Test Bank For Maternal Child Nursing Care, 5th Edition

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Chapter 01: 21st Century Maternity NursingChapter 01: 21st Century Maternity NursingMULTIPLE CHOICE1.When providing care for a pregnant woman, the nurse should be aware that one ofthe most frequently reported maternal medical risk factors is:a.Diabetesmellitus.c.Chronichypertension.b.Mitralvalveprolapse(MVP).d.Anemia.ANS: AThe most frequently reported maternal medical risk factors are diabetes andhypertension associated with pregnancy. Both of these conditions are associated withmaternal obesity. There are no studies that indicate MVP is among the mostfrequently reported maternal risk factors. Hypertension associated with pregnancy, notchronic hypertension, is one of the most frequently reported maternal medical riskfactors. Although anemia is a concern in pregnancy, it is not one of the mostfrequently reported maternal medical risk factors in pregnancy.PTS: 1 DIF: Cognitive Level: Knowledge REF: 6OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity2.To ensure optimal outcomes for the patient, the contemporary maternity nurse mustincorporate both teamwork and communication with clinicians into her care delivery,The SBAR technique of communication is an easy-to-remember mechanism forcommunication. Which of the following correctly defines this acronym?a.Situation,baselineassessment,responseb.Situation,background,assessment,recommendationc.Subjectivebackground,assessment,recommendationd.Situation,background,anticipatedrecommendationANS: BThe situation, background, assessment, recommendation (SBAR) technique providesa specific framework for communication among health care providers. Failure tocommunicate is one of the major reasons for errors in health care. The SBARtechnique has the potential to serve as a means to reduce errors.PTS: 1 DIF: Cognitive Level: Comprehension REF: 14OBJ: Nursing Process: Assessment, Planning

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MSC: Client Needs: Safe and Effective Care Environment3.The role of the professional nurse caring for childbearing families has evolved toemphasize:a.Providingcaretopatientsdirectlyatthebedside.b.Primarilyhospitalcareofmaternitypatients.c.Practiceusinganevidence-basedapproach.d.Planningpatientcaretocoverlongerhospitalstays.ANS: CProfessional nurses are part of the team of health care providers who collaborativelycare for patients throughout the childbearing cycle. Providing care to patients directlyat the bedside is one of thenurse’stasks; however, it does not encompass the conceptof the evolved professional nurse. Throughout the prenatal period, nurses care forwomen in clinics andphysician’soffices and teach classes to help families prepare forchildbirth. Nurses also care for childbearing families in birthing centers and in thehome. Nurses have been critically important in developing strategies to improve thewell-being of women and their infants and have led the efforts to implement clinicalpractice guidelines using an evidence-based approach. Maternity patients haveexperienced a decreased, rather than an increased, length of stay over the past 2decades.PTS: 1 DIF: Cognitive Level: Comprehension REF: 1OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care Environment4.A 23-year-old African-American woman is pregnant with her first child. Based onthe statistics for infant mortality, which plan is most important for the nurse toimplement?a.Performanutritionassessment.b.Referthewomantoasocialworker.c.Advisethewomantoseeanobstetrician,notamidwife.d.Explaintothewomantheimportanceofkeepingherprenatalcareappointments.ANS: DConsistent prenatal care is the best method of preventing or controlling risk factorsassociated with infant mortality. Nutritional status is an important modifiable risk

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factor, but a nutrition assessment is not the most important action a nurse should takein this situation. The patient may need assistance from a social worker at some timeduring her pregnancy, but a referral to a social worker is not the most important aspectthe nurse should address at this time. If the woman has identifiable high-riskproblems, her health care may need to be provided by a physician. However, it cannotbe assumed that all African-American women have high-risk issues. In addition,advising the woman to see an obstetrician is not the most important aspect on whichthe nurse should focus at this time, and it is not appropriate for a nurse to advise ormanage the type of care a patient is to receive.PTS: 1 DIF: Cognitive Level: Comprehension REF: 6OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance5.During a prenatal intake interview, the nurse is in the process of obtaining an initialassessment of a 21-year-old Hispanic patient with limited English proficiency. It isimportant for the nurse to:a.Usematernityjargoninorderforthepatienttobecomefamiliarwiththeseterms.b.Speakquicklyandefficientlytoexpeditethevisit.c.Providethepatientwithhandouts.d.Assesswhetherthepatientunderstandsthediscussion.ANS: DNurses contribute to health literacy by using simple, common words; avoiding jargon;and evaluating whether the patient understands the discussion. Speaking slowly andclearly and focusing on what is important increase understanding. Most patienteducation materials are written at too high a level for the average adult and may not beuseful for a client with limited English proficiency.PTS: 1 DIF: Cognitive Level: Application REF: 5OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance6.When managing health care for pregnant women at a prenatal clinic, the nurseshould recognize that the most significant barrier to access to care is the pregnantwoman’s:a.Age.c.Educationallevel.b.Minoritystatus.d.Inabilitytopay.ANS: D

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The most significant barrier to health care access is the inability to pay for services;this is compounded by the fact that many physicians refuse to care for women whocannot pay. Although adolescent pregnant clients statistically receive less prenatalcare, age is not the most significant barrier. Significant disparities in morbidity andmortality rates exist for minority women; however, minority status is not the mostsignificant barrier to access of care. Disparities in educational level are associatedwith morbidity and mortality rates; however, educational level is not the mostsignificant barrier to access of care.PTS: 1 DIF: Cognitive Level: Knowledge REF: 5OBJ: Nursing Process: AssessmentMSC: Client Needs: Safe and Effective Care Environment7.What is the primary role of practicing nurses in the research process?a.Designingresearchstudiesb.Collectingdataforotherresearchersc.Identifyingresearchableproblemsd.SeekingfundingtosupportresearchstudiesANS: CWhen problems are identified, research can be conducted properly. Research of healthcare issues leads to evidence-based practice guidelines. Designing research studies isonly one factor of the research process. Data collection is one factor of research.Financial support is necessary to conduct research, but it is not the primary role of thenurse in the research process.PTS: 1 DIF: Cognitive Level: Comprehension REF: 9OBJ: Nursing Process: Diagnosis, EvaluationMSC: Client Needs: Safe and Effective Care Environment8.When the nurse is unsure about how to perform a patient care procedure, the bestaction would be to:a.Askanothernurse.b.Discusstheprocedurewiththepatient’sphysician.c.Lookuptheprocedureinanursingtextbook.d.Consulttheagencyproceduremanualandfollowtheguidelinesfortheprocedure.ANS: D

