Test Bank For Maternal Child Nursing Care, 5th Edition
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Chapter 01: 21st Century Maternity Nursing
Chapter 01: 21st Century Maternity Nursing
MULTIPLE CHOICE
1. When providing care for a pregnant woman, the nurse should be aware that one of
the most frequently reported maternal medical risk factors is:
a. Diabetes mellitus. c. Chronic hypertension.
b. Mitral valve prolapse (MVP). d. Anemia.
ANS: A
The most frequently reported maternal medical risk factors are diabetes and
hypertension associated with pregnancy. Both of these conditions are associated with
maternal obesity. There are no studies that indicate MVP is among the most
frequently reported maternal risk factors. Hypertension associated with pregnancy, not
chronic hypertension, is one of the most frequently reported maternal medical risk
factors. Although anemia is a concern in pregnancy, it is not one of the most
frequently reported maternal medical risk factors in pregnancy.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 6
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. To ensure optimal outcomes for the patient, the contemporary maternity nurse must
incorporate both teamwork and communication with clinicians into her care delivery,
The SBAR technique of communication is an easy-to-remember mechanism for
communication. Which of the following correctly defines this acronym?
a. Situation, baseline assessment, response
b. Situation, background, assessment, recommendation
c. Subjective background, assessment, recommendation
d. Situation, background, anticipated recommendation
ANS: B
The situation, background, assessment, recommendation (SBAR) technique provides
a specific framework for communication among health care providers. Failure to
communicate is one of the major reasons for errors in health care. The SBAR
technique has the potential to serve as a means to reduce errors.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 14
OBJ: Nursing Process: Assessment, Planning
Chapter 01: 21st Century Maternity Nursing
MULTIPLE CHOICE
1. When providing care for a pregnant woman, the nurse should be aware that one of
the most frequently reported maternal medical risk factors is:
a. Diabetes mellitus. c. Chronic hypertension.
b. Mitral valve prolapse (MVP). d. Anemia.
ANS: A
The most frequently reported maternal medical risk factors are diabetes and
hypertension associated with pregnancy. Both of these conditions are associated with
maternal obesity. There are no studies that indicate MVP is among the most
frequently reported maternal risk factors. Hypertension associated with pregnancy, not
chronic hypertension, is one of the most frequently reported maternal medical risk
factors. Although anemia is a concern in pregnancy, it is not one of the most
frequently reported maternal medical risk factors in pregnancy.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 6
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. To ensure optimal outcomes for the patient, the contemporary maternity nurse must
incorporate both teamwork and communication with clinicians into her care delivery,
The SBAR technique of communication is an easy-to-remember mechanism for
communication. Which of the following correctly defines this acronym?
a. Situation, baseline assessment, response
b. Situation, background, assessment, recommendation
c. Subjective background, assessment, recommendation
d. Situation, background, anticipated recommendation
ANS: B
The situation, background, assessment, recommendation (SBAR) technique provides
a specific framework for communication among health care providers. Failure to
communicate is one of the major reasons for errors in health care. The SBAR
technique has the potential to serve as a means to reduce errors.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 14
OBJ: Nursing Process: Assessment, Planning
Chapter 01: 21st Century Maternity Nursing
Chapter 01: 21st Century Maternity Nursing
MULTIPLE CHOICE
1. When providing care for a pregnant woman, the nurse should be aware that one of
the most frequently reported maternal medical risk factors is:
a. Diabetes mellitus. c. Chronic hypertension.
b. Mitral valve prolapse (MVP). d. Anemia.
ANS: A
The most frequently reported maternal medical risk factors are diabetes and
hypertension associated with pregnancy. Both of these conditions are associated with
maternal obesity. There are no studies that indicate MVP is among the most
frequently reported maternal risk factors. Hypertension associated with pregnancy, not
chronic hypertension, is one of the most frequently reported maternal medical risk
factors. Although anemia is a concern in pregnancy, it is not one of the most
frequently reported maternal medical risk factors in pregnancy.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 6
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. To ensure optimal outcomes for the patient, the contemporary maternity nurse must
incorporate both teamwork and communication with clinicians into her care delivery,
The SBAR technique of communication is an easy-to-remember mechanism for
communication. Which of the following correctly defines this acronym?
a. Situation, baseline assessment, response
b. Situation, background, assessment, recommendation
c. Subjective background, assessment, recommendation
d. Situation, background, anticipated recommendation
ANS: B
The situation, background, assessment, recommendation (SBAR) technique provides
a specific framework for communication among health care providers. Failure to
communicate is one of the major reasons for errors in health care. The SBAR
technique has the potential to serve as a means to reduce errors.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 14
OBJ: Nursing Process: Assessment, Planning
Chapter 01: 21st Century Maternity Nursing
MULTIPLE CHOICE
1. When providing care for a pregnant woman, the nurse should be aware that one of
the most frequently reported maternal medical risk factors is:
a. Diabetes mellitus. c. Chronic hypertension.
b. Mitral valve prolapse (MVP). d. Anemia.
