Test Bank For Population-Based Nursing Fourth Edition by Ann L. Curley Barbara A. Niedz Alyssa Eriks

Test Bank For Population-Based Nursing Fourth Edition by Ann L. Curley Barbara A. Niedz Alyssa Erikson Alyssa E. Erikson Erikson Chapter 1-13

Chapter 01: Introduction to Population-Based Nursing 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? a. Provide free health care to all citizens b. To increase the number of individuals with access to effective health care benefits c. Lower the cost of health care to the American population d. To lessen the governmental burden of providing health care to Americans 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. 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.

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.

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.

Chapter 02: Principles of Public and Community Health 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 was to ensure the health of the population.

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.

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.

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 life. 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 concepts. b. Diploma schools of nursing continued to expand their student numbers. c. Junior and community colleges began offering nursing programs. d. Nurses were strongly encouraged to have a scientific basis for their practice. e. 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.

Chapter 03: Identifying Outcomes in Population-Based Nursing 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 c. 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 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.

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.

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, prepare for, recognize, and respond to terrorist threats or natural disasters—has required an unprecedented level of interstate and federal-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. b. c. d.

Projection Disparity Racism 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 patient.

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. b. c. d. e.

To improve health programming and services To improve community relationships To improve performance and quality To improve management 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.

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. c. d. e.

Incompetent or negligent nurses are an ongoing source of medical errors.

Long work hours and provider fatigue are a major factor in medical errors.

More punitive measures must be taken to decrease provider errors.

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.

Chapter 04: Epidemiological Methods and Measurements in Population-Based Nursing Practice: Part I 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. c. 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.

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.

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 define 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.

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? a. None, because they are just helpful guidelines for maximum safety. b. None, because they just give specifics that may change over time. c. Major, because prudent nurses would follow such regulations. d. Major, because these rules and regulations have the effect of law and must be obeyed.

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 legislation. 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).

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 nurses 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.

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 others.

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. c. d. e.

Discuss how the bill affects more than just nurses.

Include factual data and, if possible, statistical information in visual form.

Provide written proof of personal and professional qualifications 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.

Chapter 05: Epidemiological Methods and Measurements in Population-Based Nursing Practice: Part II 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.

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.

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.

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 services 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 condition 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.

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 preexisting 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 substitution 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.

Chapter 06: Applying Evidence at the Population Level 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.

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.

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 autonomy 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.

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. b. c. d.

Ask community leaders for their opinion of the interventions.

Examine the morbidity and mortality rate of the community.

Reassess the community to determine whether obvious needs have been met.

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.

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 allocation, 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.

Chapter 07: Using Information Technology to Improve Population Outcomes 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.

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 illness 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 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.

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.

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.

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 unintentionally. 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.

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.

Chapter 08: Concepts in Program Design and Development 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. b. c. d.

Conduct health risk assessments of randomly selected individuals.

Perform a windshield survey.

Review facility permits and consumer confidence reports.

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.

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 growing 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 radiation 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.

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.

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. c. d. e.

Communicate the correct information in a timely fashion.

Share all the data found on the community assessment.

Talk to those affected or those worried about the situation.

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.

Chapter 09: Evaluation of Practice at the Population Level

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 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.

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.

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.

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

Chapter 10: The Role of Accreditation and Certification in Validating Population-Based Practice/Programs 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.

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 the 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.

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.

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 already 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 identifies 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 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 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.

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 disease. 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, interpreted as the probability that an individual with a positive test has the disease. A negative predictive value is the proportion of persons with a negative test who are actually disease free. Reliability relates to the consistency or repeatability of the measure.

Validity in a screening test is typically measured by sensitivity (how accurately it identifies those with the condition) and specificity (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.

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.

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.

Chapter 11: Building Relationships and Engaging Communities Through Collaboration 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 terrorism 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.

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. b. c. d.

Incidence of bioterrorism attacks Number of air travelers Incidence of school absenteeism 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.

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.

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.

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 system is impacted by these increased costs it is most likely not impacting the clinic itself.

Chapter 12: Challenges in Program Implementation 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.

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.

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.

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 responding 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.

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.

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.

Chapter 13: Implications of Global Health in Population-Based Nursing 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.

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.

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 have been created.

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 intervention, 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.

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.) a. Changes in staffing patterns in the health agency b. Demographic data c. Education and school statistics d. Environmental factors e. Utilization of health services 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.