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It is always best to follow theagency’spolicies and procedures manual when seekinginformation on correct patient procedures. These policies should reflect the currentstandards of care and state guidelines. Each nurse is responsible for her own practice.Relying on another nurse may not always be safe practice. Each nurse is obligated tofollow the standards of care for safe client care delivery. Physicians are responsiblefor their own client care activity. Nurses may follow safe orders from physicians, butthey are also responsible for the activities that they as nurses are to carry out.Information provided in a nursing textbook is basic information for generalknowledge. Furthermore, the information in a textbook may not reflect the currentstandard of care or individual state or hospital policies.PTS: 1 DIF: Cognitive Level: Comprehension REF: 11OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity9.From thenurse’sperspective, what measure should be the focus of the health caresystem to reduce the rate of infant mortality further?a.Implementingprogramstoensurewomen’searlyparticipationinongoingprenatalcareb.Increasingthelengthofstayinahospitalaftervaginalbirthfrom2to3daysc.Expandingthenumberofneonatalintensivecareunits(NICUs)d.MandatingthatallpregnantwomenreceivecarefromanobstetricianANS: AEarly prenatal care allows for early diagnosis and appropriate interventions to reducethe rate of infant mortality. An increased length of stay has been shown to fosterimproved self-care and parental education. However, it does not prevent the incidenceof leading causes of infant mortality rates, such as low birth weight. Early preventionand diagnosis reduce the rate of infant mortality. NICUs offer care to high-risk infantsafter they are born. Expanding the number of NICUs would offer better access forhigh-risk care, but this factor is not the primary focus for further reduction of infantmortality rates. A mandate that all pregnant women receive obstetric care would benearly impossible to enforce. Furthermore, certified nurse-midwives (CNMs) havedemonstrated reliable, safe care for pregnant women.PTS: 1 DIF: Cognitive Level: Comprehension REF: 10OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance10.Alternative and complementary therapies:a.ReplaceconventionalWesternmodalitiesoftreatment.

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b.AreusedbyonlyasmallnumberofAmericanadults.c.Recognizethevalueofclients’inputintotheirhealthcare.d.Focusprimarilyonthediseaseanindividualisexperiencing.ANS: CMany popular alternative healing modalities offer human-centered care based onphilosophies that recognize the value of thepatient’sinput and honor theindividual’sbeliefs, values, and desires. Alternative and complementary therapies are part of anintegrative approach to health care. An increasing number of American adults areseeking alternative and complementary health care options. Alternative healingmodalities offer an holistic approach to health, focusing on the whole person, not justthe disease.PTS: 1 DIF: Cognitive Level: Comprehension REF: 4OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity11.A 38-year-old Hispanic woman delivered a 9-pound, 6-ounce girl vaginally afterbeing in labor for 43 hours. The baby died 3 days later from sepsis. On what groundswould the woman potentially have a legitimate legal case for negligence?a.SheisHispanic.c.Thestandardsofcarewerenotmetb.Shedeliveredagirl.d.Sherefusedfetalmonitoring.ANS: CNot meeting the standards of care is a legitimate factor for a case of negligence. Theclient’srace is not a factor for a case of negligence. Theinfant’sgender is not a factorfor a case of negligence. Although fetal monitoring is the standard of care, the clienthas the right to refuse treatment. This refusal is not a case for negligence; however,informed consent should be properly obtained, and the client should sign an againstmedical advice form for refusal of any treatment that is within the standard of care.PTS: 1 DIF: Cognitive Level: Comprehension REF: 12OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance12.A newly graduated nurse is attempting to understand the reason for increasinghealth care spending in the United States. Her research finds that these costs are muchhigher compared with other developed countries as a result of:a.Ahigherrateofobesityamongpregnantwomen.b.Limitedaccesstotechnology.

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c.Increasedusageofhealthcareservicesalongwithlowerprices.d.Homogeneityofthepopulation.ANS: AHealth care is one of the fastest growing sectors of the U.S. economy. Currently,17.4% of the gross domestic product is spent on health care. Higher spending in theUnited States compared with 12 other industrialized countries is related to higherprices and readily accessible technology along with greater obesity rates amongwomen. More than one third of women in the United States are obese. Of the U.S.population, 16% is uninsured and has limited access to health care. Maternalmorbidity and mortality are directly related to racial disparities.PTS: 1 DIF: Cognitive Level: Analysis REF: 5OBJ: Nursing Process: PlanningMSC: Client Needs: Safe and Effective Care Environment13.The term used to describe legal and professional responsibility for practice formaternity nurses is:a.Collegiality.c.Evaluation.b.Ethics.d.Accountability.ANS: DAccountability refers to legal and professional responsibility for practice. Collegialityrefers to a working relationship withone’scolleagues. Ethics refers to a code to guidepractice. Evaluation refers to examination of the effectiveness of interventions inrelation to expected outcomes.PTS: 1 DIF: Cognitive Level: Evaluation REF: 12OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance14.Through the use of social media technology, nurses can link with other nurses whomay share similar interests, insights about practice, and advocate for patients. Themost concerning pitfall for nurses using this technology is:a.Violationofpatientprivacyandconfidentiality.b.Institutionsandcolleaguesmaybecastinanunfavorablelight.c.Unintendednegativeconsequencesforusingsocialmedia.d.Lackofinstitutionalpolicygoverningonlinecontact.ANS: A