ANS: A
The most frequently reported maternal medical risk factors are diabetes and
hypertension associated with pregnancy. Both of these conditions are associated with
maternal obesity. There are no studies that indicate MVP is among the most
frequently reported maternal risk factors. Hypertension associated with pregnancy, not
chronic hypertension, is one of the most frequently reported maternal medical risk
factors. Although anemia is a concern in pregnancy, it is not one of the most
frequently reported maternal medical risk factors in pregnancy.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 6
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. To ensure optimal outcomes for the patient, the contemporary maternity nurse must
incorporate both teamwork and communication with clinicians into her care delivery,
The SBAR technique of communication is an easy-to-remember mechanism for
communication. Which of the following correctly defines this acronym?
a. Situation, baseline assessment, response
b. Situation, background, assessment, recommendation
c. Subjective background, assessment, recommendation
d. Situation, background, anticipated recommendation
ANS: B
The situation, background, assessment, recommendation (SBAR) technique provides
a specific framework for communication among health care providers. Failure to
communicate is one of the major reasons for errors in health care. The SBAR
technique has the potential to serve as a means to reduce errors.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 14
OBJ: Nursing Process: Assessment, Planning
MSC: Client Needs: Safe and Effective Care Environment
3. The role of the professional nurse caring for childbearing families has evolved to
emphasize:
a. Providing care to patients directly at the bedside.
b. Primarily hospital care of maternity patients.
c. Practice using an evidence-based approach.
d. Planning patient care to cover longer hospital stays.
ANS: C
Professional nurses are part of the team of health care providers who collaboratively
care for patients throughout the childbearing cycle. Providing care to patients directly
at the bedside is one of the nurse’s tasks; however, it does not encompass the concept
of the evolved professional nurse. Throughout the prenatal period, nurses care for
women in clinics and physician’s offices and teach classes to help families prepare for
childbirth. Nurses also care for childbearing families in birthing centers and in the
home. Nurses have been critically important in developing strategies to improve the
well-being of women and their infants and have led the efforts to implement clinical
practice guidelines using an evidence-based approach. Maternity patients have
experienced a decreased, rather than an increased, length of stay over the past 2
decades.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 1
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
4. A 23-year-old African-American woman is pregnant with her first child. Based on
the statistics for infant mortality, which plan is most important for the nurse to
implement?
a. Perform a nutrition assessment.
b. Refer the woman to a social worker.
c. Advise the woman to see an obstetrician, not a midwife.
d. Explain to the woman the importance of keeping her prenatal care appointments.
ANS: D
Consistent prenatal care is the best method of preventing or controlling risk factors
associated with infant mortality. Nutritional status is an important modifiable risk
3. The role of the professional nurse caring for childbearing families has evolved to
emphasize:
a. Providing care to patients directly at the bedside.
b. Primarily hospital care of maternity patients.
c. Practice using an evidence-based approach.
d. Planning patient care to cover longer hospital stays.
ANS: C
Professional nurses are part of the team of health care providers who collaboratively
care for patients throughout the childbearing cycle. Providing care to patients directly
at the bedside is one of the nurse’s tasks; however, it does not encompass the concept
of the evolved professional nurse. Throughout the prenatal period, nurses care for
women in clinics and physician’s offices and teach classes to help families prepare for
childbirth. Nurses also care for childbearing families in birthing centers and in the
home. Nurses have been critically important in developing strategies to improve the
well-being of women and their infants and have led the efforts to implement clinical
practice guidelines using an evidence-based approach. Maternity patients have
experienced a decreased, rather than an increased, length of stay over the past 2
decades.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 1
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
4. A 23-year-old African-American woman is pregnant with her first child. Based on
the statistics for infant mortality, which plan is most important for the nurse to
implement?
a. Perform a nutrition assessment.
b. Refer the woman to a social worker.
c. Advise the woman to see an obstetrician, not a midwife.
d. Explain to the woman the importance of keeping her prenatal care appointments.
ANS: D
Consistent prenatal care is the best method of preventing or controlling risk factors
associated with infant mortality. Nutritional status is an important modifiable risk
factor, but a nutrition assessment is not the most important action a nurse should take
in this situation. The patient may need assistance from a social worker at some time
during her pregnancy, but a referral to a social worker is not the most important aspect
the nurse should address at this time. If the woman has identifiable high-risk
problems, her health care may need to be provided by a physician. However, it cannot
be 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 which
the nurse should focus at this time, and it is not appropriate for a nurse to advise or
manage the type of care a patient is to receive.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 6
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
5. During a prenatal intake interview, the nurse is in the process of obtaining an initial
assessment of a 21-year-old Hispanic patient with limited English proficiency. It is
important for the nurse to:
a. Use maternity jargon in order for the patient to become familiar with these terms.
b. Speak quickly and efficiently to expedite the visit.
c. Provide the patient with handouts.
d. Assess whether the patient understands the discussion.
ANS: D
Nurses contribute to health literacy by using simple, common words; avoiding jargon;
and evaluating whether the patient understands the discussion. Speaking slowly and
clearly and focusing on what is important increase understanding. Most patient
education materials are written at too high a level for the average adult and may not be
useful for a client with limited English proficiency.
