designing the environment to encourage employees to follow workplace

procedures ANS: C

Personal protective control is the last resort and requires the worker to actively engage in strategies for protection s uch as use of gloves, masks, and gowns to prevent blood/body fluid exposure. Various control strategies are used to eliminate or reduce exposure and hence risk. Engineering controls can reduce worker exposure by modifying the exposure source. Administrative controls reduce exposure through job rotation, workplace monitoring, and employee training and education. External controls—the way equipment is built or manufacturing processes are established—are controllable and much more effective than asking a great many individuals to engage in behaviors that they may not want to do (such as using personal protective equipment). Humans are much less programmable than external controls.

21. Which of the following best describes the mission of OSHA? a. To create an inspection system to avoid preventable loss of life b. To ensure safe and healthful working conditions c. To establish rules for employee safety d. To share factory illness and injury rates with the public ANS: B

The Occupational Safety and Health Act of 1970 had as its purpose to ensure “safe and healthful working conditions for working men and women.” OSHA enforces occupational health standards; its mission is not to have an inspection system. Safe and healthful working conditions are ensured because of the standards that have been enforced by OSHA. OSHA does maintain a databased of work-related injuries, illnesses, and death, but its mission is not to share this information with the public.

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22. Which of the following statements best describes how workers’ compensation legislation has changed employer behavior? a. Employers have improved safety of working conditions because safety data is

now public information. b. Companies have improved safety of working conditions because workers’ compensation insurance premiums are now based on previous claims. c. Employers were legally required to implement safety changes. d. Companies have become more involved in the legislative process.

ANS: B

Workers’ compensation acts are important state laws that govern financial compensation of employees who suffer work-related health problems. Each state sets rules for the reimbursement of employees with occupational health problems for medical expenses and lost work time associated with the illness or injury. Workers’ compensation claims and the experience-based insurance premiums paid by industry have been important motivators for increasing the health and safety of the workplace. The financial incentive of having reduced claims is much more important to the employer than if the safety data may be available for the public to view. Workers’ compensation legislation did not mandate safety changes or cause companies to become more involved with the legislative process.

23. Which of the following would most likely be one of the first steps taken in employer disaster planning? a. All employees are invited to attend sessions on disaster planning. b. Employers stress the importance of disaster drills and encourage active

participation. c. Exhaustive inventory of chemicals and industrial hazards is completed. d. Written disaster plans are distributed to each employee and each worksite.

ANS: C

The goals of a disaster plan are to prevent or minimize injuries and deaths of workers and residents, minimize property damage, provide effective triage, and facilitate necessary business activities. A disaster plan requires the cooperation of company and community. The nurse is often a key person on the disaster planning team. The potential for disaster must be identified; this is best achieved by completing an exhaustive chemical and hazard inventory of the workplace. The MSDSs and plant blueprints are critical for correctly identifying substances and work areas that may be hazardous. Worksite surveys are the first step to completing this inventory. After potential hazards have been identified, it would be appropriate for the other events to occur. This would include providing employee education, circulating a written disaster plan, and encouraging participation in disaster pla nning drills.

MULTIPLE RESPONSE 1. Which of the following describes how occupational health nursing differs from other nursing specialties? (Select all that apply.) a. It is autonomous because the occupational nurse works independently. b. The major focus is on the environment. c. Nurses focus on health promotion and disease prevention. d. Nursing care is given in the community. e. A focus is directed toward restoration of health.

ANS: A, B, E

Occupational health specialty practice focuses on the promotion, prevention, and restoration of health within the context of a safe and healthy environment. It involves the prevention of adverse health effects from occupational and environmental hazards. It provides for and delivers occupational and environmental health and safety services to workers, worker populations, and community groups. It is an autonomous specialty, and nurses make independent nursing judgments in providing health care. All nurses should engage in health promotion and disease prevention, and many specialties provide care in the community.

2. An occupational health nurse should be aware of which of the following trends in the marketplace? (Select all that apply.) a. A majority of new jobs will be in service-oriented employment. b. Employees will often have longer hours within a compressed work week. c. Jobs are shifting from service to manufacturing. d. Many employees will be older and suffer chronic health problems. e. Reduced job security is common.

ANS: A, B, D, E

Longer hours, compressed work weeks, shift work, reduced job security, and part-time and temporary work are realities of the modern workplace. The workforce will become older, including many employees with chronic health problems. The US economy was once based on agriculture, then primarily on manufacturing, and now on highly technological positions. Currently, service-providing positions account for virtually all job growth; soon almost one of every two worker jobs will be in service positions.

3. Which of the following explains why some occupational health specialists are very concerned about chemicals in the workplace?

(Select all that apply.) a. All chemicals are inherently dangerous to humans. b. Chemicals are often used when natural substances are equally effective. c. Effects of chemicals can be cumulative. d. Interactions of chemicals are typically unknown. e. It is difficult to accurately predict the reaction of chemical contact.

ANS: C, D, E

Most chemicals have not been studied epidemiologically to determine the effects of exposure on humans. A variety of chemicals are found in the body tissues of the general population. Daily, low-level doses of chemicals may be below the exposure standards but may still carry a potentially chronic and perhaps cumulative assault on workers’ health. Predicting human responses to such exposures is further complicated because several chemicals are often combined to create a new chemical agent. Human effects may be associated with the interaction of these agents rather than with a single chemical. Another concern about occupational exposure to chemicals is reproductive health effects. Not all chemicals are dangerous; however, less than 0.1% of them have been adequately studied for their effects on humans. There is no evidence to support the statement that chemicals are being used when there are other natural substances available.

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4. Which of the following are the primary reasons that employers have increasingly focused on ensuring a healthy and safe

environment for workers? (Select all that apply.)

To fulfill their ethical and moral responsibility To avoid the cost of liability suits, workers’ compensation, etc.

To maintain good public relations To meet enacted legislated standards To avoid significant penalties for noncompliance

a. b. c. d. e.

ANS: B, D, E

Legislation at the federal and state levels has had a significant effect on efforts to provide a healthy and safe environment for all workers. OSHA employees have distributed citations to companies that do not meet minimal occupational health and safety standards. Criminal charges have been filed against business owners when preventable work-related deaths have occurred. Another important stimulus for health and safety programs is the desire to avoid the cost of liability and workers’ compensation claims and other expenses when employees are injured or killed. Having a healthy and safe environment for workers should provide the public with a positive image of the company; however, this is not a primary reason employers ensuring this type of an environment.

5. An occupational health nurse wants to know the NAICS code of a prospective employer. Which of the following best explains why

the nurse would be interested in this information? (Select all that apply.) a. To assess how others have rated the company in relation to employment there b. To compare the prospective employer’s injury rate with similar employers’ rates c. To learn more about the usual processes and products of the company as well as typical hazards d. To learn how employees feel about their employer e. To identify useful information about the employer ANS: B, C, E

All business organizations are classified within the North American Industry Classification System (NAICS) with a numerical code indicating a company’s product and, therefore, the possible types of occupational health hazards that may be associated with the processes and materials used by its employees. NAICS codes are used to collect and report data on businesses. For example, illness and injury rates of one company are compared with the rates of other companies of similar size with the same NAICS code to determine whether the company is having an excess of illness or injury. By knowing the NAICS code of a company, a health care professional can access reference books that describe the usual processes, materials, and by products of that kind of company. The NAICS code indicates a company’s product, not how others or their employees have rated them as an employer.

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