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The most significant pitfall for nurses using this technology is the violation of patientprivacy and confidentiality. Furthermore, institutions and colleagues can be cast inunfavorable lights with negative consequences for those posting information. Nursingstudents have been expelled from school and nurses have been fired or reprimandedby their Board of Nursing for injudicious posts. The American Nurses Association haspublished six principles for social networking and nurses. All institutions should havepolicies guiding the use of social media, and nurses should be familiar with theseguidelines.PTS: 1 DIF: Cognitive Level: Analysis REF: 7OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care Environment15.An important development that affects maternity nursing is integrative health care,which:a.Seekstoprovidethesamehealthcareforallracialandethnicgroups.b.BlendscomplementaryandalternativetherapieswithconventionalWesterntreatment.c.Focusesonthediseaseorconditionratherthanthebackgroundoftheclient.d.HasbeenmandatedbyCongress.ANS: BIntegrative health care tries to mix the old with the new at the discretion of the clientand health care providers. Integrative health care is a blending of new and traditionalpractices. Integrative health care focuses on the whole person, not just the disease orcondition. U.S. law supports complementary and alternative therapies but does notmandate them.PTS: 1 DIF: Cognitive Level: Application REF: 4OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance16.Recent trends in childbirth practices in the United States indicate that:a.Morethan15%ofmothershadlateornoprenatalcare.b.ThepercentageofHispanics,non-HispanicAfricanAmericans,andCaucasianswhoreceivprenatalcarewasessentiallythesame.c.Birthsoccurringinthehospitalaccountedfor99%ofbirths.d.Cesareanbirthshavebeendecliningasapercentageoflivebirths.ANS: C

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Almost all births occur within the hospital setting. Only 5.2% of Caucasians mothershad either late care or no care. There are disparities in the receipt of prenatal care byethnicity: 12.2% of Hispanic women and 11.8% of non-Hispanic black womenreceived either late or no prenatal care. The percentage of cesarean births isincreasing.PTS: 1 DIF: Cognitive Level: Knowledge REF: 7OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity17.Recent trends in childbirth practice indicate that:a.Delayedpushingisnowdiscouragedinthesecondstageoflabor.b.Episiotomyratesareincreasing.c.Midwivesperformmoreepisiotomiesthanphysicians.d.Newborninfantsremainwiththemotherandareencouragedtobreastfeed.ANS: DBreastfeeding is encouraged for newborns immediately after birth. Delayed pushing isencouraged for several reasons. Episiotomy rates are declining. Midwives performfewer episiotomies than physicians.PTS: 1 DIF: Cognitive Level: Knowledge REF: 8OBJ: Nursing Process: PlanningMSC: Client Needs: Safe and Effective Care Environment18.The nurse caring for a pregnant client should be aware that the U.S. birth rateshows which trend?a.Birthstounmarriedwomenaremorelikelytohavelessfavorableoutcomes.b.Birthratesforwomen40to44yearsoldarebeginningtodecline.c.Cigarettesmokingamongpregnantwomencontinuestoincrease.d.TheratesofmaternaldeathowingtoracialdisparityareelevatedintheUnitedStates.ANS: ALow-birth-weight infants and preterm birth are more likely because of the largenumber of teenagers in the unmarried group. Birth rates for women in their early 40scontinue to increase. Fewer pregnant women smoke. In the United States, there issignificant racial disparity in the rates of maternal death.PTS: 1 DIF: Cognitive Level: Comprehension REF: 6OBJ: Nursing Process: Assessment

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MSC: Client Needs: Safe and Effective Care Environment19.Maternity nursing care that is based on knowledge gained through research andclinical trials is:a.DerivedfromtheNursingInterventionClassification.b.Knownasevidence-basedpractice.c.AtoddswiththeCochraneSchooloftraditionalnursing.d.Anoutgrowthoftelemedicine.ANS: BEvidence-based practice is based on knowledge gained from research and clinicaltrials. The Nursing Intervention Classification is a method of standardizing languageand categorizing care. Dr. Cochrane systematically reviewed research trials and is partof the evidence-based practice movement. Telemedicine uses communicationtechnologies to support health care.PTS: 1 DIF: Cognitive Level: Comprehension REF: 9OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity20.The level of practice a reasonably prudent nurse provides is called:a.Thestandardofcare.c.Asentinelevent.b.Riskmanagement.d.Failuretorescue.ANS: AGuidelines for standards of care are published by various professional nursingorganizations. Risk management identifies risks and establishes preventive practices,but it does not define the standard of care. Sentinel events are unexpected negativeoccurrences. They do not establish the standard of care. Failure to rescue is anevaluative process for nursing, but it does not define the standard of care.PTS: 1 DIF: Cognitive Level: Comprehension REF: 11OBJ: Nursing Process: DiagnosisMSC: Client Needs: Safe and Effective Care Environment21.During a prenatal intake interview, the client informs the nurse that she wouldprefer a midwife to provide her care during pregnancy and deliver her infant. Whatinformation would be most appropriate for the nurse to share with this patient?a.Midwiferycareisavailableonlytoclientswhoareuninsuredbecausetheirservicesarelessexpensivethananobstetrician.Costsareoftenlowerthananobstetricprovider.b.Theclientwillreceivefewerinterventionsduringthebirthprocess.

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c.Theclientshouldbeawarethatmidwivesarenotcertified.d.Deliverycantakeplaceonlyattheclient’shomeorinabirthcenter.ANS: BThis patient will be able to participate actively in all decisions related to the birthprocess and is likely to receive fewer interventions during the birth process.Midwifery services are available to all low-risk pregnant women, regardless of thetype of insurance they have. Midwifery care in all developed countries is strictlyregulated by a governing body, which ensures that core competencies are met. In theUnited States, this body is the American College of Nurse-Midwives. Midwives canprovide care and delivery at home, in freestanding birth centers, and in communityand teaching hospitals.PTS: 1 DIF: Cognitive Level: Knowledge REF: 7OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care Environment22.While obtaining a detailed history from a woman who has recently emigrated fromSomalia, the nurse realizes that the client has undergone female genital mutilation(FGM). Thenurse’sbest response to this patient is:a.“ThisisaveryabnormalpracticeandrarelyseenintheUnitedStates.”b.“Doyouknowwhoperformedthissothatitcanbereportedtotheauthorities?”c.“Wewillbeabletorestoreyourcircumcisionfullyafterdelivery.”d.“Theextentofyourcircumcisionwillaffectthepotentialforcomplications.”ANS: D“The extent of your circumcision will affect the potential forcomplications”is themost appropriate response. The patient may experience pain, bleeding, scarring, orinfection and may require surgery before childbirth. With the growing number ofimmigrants from countries where FGM is practiced, nurses will increasinglyencounter women who have undergone the procedure. Although this practice is notprevalent in the United States, it is very common in many African and Middle Easterncountries for religious reasons. Responding with,“Thisis a very abnormal practiceand rarely seen in the UnitedStates”is culturally insensitive. The infibulation mayhave occurred during infancy or childhood. The client will have little to norecollection of the event. She would have considered this to be a normal milestone