PTS: 1 DIF: Cognitive Level: Application REF: 5
OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
6. When managing health care for pregnant women at a prenatal clinic, the nurse
should recognize that the most significant barrier to access to care is the pregnant
woman’s:
a. Age. c. Educational level.
b. Minority status. d. Inability to pay.
ANS: D
in this situation. The patient may need assistance from a social worker at some time
during her pregnancy, but a referral to a social worker is not the most important aspect
the nurse should address at this time. If the woman has identifiable high-risk
problems, her health care may need to be provided by a physician. However, it cannot
be 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 which
the nurse should focus at this time, and it is not appropriate for a nurse to advise or
manage the type of care a patient is to receive.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 6
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
5. During a prenatal intake interview, the nurse is in the process of obtaining an initial
assessment of a 21-year-old Hispanic patient with limited English proficiency. It is
important for the nurse to:
a. Use maternity jargon in order for the patient to become familiar with these terms.
b. Speak quickly and efficiently to expedite the visit.
c. Provide the patient with handouts.
d. Assess whether the patient understands the discussion.
ANS: D
Nurses contribute to health literacy by using simple, common words; avoiding jargon;
and evaluating whether the patient understands the discussion. Speaking slowly and
clearly and focusing on what is important increase understanding. Most patient
education materials are written at too high a level for the average adult and may not be
useful for a client with limited English proficiency.
PTS: 1 DIF: Cognitive Level: Application REF: 5
OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
6. When managing health care for pregnant women at a prenatal clinic, the nurse
should recognize that the most significant barrier to access to care is the pregnant
woman’s:
a. Age. c. Educational level.
b. Minority status. d. Inability to pay.
ANS: D
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 who
cannot pay. Although adolescent pregnant clients statistically receive less prenatal
care, age is not the most significant barrier. Significant disparities in morbidity and
mortality rates exist for minority women; however, minority status is not the most
significant barrier to access of care. Disparities in educational level are associated
with morbidity and mortality rates; however, educational level is not the most
significant barrier to access of care.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 5
OBJ: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
7. What is the primary role of practicing nurses in the research process?
a. Designing research studies
b. Collecting data for other researchers
c. Identifying researchable problems
d. Seeking funding to support research studies
ANS: C
When problems are identified, research can be conducted properly. Research of health
care issues leads to evidence-based practice guidelines. Designing research studies is
only 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 the
nurse in the research process.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 9
OBJ: Nursing Process: Diagnosis, Evaluation
MSC: Client Needs: Safe and Effective Care Environment
8. When the nurse is unsure about how to perform a patient care procedure, the best
action would be to:
a. Ask another nurse.
b. Discuss the procedure with the patient’s physician.
c. Look up the procedure in a nursing textbook.
d. Consult the agency procedure manual and follow the guidelines for the procedure.
ANS: D
this is compounded by the fact that many physicians refuse to care for women who
cannot pay. Although adolescent pregnant clients statistically receive less prenatal
care, age is not the most significant barrier. Significant disparities in morbidity and
mortality rates exist for minority women; however, minority status is not the most
significant barrier to access of care. Disparities in educational level are associated
with morbidity and mortality rates; however, educational level is not the most
significant barrier to access of care.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 5
OBJ: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
7. What is the primary role of practicing nurses in the research process?
a. Designing research studies
b. Collecting data for other researchers
c. Identifying researchable problems
d. Seeking funding to support research studies
ANS: C
When problems are identified, research can be conducted properly. Research of health
care issues leads to evidence-based practice guidelines. Designing research studies is
only 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 the
nurse in the research process.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 9
OBJ: Nursing Process: Diagnosis, Evaluation
MSC: Client Needs: Safe and Effective Care Environment
8. When the nurse is unsure about how to perform a patient care procedure, the best
action would be to:
a. Ask another nurse.
b. Discuss the procedure with the patient’s physician.
c. Look up the procedure in a nursing textbook.
d. Consult the agency procedure manual and follow the guidelines for the procedure.
ANS: D
It is always best to follow the agency’s policies and procedures manual when seeking
information on correct patient procedures. These policies should reflect the current
standards 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 to
follow the standards of care for safe client care delivery. Physicians are responsible
for their own client care activity. Nurses may follow safe orders from physicians, but
they are also responsible for the activities that they as nurses are to carry out.
Information provided in a nursing textbook is basic information for general
knowledge. Furthermore, the information in a textbook may not reflect the current
standard of care or individual state or hospital policies.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 11
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
9. From the nurse’s perspective, what measure should be the focus of the health care
system to reduce the rate of infant mortality further?
a. Implementing programs to ensure women’s early participation in ongoing prenatal care
b. Increasing the length of stay in a hospital after vaginal birth from 2 to 3 days
c. Expanding the number of neonatal intensive care units (NICUs)
d. Mandating that all pregnant women receive care from an obstetrician
ANS: A
Early prenatal care allows for early diagnosis and appropriate interventions to reduce
the rate of infant mortality. An increased length of stay has been shown to foster
improved self-care and parental education. However, it does not prevent the incidence
of leading causes of infant mortality rates, such as low birth weight. Early prevention
and diagnosis reduce the rate of infant mortality. NICUs offer care to high-risk infants
after they are born. Expanding the number of NICUs would offer better access for
high-risk care, but this factor is not the primary focus for further reduction of infant
mortality rates. A mandate that all pregnant women receive obstetric care would be
nearly impossible to enforce. Furthermore, certified nurse-midwives (CNMs) have
demonstrated reliable, safe care for pregnant women.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 10
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
10. Alternative and complementary therapies:
a. Replace conventional Western modalities of treatment.
information on correct patient procedures. These policies should reflect the current
standards 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 to
follow the standards of care for safe client care delivery. Physicians are responsible
for their own client care activity. Nurses may follow safe orders from physicians, but
they are also responsible for the activities that they as nurses are to carry out.
Information provided in a nursing textbook is basic information for general
knowledge. Furthermore, the information in a textbook may not reflect the current
standard of care or individual state or hospital policies.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 11
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
9. From the nurse’s perspective, what measure should be the focus of the health care
system to reduce the rate of infant mortality further?
a. Implementing programs to ensure women’s early participation in ongoing prenatal care
b. Increasing the length of stay in a hospital after vaginal birth from 2 to 3 days
c. Expanding the number of neonatal intensive care units (NICUs)
d. Mandating that all pregnant women receive care from an obstetrician
ANS: A
Early prenatal care allows for early diagnosis and appropriate interventions to reduce
the rate of infant mortality. An increased length of stay has been shown to foster
improved self-care and parental education. However, it does not prevent the incidence
of leading causes of infant mortality rates, such as low birth weight. Early prevention
and diagnosis reduce the rate of infant mortality. NICUs offer care to high-risk infants
after they are born. Expanding the number of NICUs would offer better access for
high-risk care, but this factor is not the primary focus for further reduction of infant
mortality rates. A mandate that all pregnant women receive obstetric care would be
nearly impossible to enforce. Furthermore, certified nurse-midwives (CNMs) have
demonstrated reliable, safe care for pregnant women.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 10
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
10. Alternative and complementary therapies:
a. Replace conventional Western modalities of treatment.
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b. Are used by only a small number of American adults.
c. Recognize the value of clients’ input into their health care.
d. Focus primarily on the disease an individual is experiencing.
ANS: C
Many popular alternative healing modalities offer human-centered care based on
philosophies that recognize the value of the patient’s input and honor the individual’s
beliefs, values, and desires. Alternative and complementary therapies are part of an
integrative approach to health care. An increasing number of American adults are
seeking alternative and complementary health care options. Alternative healing
modalities offer an holistic approach to health, focusing on the whole person, not just
the disease.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 4
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
11. A 38-year-old Hispanic woman delivered a 9-pound, 6-ounce girl vaginally after
being in labor for 43 hours. The baby died 3 days later from sepsis. On what grounds
would the woman potentially have a legitimate legal case for negligence?
a. She is Hispanic. c. The standards of care were not met
b. She delivered a girl. d. She refused fetal monitoring.
ANS: C
Not meeting the standards of care is a legitimate factor for a case of negligence. The
client’s race is not a factor for a case of negligence. The infant’s gender is not a factor
for a case of negligence. Although fetal monitoring is the standard of care, the client
has 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 against
medical advice form for refusal of any treatment that is within the standard of care.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 12
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
12. A newly graduated nurse is attempting to understand the reason for increasing
health care spending in the United States. Her research finds that these costs are much
higher compared with other developed countries as a result of:
a. A higher rate of obesity among pregnant women.
b. Limited access to technology.
c. Recognize the value of clients’ input into their health care.
d. Focus primarily on the disease an individual is experiencing.
ANS: C
Many popular alternative healing modalities offer human-centered care based on
philosophies that recognize the value of the patient’s input and honor the individual’s
beliefs, values, and desires. Alternative and complementary therapies are part of an
integrative approach to health care. An increasing number of American adults are
seeking alternative and complementary health care options. Alternative healing
modalities offer an holistic approach to health, focusing on the whole person, not just
the disease.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 4
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
11. A 38-year-old Hispanic woman delivered a 9-pound, 6-ounce girl vaginally after
being in labor for 43 hours. The baby died 3 days later from sepsis. On what grounds
would the woman potentially have a legitimate legal case for negligence?
a. She is Hispanic. c. The standards of care were not met
b. She delivered a girl. d. She refused fetal monitoring.
ANS: C
Not meeting the standards of care is a legitimate factor for a case of negligence. The
client’s race is not a factor for a case of negligence. The infant’s gender is not a factor
for a case of negligence. Although fetal monitoring is the standard of care, the client
has 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 against
medical advice form for refusal of any treatment that is within the standard of care.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 12
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
12. A newly graduated nurse is attempting to understand the reason for increasing
health care spending in the United States. Her research finds that these costs are much
higher compared with other developed countries as a result of:
a. A higher rate of obesity among pregnant women.
b. Limited access to technology.