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during her growth and development. The International Council of Nurses has spokenout against this procedure as harmful to awoman’shealth.PTS: 1 DIF: Cognitive Level: Comprehension REF: 8OBJ: Nursing Process: PlanningMSC: Client Needs: Safe and Effective Care Environment23.To ensure patient safety, the practicing nurse must have knowledge of the currentJointCommission’s“DoNotUse”list of abbreviations. Which of the following isacceptable for use?a.q.o.d.orQ.O.D.c.InternationalUnitb.MSO4orMgSO4d.LackofaleadingzeroANS: CThe abbreviations“i.u.”and“I.U.”are no longer acceptable because they could bemisread as“I.V.”or the number“10.”The abbreviation“q.o.d.orQ.O.D.”should bewritten out as“everyotherday.”The period after the“Q”could be mistaken for an“I”;the“o”could also be mistaken for an“i.”With MSO4 or MgSO4, it is too easy toconfuse one medication for another. These medications are used for very differentpurposes and could put a client at risk for an adverse outcome. They should be writtenas morphine sulfate and magnesium sulfate. The decimal point should never bemissed before a number to avoid confusion (i.e., 0.4 rather than .4).PTS: 1 DIF: Cognitive Level: Analysis REF: 13OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity24.Healthy People 2020has established national health priorities that focus on anumber of maternal-child health indicators. Nurses are assuming greater roles inassessing family health and providing care across the perinatal continuum. Thereforeit is important for the nurse to be aware that significant progress has been made in:a.Thereductionoffetaldeathsanduseofprenatalcare.b.Lowbirthweightandpretermbirth.c.Eliminationofhealthdisparitiesbasedonrace.d.Infantmortalityandthepreventionofbirthdefects.ANS: ATrends in maternal child health indicate that progress has been made in relation toreduced infant and fetal deaths and increased prenatal care. Notable gaps remain in therates of low birth weight and preterm births. According to the March of Dimes,

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persistent disparities still exist between African Americans and non-HispanicCaucasians. Many of these negative outcomes are preventable through access toprenatal care and the use of preventive health practices. This demonstrates the needfor comprehensive community-based care for all mothers, infants, and families.PTS: 1 DIF: Cognitive Level: Knowledge REF: 3OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care EnvironmentMULTIPLE RESPONSE25.Which interventions would help alleviate the problems associated with access tohealth care for maternity patients(Select all that apply)?a.Providetransportationtoprenatalvisits.b.Providechildcaresothatapregnantwomanmaykeepprenatalvisits.c.Mandatethatphysiciansmakehousecalls.d.Providelow-costorno-costhealthcareinsurance.e.Providejobtraining.ANS: A, B, DLack of transportation to visits, lack of childcare, and lack of affordable healthinsurance are prohibitive factors associated with lack of prenatal care. House calls arenot a cost-effective approach to health care. Although job training may result inemployment and income, the likelihood of significant changes during the time frameof the pregnancy is remote.PTS: 1 DIF: Cognitive Level: Implementation REF: 5OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance26.Which of the following statements indicate that the nurse is practicing appropriatefamily-centered care techniques(Select all that apply)?a.Thenursecommandsthemothertodoassheistold.b.Thenurseallowstimeforthepartnertoaskquestions.c.Thenurseallowsthemotherandfathertomakechoiceswhenpossible.d.Thenurseinformsthefamilyaboutwhatisgoingtohappen.e.Thenursetellsthepatient’ssister,whoisanurse,thatshecannotbeintheroomduringthedelivery.ANS: B, C

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Including the partner in the care process and allowing the couple to make choices areimportant elements of family-centered care. The nurse should never tell the motherwhat to do. Family-centered care involves collaboration between the health care teamand the client. Unless an institutional policy limits the number of attendants at adelivery, the client should be allowed to have whomever she wants present (exceptwhen the situation is an emergency and guests are asked to leave).PTS: 1 DIF: Cognitive Level: Analysis REF: 8OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial IntegrityMATCHINGMedical errors are a leading cause of death in the United States. The NationalQuality Forum has recommended numerous safe practices that nursing can promoteto reduce errors. Match each safe practice with the correct statement.a.Askthepatientto“teachback.”b.ComplywithCDCguidelines.c.Ensurethatinformationisdocumentedinatimelymanner.d.Promoteinterventionsthatwillreducepatientrisk.e.Reduceexposuretoradiation.27.Hand hygiene28.Informed consent29.Culture measurement, feedback, and intervention30.Pediatric imaging31.Patient care information27. ANS: B PTS: 1 DIF: Cognitive Level: ApplicationREF: 5 OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care EnvironmentNOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in2010, outlining 24 safe practices that should be used in all health care settings to reduce the riskof harm from the environment of care, processes, and systems. These are only a few of therecommended practices; however, nurses should be familiar with these guidelines.28. ANS: A PTS: 1 DIF: Cognitive Level: ApplicationREF: 5 OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care Environment

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NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in2010, outlining 24 safe practices that should be used in all health care settings to reduce the riskof harm from the environment of care, processes, and systems. These are only a few of therecommended practices; however, nurses should be familiar with these guidelines.29. ANS: D PTS: 1 DIF: Cognitive Level: ApplicationREF: 5 OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care EnvironmentNOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in2010, outlining 24 safe practices that should be used in all health care settings to reduce the riskof harm from the environment of care, processes, and systems. These are only a few of therecommended practices; however, nurses should be familiar with these guidelines.30. ANS: E PTS: 1 DIF: Cognitive Level: ApplicationREF: 5 OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care EnvironmentNOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in2010, outlining 24 safe practices that should be used in all health care settings to reduce the riskof harm from the environment of care, processes, and systems. These are only a few of therecommended practices; however, nurses should be familiar with these guidelines.31. ANS: C PTS: 1 DIF: Cognitive Level: ApplicationREF: 5 OBJ: Nursing Process: ImplementationMSC: Client Needs: Safe and Effective Care EnvironmentNOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in2010, outlining 24 safe practices that should be used in all health care settings to reduce the riskof harm from the environment of care, processes, and systems. These are only a few of therecommended practices; however, nurses should be familiar with these guidelines.Chapter 02: Community Care: The Family andCultureChapter 02: Community Care: The Family and CultureMULTIPLE CHOICE1.A married couple lives in a single-family house with their newborn son and thehusband’sdaughter from a previous marriage. On the basis of the information given,what family form best describes this family?a.Married-blendedfamilyc.Nuclearfamily