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c. Increased usage of health care services along with lower prices.
d. Homogeneity of the population.
ANS: A
Health 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 the
United States compared with 12 other industrialized countries is related to higher
prices and readily accessible technology along with greater obesity rates among
women. 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. Maternal
morbidity and mortality are directly related to racial disparities.
PTS: 1 DIF: Cognitive Level: Analysis REF: 5
OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
13. The term used to describe legal and professional responsibility for practice for
maternity nurses is:
a. Collegiality. c. Evaluation.
b. Ethics. d. Accountability.
ANS: D
Accountability refers to legal and professional responsibility for practice. Collegiality
refers to a working relationship with one’s colleagues. Ethics refers to a code to guide
practice. Evaluation refers to examination of the effectiveness of interventions in
relation to expected outcomes.
PTS: 1 DIF: Cognitive Level: Evaluation REF: 12
OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
14. Through the use of social media technology, nurses can link with other nurses who
may share similar interests, insights about practice, and advocate for patients. The
most concerning pitfall for nurses using this technology is:
a. Violation of patient privacy and confidentiality.
b. Institutions and colleagues may be cast in an unfavorable light.
c. Unintended negative consequences for using social media.
d. Lack of institutional policy governing online contact.
ANS: A
d. Homogeneity of the population.
ANS: A
Health 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 the
United States compared with 12 other industrialized countries is related to higher
prices and readily accessible technology along with greater obesity rates among
women. 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. Maternal
morbidity and mortality are directly related to racial disparities.
PTS: 1 DIF: Cognitive Level: Analysis REF: 5
OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
13. The term used to describe legal and professional responsibility for practice for
maternity nurses is:
a. Collegiality. c. Evaluation.
b. Ethics. d. Accountability.
ANS: D
Accountability refers to legal and professional responsibility for practice. Collegiality
refers to a working relationship with one’s colleagues. Ethics refers to a code to guide
practice. Evaluation refers to examination of the effectiveness of interventions in
relation to expected outcomes.
PTS: 1 DIF: Cognitive Level: Evaluation REF: 12
OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
14. Through the use of social media technology, nurses can link with other nurses who
may share similar interests, insights about practice, and advocate for patients. The
most concerning pitfall for nurses using this technology is:
a. Violation of patient privacy and confidentiality.
b. Institutions and colleagues may be cast in an unfavorable light.
c. Unintended negative consequences for using social media.
d. Lack of institutional policy governing online contact.
ANS: A
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The most significant pitfall for nurses using this technology is the violation of patient
privacy and confidentiality. Furthermore, institutions and colleagues can be cast in
unfavorable lights with negative consequences for those posting information. Nursing
students have been expelled from school and nurses have been fired or reprimanded
by their Board of Nursing for injudicious posts. The American Nurses Association has
published six principles for social networking and nurses. All institutions should have
policies guiding the use of social media, and nurses should be familiar with these
guidelines.
PTS: 1 DIF: Cognitive Level: Analysis REF: 7
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
15. An important development that affects maternity nursing is integrative health care,
which:
a. Seeks to provide the same health care for all racial and ethnic groups.
b. Blends complementary and alternative therapies with conventional Western treatment.
c. Focuses on the disease or condition rather than the background of the client.
d. Has been mandated by Congress.
ANS: B
Integrative health care tries to mix the old with the new at the discretion of the client
and health care providers. Integrative health care is a blending of new and traditional
practices. Integrative health care focuses on the whole person, not just the disease or
condition. U.S. law supports complementary and alternative therapies but does not
mandate them.
PTS: 1 DIF: Cognitive Level: Application REF: 4
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
16. Recent trends in childbirth practices in the United States indicate that:
a. More than 15% of mothers had late or no prenatal care.
b.
The percentage of Hispanics, non-Hispanic African Americans, and Caucasians who receiv
prenatal care was essentially the same.
c. Births occurring in the hospital accounted for 99% of births.
d. Cesarean births have been declining as a percentage of live births.
ANS: C
privacy and confidentiality. Furthermore, institutions and colleagues can be cast in
unfavorable lights with negative consequences for those posting information. Nursing
students have been expelled from school and nurses have been fired or reprimanded
by their Board of Nursing for injudicious posts. The American Nurses Association has
published six principles for social networking and nurses. All institutions should have
policies guiding the use of social media, and nurses should be familiar with these
guidelines.
PTS: 1 DIF: Cognitive Level: Analysis REF: 7
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
15. An important development that affects maternity nursing is integrative health care,
which:
a. Seeks to provide the same health care for all racial and ethnic groups.
b. Blends complementary and alternative therapies with conventional Western treatment.
c. Focuses on the disease or condition rather than the background of the client.
d. Has been mandated by Congress.
ANS: B
Integrative health care tries to mix the old with the new at the discretion of the client
and health care providers. Integrative health care is a blending of new and traditional
practices. Integrative health care focuses on the whole person, not just the disease or
condition. U.S. law supports complementary and alternative therapies but does not
mandate them.