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b.Extendedfamilyd.Same-sexfamilyANS: AMarried-blended families are formed as the result of divorce and remarriage.Unrelated family members join together to create a new household. Members of anextended family are kin, or family members related by blood, such as grandparents,aunts, and uncles. A nuclear family is a traditional family with male and femalepartners and the children resulting from that union. A same-sex family is a familywith homosexual partners who cohabit with or without children.PTS: 1 DIF: Cognitive Level: Knowledge REF: 18OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity2.In what form do families tend to be most socially vulnerable?a.Married-blendedfamilyc.Nuclearfamilyb.Extendedfamilyd.Single-parentfamilyANS: DThe single-parent family tends to be vulnerable economically and socially, creating anunstable and deprived environment for the growth potential of children. The married-blended family, the extended family, and the nuclear family are not the most sociallyvulnerable.PTS: 1 DIF: Cognitive Level: Knowledge REF: 18OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity3.Health care functions carried out by families to meet theirmembers’needs include:a.Developingfamilybudgets.b.Socializingchildren.c.Meetingnutritionalrequirements.d.Teachingfamilymembersaboutbirthcontrol.ANS: CMeeting nutritional requirements is a fundamental health promotion behavior.Although creating a family budget may be helpful, it does not indicate that funds willbe allotted to meet health needs if money is scarce. Often families cannot affordpreventive care and rely on emergency departments for their health care needs.Socialization of children may be important, but it is not directly related to the healthcare of individuals in a family unit. Birth control may be important, but it is not abasic survival health care function.

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PTS: 1 DIF: Cognitive Level: Comprehension REF: 28OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity4.The nurse should be aware that the criteria used to make decisions and solveproblems within families are based primarily on family:a.Ritualsandcustoms.c.Boundariesandchannels.b.Valuesandbeliefs.d.Socializationprocesses.ANS: BValues and beliefs are the most prevalent factors in the decision-making and problem-solving techniques of families. Although culture may play a part in the decision-making process of a family, ultimately values and beliefs dictate the course of actiontaken by family members. Boundaries and channels affect the relationship betweenthe family members and the health care team, not the decisions within the family.Socialization processes may help families with interactions with the community, butthey are not the criteria used for decision making within the family.PTS: 1 DIF: Cognitive Level: Comprehension REF: 25OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity5.Using the family stress theory as an intervention approach for working with familiesexperiencing parenting, the nurse can help the family change internal context factors.These include:a.Biologicandgeneticmakeup.b.Maturationoffamilymembers.c.Thefamily’sperceptionoftheevent.d.Theprevailingculturalbeliefsofsociety.ANS: CThe family stress theory is concerned with thefamily’sreaction to stressful events;internal context factors include elements that a family can control such as psychologicdefenses. It is not concerned with biologic and genetic makeup, maturation of familymembers, or the prevailing cultural beliefs of society.PTS: 1 DIF: Cognitive Level: Comprehension REF: 20OBJ: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity6.While working in the prenatal clinic, you care for a very diverse group of patients.When planning interventions for these families, you realize that acceptance of theinterventions will be most influenced by:

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a.Educationalachievement.c.Subculturalgroup.b.Incomelevel.d.Individualbeliefs.ANS: DThepatient’sbeliefs are ultimately the key to acceptance of health care interventions.However, these beliefs may be influenced by factors such as educational level, incomelevel, and ethnic background. Educational achievement, income level, and subculturalgroup all are important factors. However, the nurse must understand that awoman’sconcerns from her own point of view will have the most influence on her compliance.PTS: 1 DIF: Cognitive Level: Application REF: 22OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity7.Thenurse’scare of a Hispanic family includes teaching about infant care. Whendeveloping a plan of care, the nurse bases interventions on the knowledge that intraditional Hispanic families:a.Breastfeedingisencouragedimmediatelyafterbirth.b.Maleinfantstypicallyarecircumcised.c.Thematernalgrandmotherparticipatesinthecareofthemotherandherinfant.d.Specialherbsmixedinwaterareusedtostimulatethepassageofmeconium.ANS: CIn Hispanic families, the expectant mother is influenced strongly by her mother ormother-in-law. Breastfeeding often is delayed until the third postpartum day. Hispanicmale infants usually are not circumcised. Olive or castor oil may be given to stimulatethe passage of meconium.PTS: 1 DIF: Cognitive Level: Application REF: 26OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity8.Thewoman’sfamily members are present when the home care maternal-child nursearrives for a postpartum and newborn visit. What should the nurse do?a.Observethefamilymembers’interactionswiththenewbornandoneanother.b.Askthewomantomeetwithherandthebabyalone.c.Doabriefassessmentonallfamilymemberspresent.d.ReschedulethevisitforanothertimesothatthemotherandinfantcanbeassessedprivatelyANS: A

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The nurse should introduce herself to the patient and the other family memberspresent. Family members in the home may be providing care and assistance to themother and infant. However, this care may not be based on sound health practices.Nurses should take the opportunity to dispel myths while family members are present.The responsibility of the home care maternal-child nurse is to provide care to the newpostpartum mother and her infant, not to all family members. The nurse can politelyask about the other people in the home and their relationships with the woman. Unlessan indication is given that the woman would prefer privacy, the visit may continue.PTS: 1 DIF: Cognitive Level: Analysis REF: 33OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity9.The nurse should be aware that during the childbearing experience an African-American woman is most likely to:a.Seekprenatalcareearlyinherpregnancy.b.Avoidself-treatmentofpregnancy-relateddiscomfort.c.Requestliverinthepostpartumperiodtopreventanemia.d.Arriveatthehospitalinadvancedlabor.ANS: DAfrican-American women often arrive at the hospital in far-advanced labor. Thesewomen may view pregnancy as a state of wellness, which is often the reason for delayin seeking prenatal care. African-American women practice many self-treatmentoptions for various discomforts of pregnancy, and they may request liver in thepostpartum period, but this is based on a belief that the liver has a high blood content.PTS: 1 DIF: Cognitive Level: Comprehension REF: 26OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance10.To provide competent care to an Asian-American family, the nurse should includewhich of the following questions during the assessment interview?a.“Doyoupreferhotorcoldbeverages?”b.“Doyouwantmilktodrink?”c.“Doyouwantmusicplayingwhileyouareinlabor?”d.“Doyouhaveanameselectedforthebaby?”ANS: A

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Asian-Americans often prefer warm beverages. Milk usually is excluded from the dietof this population. Asian-American women typically labor in a quiet atmosphere.Delaying naming the child is common for Asian-American families.PTS: 1 DIF: Cognitive Level: Application REF: 27OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity11.Thepatient’sfamily is important to the maternity nurse because:a.Theypaythebills.b.Thenursewillknowwhichfamilymembertoavoid.c.Thenursewillknowwhichmotherswillreallycarefortheirchildren.d.Thefamilycultureandstructurewillinfluencenursingcaredecisions.ANS: DFamily structure and culture influence the health decisions of mothers.PTS: 1 DIF: Cognitive Level: Comprehension REF: 17OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity12.Amother’shousehold consists of her husband, his mother, and another child. Sheis living in a(n):a.Extendedfamily.c.Married-blendedfamily.b.Single-parentfamily.d.Nuclearfamily.ANS: AAn extended family includes blood relatives living with the nuclear family. Bothparents and a grandparent are living in this extended family. Single-parent familiescomprise an unmarried biologic or adoptive parent who may or may not be living withother adults. Married-blended refers to families reconstructed after divorce. A nuclearfamily is where male and female partners and their children live as an independentunit.PTS: 1 DIF: Cognitive Level: Application REF: 17OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity13.A traditional family structure in which male and female partners and their childrenlive as an independent unit is known as a(n):a.Extendedfamily.c.Nuclearfamily.b.Binuclearfamily.d.Blendedfamily.ANS: C

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About two thirds of U.S. households meet the definition of a nuclear family. Extendedfamilies include additional blood relatives other than the parents. A binuclear familyinvolves two households. A blended family is reconstructed after divorce and involvesthe merger of two families.PTS: 1 DIF: Cognitive Level: Knowledge REF: 17OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity14.Which statement about family systems theory is inaccurate?a.Afamilysystemispartofalargersuprasystem.b.Afamilyasawholeisequaltothesumoftheindividualmembers.c.Achangeinonefamilymemberaffectsallfamilymembers.d.Thefamilyisabletocreateabalancebetweenchangeandstability.ANS: BA family as a whole is greater than the sum of its parts. The other statements arecharacteristics of a system that states that a family is greater than the sum of its parts.PTS: 1 DIF: Cognitive Level: Comprehension REF: 20OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity15.A pictorial tool that can assist the nurse in assessing aspects of family life relatedto health care is the:a.Genogram.c.Lifecyclemodel.b.Familyvaluesconstruct.d.Humandevelopmentwheel.ANS: AA genogram depicts the relationships of family members over generations.PTS: 1 DIF: Cognitive Level: Knowledge REF: 19OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity16.The process by which people retain some of their own culture while adopting thepractices of the dominant society is known as:a.Acculturation.c.Ethnocentrism.b.Assimilation.d.Culturalrelativism.ANS: AAcculturation is the process by which people retain some of their own culture whileadopting the practices of the dominant society. This process takes place over thecourse of generations. Assimilation is a loss of cultural identity. Acculturation

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describes the process by which people retain some of their own culture while adoptingthe practices of the dominant society. Ethnocentrism is the belief in the superiority ofone’sown culture over the cultures of others. Acculturation describes the process bywhich people retain some of their own culture while adopting the practices of thedominant society. Cultural relativism recognizes the roles of different cultures.Acculturation describes the process by which people retain some of their own culturewhile adopting the practices of the dominant society.PTS: 1 DIF: Cognitive Level: Knowledge REF: 22OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity17.When attempting to communicate with a patient who speaks a different language,the nurse should:a.Respondpromptlyandpositivelytoprojectauthority.b.Neveruseafamilymemberasaninterpreter.c.Talktotheinterpretertoavoidconfusingthepatient.d.Provideasmuchprivacyaspossible.ANS: DProviding privacy creates an atmosphere of respect and puts the patient at ease. Thenurse should not rush to judgment and should make sure that he or she understandsthepatient’smessage clearly. In crisis situations, the nurse may need to use a familymember or neighbor as a translator. The nurse should talk directly to the patient tocreate an atmosphere of respect.PTS: 1 DIF: Cognitive Level: Application REF: 23OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity18.In which culture is the father more likely to be expected to participate in the laborand delivery?a.Asian-Americanc.European-Americanb.African-Americand.HispanicANS: CEuropean-Americans expect the father to take a more active role in the labor anddelivery than the other cultures.PTS: 1 DIF: Cognitive Level: Comprehension REF: 26OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity19.Which statement about cultural competence isnotaccurate?

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a.Localhealthcareworkersandcommunityadvocatescanhelpextendhealthcaretoundersepopulations.b.Nursingcareisdeliveredinthecontextoftheclient’sculturebutnotinthecontextofthenculture.c.Nursesmustdevelopanawarenessofandsensitivitytovariouscultures.d.Aculture’seconomic,religious,andpoliticalstructuresinfluencepracticesthataffectchildANS: BThe cultural context of the nurse also affects nursing care. The work of local healthcare workers and community advocates is part of cultural competence; thenurse’scultural context is also important. Developing sensitivity to various cultures is part ofcultural competence, but thenurse’scultural context is also important. The impact ofeconomic, religious, and political structures is part of cultural competence; thenurse’scultural context is also important.PTS: 1 DIF: Cognitive Level: Comprehension REF: 25OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial IntegrityMULTIPLE RESPONSE20.The nurse is preparing for a home visit to complete a newborn wellness checkup.The neighborhood has a reputation for being dangerous. Identify which precautionsthe nurse should take to ensure her safety(Select all that apply).a.Havingaccesstoacellphoneatalltimes.b.Visitingaloneduetotheagency’sstaffingmodel.c.Carryinganextrasetofcarkeys.d.Avoidinggroupsofstrangershangingoutindoorways.e.Wearingherusualamountofjewelry.ANS: A, C, DNurse safety is an important component of home care. The nurse should be fullyaware of the home environment and the neighborhood in which the home care is beingprovided. In this situation, nurses should visit in pairs, have access to a cell phone atall times, and wear a limited amount of jewelry. The car should be parked in a well-litarea and locked at all times. An extra set of keys kept in the nursing home care bagavoids time and frustration if the nurse should become locked out of her automobile.Car keys spread between the fingers can also be used of the weapon if necessary.Groups of strangers, dark alleys, and unrestrained dogs should be avoided at all times.