PTS: 1 DIF: Cognitive Level: Application REF: 4
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
16. Recent trends in childbirth practices in the United States indicate that:
a. More than 15% of mothers had late or no prenatal care.
b.
The percentage of Hispanics, non-Hispanic African Americans, and Caucasians who receiv
prenatal care was essentially the same.
c. Births occurring in the hospital accounted for 99% of births.
d. Cesarean births have been declining as a percentage of live births.
ANS: C
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Almost all births occur within the hospital setting. Only 5.2% of Caucasians mothers
had either late care or no care. There are disparities in the receipt of prenatal care by
ethnicity: 12.2% of Hispanic women and 11.8% of non-Hispanic black women
received either late or no prenatal care. The percentage of cesarean births is
increasing.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 7
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
17. Recent trends in childbirth practice indicate that:
a. Delayed pushing is now discouraged in the second stage of labor.
b. Episiotomy rates are increasing.
c. Midwives perform more episiotomies than physicians.
d. Newborn infants remain with the mother and are encouraged to breastfeed.
ANS: D
Breastfeeding is encouraged for newborns immediately after birth. Delayed pushing is
encouraged for several reasons. Episiotomy rates are declining. Midwives perform
fewer episiotomies than physicians.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 8
OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
18. The nurse caring for a pregnant client should be aware that the U.S. birth rate
shows which trend?
a. Births to unmarried women are more likely to have less favorable outcomes.
b. Birth rates for women 40 to 44 years old are beginning to decline.
c. Cigarette smoking among pregnant women continues to increase.
d. The rates of maternal death owing to racial disparity are elevated in the United States.
ANS: A
Low-birth-weight infants and preterm birth are more likely because of the large
number of teenagers in the unmarried group. Birth rates for women in their early 40s
continue to increase. Fewer pregnant women smoke. In the United States, there is
significant racial disparity in the rates of maternal death.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 6
OBJ: Nursing Process: Assessment
had either late care or no care. There are disparities in the receipt of prenatal care by
ethnicity: 12.2% of Hispanic women and 11.8% of non-Hispanic black women
received either late or no prenatal care. The percentage of cesarean births is
increasing.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 7
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
17. Recent trends in childbirth practice indicate that:
a. Delayed pushing is now discouraged in the second stage of labor.
b. Episiotomy rates are increasing.
c. Midwives perform more episiotomies than physicians.
d. Newborn infants remain with the mother and are encouraged to breastfeed.
ANS: D
Breastfeeding is encouraged for newborns immediately after birth. Delayed pushing is
encouraged for several reasons. Episiotomy rates are declining. Midwives perform
fewer episiotomies than physicians.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 8
OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
18. The nurse caring for a pregnant client should be aware that the U.S. birth rate
shows which trend?
a. Births to unmarried women are more likely to have less favorable outcomes.
b. Birth rates for women 40 to 44 years old are beginning to decline.
c. Cigarette smoking among pregnant women continues to increase.
d. The rates of maternal death owing to racial disparity are elevated in the United States.
ANS: A
Low-birth-weight infants and preterm birth are more likely because of the large
number of teenagers in the unmarried group. Birth rates for women in their early 40s
continue to increase. Fewer pregnant women smoke. In the United States, there is
significant racial disparity in the rates of maternal death.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 6
OBJ: Nursing Process: Assessment
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MSC: Client Needs: Safe and Effective Care Environment
19. Maternity nursing care that is based on knowledge gained through research and
clinical trials is:
a. Derived from the Nursing Intervention Classification.
b. Known as evidence-based practice.
c. At odds with the Cochrane School of traditional nursing.
d. An outgrowth of telemedicine.
ANS: B
Evidence-based practice is based on knowledge gained from research and clinical
trials. The Nursing Intervention Classification is a method of standardizing language
and categorizing care. Dr. Cochrane systematically reviewed research trials and is part
of the evidence-based practice movement. Telemedicine uses communication
technologies to support health care.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 9
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
20. The level of practice a reasonably prudent nurse provides is called:
a. The standard of care. c. A sentinel event.
b. Risk management. d. Failure to rescue.
ANS: A
Guidelines for standards of care are published by various professional nursing
organizations. Risk management identifies risks and establishes preventive practices,
but it does not define the standard of care. Sentinel events are unexpected negative
occurrences. They do not establish the standard of care. Failure to rescue is an
evaluative process for nursing, but it does not define the standard of care.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 11
OBJ: Nursing Process: Diagnosis
MSC: Client Needs: Safe and Effective Care Environment
21. During a prenatal intake interview, the client informs the nurse that she would
prefer a midwife to provide her care during pregnancy and deliver her infant. What
information would be most appropriate for the nurse to share with this patient?
a.
Midwifery care is available only to clients who are uninsured because their services are less
expensive than an obstetrician. Costs are often lower than an obstetric provider.
b. The client will receive fewer interventions during the birth process.
19. Maternity nursing care that is based on knowledge gained through research and
clinical trials is:
a. Derived from the Nursing Intervention Classification.
b. Known as evidence-based practice.
c. At odds with the Cochrane School of traditional nursing.
d. An outgrowth of telemedicine.
ANS: B
Evidence-based practice is based on knowledge gained from research and clinical
trials. The Nursing Intervention Classification is a method of standardizing language
and categorizing care. Dr. Cochrane systematically reviewed research trials and is part
of the evidence-based practice movement. Telemedicine uses communication
technologies to support health care.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 9
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
20. The level of practice a reasonably prudent nurse provides is called:
a. The standard of care. c. A sentinel event.
b. Risk management. d. Failure to rescue.
ANS: A
Guidelines for standards of care are published by various professional nursing
organizations. Risk management identifies risks and establishes preventive practices,
but it does not define the standard of care. Sentinel events are unexpected negative
occurrences. They do not establish the standard of care. Failure to rescue is an
evaluative process for nursing, but it does not define the standard of care.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 11
OBJ: Nursing Process: Diagnosis
MSC: Client Needs: Safe and Effective Care Environment
21. During a prenatal intake interview, the client informs the nurse that she would
prefer a midwife to provide her care during pregnancy and deliver her infant. What
information would be most appropriate for the nurse to share with this patient?
a.
Midwifery care is available only to clients who are uninsured because their services are less
expensive than an obstetrician. Costs are often lower than an obstetric provider.
b. The client will receive fewer interventions during the birth process.
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c. The client should be aware that midwives are not certified.
d. Delivery can take place only at the client’s home or in a birth center.
ANS: B
This patient will be able to participate actively in all decisions related to the birth
process and is likely to receive fewer interventions during the birth process.
Midwifery services are available to all low-risk pregnant women, regardless of the
type of insurance they have. Midwifery care in all developed countries is strictly
regulated by a governing body, which ensures that core competencies are met. In the
United States, this body is the American College of Nurse-Midwives. Midwives can
provide care and delivery at home, in freestanding birth centers, and in community
and teaching hospitals.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 7
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
22. While obtaining a detailed history from a woman who has recently emigrated from
Somalia, the nurse realizes that the client has undergone female genital mutilation
(FGM). The nurse’s best response to this patient is:
a. “This is a very abnormal practice and rarely seen in the United States.”
b. “Do you know who performed this so that it can be reported to the authorities?”
c. “We will be able to restore your circumcision fully after delivery.”
d. “The extent of your circumcision will affect the potential for complications.”
ANS: D
“The extent of your circumcision will affect the potential for complications” is the
most appropriate response. The patient may experience pain, bleeding, scarring, or
infection and may require surgery before childbirth. With the growing number of
immigrants from countries where FGM is practiced, nurses will increasingly
encounter women who have undergone the procedure. Although this practice is not
prevalent in the United States, it is very common in many African and Middle Eastern
countries for religious reasons. Responding with, “This is a very abnormal practice
and rarely seen in the United States” is culturally insensitive. The infibulation may
have occurred during infancy or childhood. The client will have little to no
recollection of the event. She would have considered this to be a normal milestone
d. Delivery can take place only at the client’s home or in a birth center.
ANS: B
This patient will be able to participate actively in all decisions related to the birth
process and is likely to receive fewer interventions during the birth process.
Midwifery services are available to all low-risk pregnant women, regardless of the
type of insurance they have. Midwifery care in all developed countries is strictly
regulated by a governing body, which ensures that core competencies are met. In the
United States, this body is the American College of Nurse-Midwives. Midwives can
provide care and delivery at home, in freestanding birth centers, and in community
and teaching hospitals.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 7
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
22. While obtaining a detailed history from a woman who has recently emigrated from
Somalia, the nurse realizes that the client has undergone female genital mutilation
(FGM). The nurse’s best response to this patient is:
a. “This is a very abnormal practice and rarely seen in the United States.”
b. “Do you know who performed this so that it can be reported to the authorities?”
c. “We will be able to restore your circumcision fully after delivery.”
d. “The extent of your circumcision will affect the potential for complications.”
ANS: D
“The extent of your circumcision will affect the potential for complications” is the
most appropriate response. The patient may experience pain, bleeding, scarring, or
infection and may require surgery before childbirth. With the growing number of
immigrants from countries where FGM is practiced, nurses will increasingly
encounter women who have undergone the procedure. Although this practice is not
prevalent in the United States, it is very common in many African and Middle Eastern
countries for religious reasons. Responding with, “This is a very abnormal practice
and rarely seen in the United States” is culturally insensitive. The infibulation may
have occurred during infancy or childhood. The client will have little to no
recollection 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 spoken
out against this procedure as harmful to a woman’s health.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 8
OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
23. To ensure patient safety, the practicing nurse must have knowledge of the current
Joint Commission’s “Do Not Use” list of abbreviations. Which of the following is
acceptable for use?
a. q.o.d. or Q.O.D. c. International Unit
b. MSO4 or MgSO4 d. Lack of a leading zero
ANS: C
The abbreviations “i.u.” and “I.U.” are no longer acceptable because they could be
misread as “I.V.” or the number “10.” The abbreviation “q.o.d. or Q.O.D.” should be
written out as “every other day.” 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 to
confuse one medication for another. These medications are used for very different
purposes and could put a client at risk for an adverse outcome. They should be written
as morphine sulfate and magnesium sulfate. The decimal point should never be
missed before a number to avoid confusion (i.e., 0.4 rather than .4).