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PTS: 1 DIF: Cognitive Level: Application REF: 33OBJ: Nursing Process: PlanningMSC: Client Needs: Safe and Effective Care EnvironmentMATCHINGYou are getting ready to participate in discharge teaching with a non–English-speaking new mother. The interpreter has arrived on the patient care unit to assistyou in providing culturally competent care. In the correct order, from 1 through 6,number the steps that you would take to work with the interpreter.a.Introduceyourselftotheinterpreterandconverseinformally.b.Outlineyourstatementsandquestions,listingthekeypiecesofinformationyouneedtoknoc.Makesuretheinterpreteriscomfortablewithtechnicalterms.d.Learnsomethingaboutthecultureofthepatient.e.Makenotesonwhatyoulearnedforfuturereference.f.Stopeverynowandthenandasktheinterpreter“Howisitgoing?”21.Step One22.Step Two23.Step Three24.Step Four25.Step Five26.Step Six21. ANS: B PTS: 1 DIF: Cognitive Level: ApplicationREF: 24 OBJ: Nursing Process: ImplementationMSC: Client Needs: Health Promotion and MaintenanceNOT: To work successfully with an interpreter, the nurse must organize her teaching into fourcategories. These include actions that are necessary before the interview, meeting with theinterpreter, during the interview, and after the interview. The nurse must be sensitive to culturaland situational differences (e.g., a woman from the Middle East may not wish to have a maleinterpreter present).22. ANS: D PTS: 1 DIF: Cognitive Level: ApplicationREF: 24 OBJ: Nursing Process: ImplementationMSC: Client Needs: Health Promotion and MaintenanceNOT: To work successfully with an interpreter, the nurse must organize her teaching into fourcategories. These include actions that are necessary before the interview, meeting with the

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interpreter, during the interview, and after the interview. The nurse must be sensitive to culturaland situational differences (e.g., a woman from the Middle East may not wish to have a maleinterpreter present).23. ANS: A PTS: 1 DIF: Cognitive Level: ApplicationREF: 24 OBJ: Nursing Process: ImplementationMSC: Client Needs: Health Promotion and MaintenanceNOT: To work successfully with an interpreter, the nurse must organize her teaching into fourcategories. These include actions that are necessary before the interview, meeting with theinterpreter, during the interview, and after the interview. The nurse must be sensitive to culturaland situational differences (e.g., a woman from the Middle East may not wish to have a maleinterpreter present).24. ANS: C PTS: 1 DIF: Cognitive Level: ApplicationREF: 24 OBJ: Nursing Process: ImplementationMSC: Client Needs: Health Promotion and MaintenanceNOT: To work successfully with an interpreter, the nurse must organize her teaching into fourcategories. These include actions that are necessary before the interview, meeting with theinterpreter, during the interview, and after the interview. The nurse must be sensitive to culturaland situational differences (e.g., a woman from the Middle East may not wish to have a maleinterpreter present).25. ANS: F PTS: 1 DIF: Cognitive Level: ApplicationREF: 24 OBJ: Nursing Process: ImplementationMSC: Client Needs: Health Promotion and MaintenanceNOT: To work successfully with an interpreter, the nurse must organize her teaching into fourcategories. These include actions that are necessary before the interview, meeting with theinterpreter, during the interview, and after the interview. The nurse must be sensitive to culturaland situational differences (e.g., a woman from the Middle East may not wish to have a maleinterpreter present).26. ANS: E PTS: 1 DIF: Cognitive Level: ApplicationREF: 24 OBJ: Nursing Process: ImplementationMSC: Client Needs: Health Promotion and MaintenanceNOT: To work successfully with an interpreter, the nurse must organize her teaching into fourcategories. These include actions that are necessary before the interview, meeting with theinterpreter, during the interview, and after the interview. The nurse must be sensitive to cultural

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and situational differences (e.g., a woman from the Middle East may not wish to have a maleinterpreter present).Chapter 03: Assessment and HealthPromotionChapter 03: Assessment and Health PromotionMULTIPLE CHOICE1.The two primary functions of the ovary are:a.Normalfemaledevelopmentandsexhormonerelease.b.Ovulationandinternalpelvicsupport.c.Sexualresponseandovulation.d.Ovulationandhormoneproduction.ANS: DThe two functions of the ovaries are ovulation and hormone production. The presenceof ovaries does not guarantee normal female development. The ovaries produceestrogen, progesterone, and androgen. Ovulation is the release of a mature ovum fromthe ovary; the ovaries are not responsible for internal pelvic support. Sexual responseis a feedback mechanism involving the hypothalamus, anterior pituitary gland, and theovaries. Ovulation does occur in the ovaries.PTS: 1 DIF: Cognitive Level: Knowledge REF: 42OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance2.The uterus is a muscular, pear-shaped organ that is responsible for:a.Cyclicmenstruation.c.Fertilization.b.Sexhormoneproduction.d.Sexualarousal.ANS: AThe uterus is an organ for reception, implantation, retention, and nutrition of thefertilized ovum; it also is responsible for cyclic menstruation. Hormone productionand fertilization occur in the ovaries. Sexual arousal is a feedback mechanisminvolving the hypothalamus, the pituitary gland, and the ovaries.PTS: 1 DIF: Cognitive Level: Knowledge REF: 40-41OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance3.Unique muscle fibers make the uterine myometrium ideally suited for:a.Menstruation.c.Ovulation.

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b.Thebirthprocess.d.Fertilization.ANS: BThe myometrium is made up of layers of smooth muscle that extend in threedirections. These muscles assist in the birth process by expelling the fetus, ligatingblood vessels after birth, and controlling the opening of the cervical os.PTS: 1 DIF: Cognitive Level: Application REF: 41OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance4.The hormone responsible for maturation of mammary gland tissue is:a.Estrogen.c.Prolactin.b.Testosterone.d.Progesterone.ANS: DProgesterone causes maturation of the mammary gland tissue, specifically acinarstructures of the lobules. Estrogen increases the vascularity of the breast tissue.Testosterone has no bearing on breast development. Prolactin is produced after birthand released from the pituitary gland. It is produced in response to infant suckling andemptying of the breasts.PTS: 1 DIF: Cognitive Level: Knowledge REF: 43OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance5.Because of the effect of cyclic ovarian changes on the breast, the best time forbreast self-examination (BSE) is:a.5to7daysaftermensesceases.c.Midmenstrualcycle.b.Day1oftheendometrialcycle.d.Anytimeduringashowerorbath.ANS: AThe physiologic alterations in breast size and activity reach their minimal level about5 to 7 days after menstruation stops. All women should perform BSE during thisphase of the menstrual cycle.PTS: 1 DIF: Cognitive Level: Knowledge REF: 44OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance6.Menstruation is periodic uterine bleeding:a.Thatoccursevery28days.b.Inwhichtheentireuterineliningisshed.c.Thatisregulatedbyovarianhormones.

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d.Thatleadstofertilization.ANS: CMenstruation is periodic uterine bleeding that is controlled by a feedback systeminvolving three cycles: endometrial, hypothalamic-pituitary, and ovarian. The averagelength of a menstrual cycle is 28 days, but variations are normal. During theendometrial cycle, the functional two thirds of the endometrium is shed. Lack offertilization leads to menstruation.PTS: 1 DIF: Cognitive Level: Knowledge REF: 45OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance7.Individual irregularities in the ovarian (menstrual) cycle are most often caused by:a.Variationsinthefollicular(preovulatory)phase.b.Anintacthypothalamic-pituitaryfeedbackmechanism.c.Afunctioningcorpusluteum.d.Aprolongedischemicphase.ANS: AAlmost all variations in the length of the ovarian cycle are the result of variations inthe length of the follicular phase. An intact hypothalamic-pituitary feedbackmechanism is regular, not irregular. The luteal phase begins after ovulation. Thecorpus luteum depends on the ovulatory phase and fertilization. During the ischemicphase, the blood supply to the functional endometrium is blocked, and necrosisdevelops. The functional layer separates from the basal layer, and menstrual bleedingbegins.PTS: 1 DIF: Cognitive Level: Comprehension REF: 45OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance8.Prostaglandins are produced in most organs of the body, including the uterus. Othersource(s) of prostaglandins is/are:a.Ovaries.c.Menstrualblood.b.Breastmilk.d.Thevagina.ANS: CMenstrual blood is a potent source of prostaglandins. Prostaglandins are produced inmost organs of the body and in menstrual blood. The ovaries, breast milk, and vaginaare neither organs nor a source of prostaglandins.PTS: 1 DIF: Cognitive Level: Knowledge REF: 47

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OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance9.Physiologically, sexual response can be characterized by:a.Coitus,masturbation,andfantasy.c.Erectionandorgasm.b.Myotoniaandvasocongestion.d.Excitement,plateau,andorgasm.ANS: BPhysiologically, according to Masters (1992), sexual response can be analyzed interms of two processes: vasocongestion and myotonia. Coitus, masturbation, andfantasy are forms of stimulation for the physical manifestation of the sexual response.Erection and orgasm occur in two of the four phases of the sexual response cycle.Excitement, plateau, and orgasm are three of the four phases of the sexual responsecycle.PTS: 1 DIF: Cognitive Level: Knowledge REF: 47OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance10.The long-term treatment plan for an adolescent with an eating disorder focuses on:a.Managingtheeffectsofmalnutrition.b.Establishingsufficientcaloricintake.c.Improvingfamilydynamics.d.Restructuringperceptionofbodyimage.ANS: DThe treatment of eating disorders is initially focused on reestablishing physiologichomeostasis. Once body systems are stabilized, the next goal of treatment for eatingdisorders is maintaining adequate caloric intake. Although family therapy is indicatedwhen dysfunctional family relationships exist, the primary focus of therapy for eatingdisorders is to help the adolescent cope with complex issues. The focus of treatment inindividual therapy for an eating disorder involves restructuring cognitive perceptionsabout theindividual’sbody image.PTS: 1 DIF: Cognitive Level: Application REF: 54OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity11.The nurse guides a woman to the examination room and asks her to remove herclothes and put on an examination gown with the front open. The woman states,“Ihave special undergarments that I do not remove for religiousreasons.”The mostappropriate response from the nurse would be:a.“Youcan’thaveanexaminationwithoutremovingallyourclothes.”

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b.“I’llaskthedoctortomodifytheexamination.”c.“Tellmeaboutyourundergarments.I’llexplaintheexaminationprocedure,andthenwecadiscusshowyoucanhaveyourexaminationcomfortably.”d.“What?I’veneverheardofsuchathing!Thatsoundsdifferentandstrange.”ANS: CThis statement reflects cultural competence by the nurse and shows respect for thewoman’sreligious practices. The nurse must respect the rich and unique qualities thatcultural diversity brings to individuals. In recognizing the value of these differences,the nurse can modify the plan of care to meet the needs of each woman.PTS: 1 DIF: Cognitive Level: Application REF: 48-49OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity12.A 62-year-old woman has not been to the clinic for an annual examination for 5years. The recent death of her husband reminded her that she should come for a visit.Her family doctor has retired, and she is going to see thewomen’shealth nursepractitioner for her visit. To facilitate a positive health care experience, the nurseshould:a.Remindthewomanthatsheislongoverdueforherexaminationandthatsheshouldcomeiannually.b.Listencarefullyandallowextratimeforthiswoman’shealthhistoryinterview.c.Reassurethewomanthatanursepractitionerisjustasgoodasherolddoctor.d.EncouragethewomantotalkaboutthedeathofherhusbandandherfearsaboutherowndeANS: BThe nurse has an opportunity to use reflection and empathy while listening and toensure open and caring communication. Scheduling a longer appointment time may benecessary because older women may have longer histories or may need to talk. Arespectful and reassuring approach to caring for women older than age 50 can helpensure that they continue to seek health care. Reminding the woman about heroverdue examination, reassuring the woman that she has a good practitioner, andencouraging conversation about the death of her husband and her own death are notthe best approaches with women in this age group.PTS: 1 DIF: Cognitive Level: Application REF: 62OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

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