PTS: 1 DIF: Cognitive Level: Analysis REF: 13
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
24. Healthy People 2020 has established national health priorities that focus on a
number of maternal-child health indicators. Nurses are assuming greater roles in
assessing family health and providing care across the perinatal continuum. Therefore
it is important for the nurse to be aware that significant progress has been made in:
a. The reduction of fetal deaths and use of prenatal care.
b. Low birth weight and preterm birth.
c. Elimination of health disparities based on race.
d. Infant mortality and the prevention of birth defects.
ANS: A
Trends in maternal child health indicate that progress has been made in relation to
reduced infant and fetal deaths and increased prenatal care. Notable gaps remain in the
rates of low birth weight and preterm births. According to the March of Dimes,
out against this procedure as harmful to a woman’s health.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 8
OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
23. To ensure patient safety, the practicing nurse must have knowledge of the current
Joint Commission’s “Do Not Use” list of abbreviations. Which of the following is
acceptable for use?
a. q.o.d. or Q.O.D. c. International Unit
b. MSO4 or MgSO4 d. Lack of a leading zero
ANS: C
The abbreviations “i.u.” and “I.U.” are no longer acceptable because they could be
misread as “I.V.” or the number “10.” The abbreviation “q.o.d. or Q.O.D.” should be
written out as “every other day.” 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 to
confuse one medication for another. These medications are used for very different
purposes and could put a client at risk for an adverse outcome. They should be written
as morphine sulfate and magnesium sulfate. The decimal point should never be
missed before a number to avoid confusion (i.e., 0.4 rather than .4).
PTS: 1 DIF: Cognitive Level: Analysis REF: 13
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
24. Healthy People 2020 has established national health priorities that focus on a
number of maternal-child health indicators. Nurses are assuming greater roles in
assessing family health and providing care across the perinatal continuum. Therefore
it is important for the nurse to be aware that significant progress has been made in:
a. The reduction of fetal deaths and use of prenatal care.
b. Low birth weight and preterm birth.
c. Elimination of health disparities based on race.
d. Infant mortality and the prevention of birth defects.
ANS: A
Trends in maternal child health indicate that progress has been made in relation to
reduced infant and fetal deaths and increased prenatal care. Notable gaps remain in the
rates 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-Hispanic
Caucasians. Many of these negative outcomes are preventable through access to
prenatal care and the use of preventive health practices. This demonstrates the need
for comprehensive community-based care for all mothers, infants, and families.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 3
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
25. Which interventions would help alleviate the problems associated with access to
health care for maternity patients (Select all that apply)?
a. Provide transportation to prenatal visits.
b. Provide childcare so that a pregnant woman may keep prenatal visits.
c. Mandate that physicians make house calls.
d. Provide low-cost or no-cost health care insurance.
e. Provide job training.
ANS: A, B, D
Lack of transportation to visits, lack of childcare, and lack of affordable health
insurance are prohibitive factors associated with lack of prenatal care. House calls are
not a cost-effective approach to health care. Although job training may result in
employment and income, the likelihood of significant changes during the time frame
of the pregnancy is remote.
PTS: 1 DIF: Cognitive Level: Implementation REF: 5
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
26. Which of the following statements indicate that the nurse is practicing appropriate
family-centered care techniques (Select all that apply)?
a. The nurse commands the mother to do as she is told.
b. The nurse allows time for the partner to ask questions.
c. The nurse allows the mother and father to make choices when possible.
d. The nurse informs the family about what is going to happen.
e.
The nurse tells the patient’s sister, who is a nurse, that she cannot be in the room during the
delivery.
ANS: B, C
Caucasians. Many of these negative outcomes are preventable through access to
prenatal care and the use of preventive health practices. This demonstrates the need
for comprehensive community-based care for all mothers, infants, and families.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 3
OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
MULTIPLE RESPONSE
25. Which interventions would help alleviate the problems associated with access to
health care for maternity patients (Select all that apply)?
a. Provide transportation to prenatal visits.
b. Provide childcare so that a pregnant woman may keep prenatal visits.
c. Mandate that physicians make house calls.
d. Provide low-cost or no-cost health care insurance.
e. Provide job training.
ANS: A, B, D
Lack of transportation to visits, lack of childcare, and lack of affordable health
insurance are prohibitive factors associated with lack of prenatal care. House calls are
not a cost-effective approach to health care. Although job training may result in
employment and income, the likelihood of significant changes during the time frame
of the pregnancy is remote.
PTS: 1 DIF: Cognitive Level: Implementation REF: 5
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
26. Which of the following statements indicate that the nurse is practicing appropriate
family-centered care techniques (Select all that apply)?
a. The nurse commands the mother to do as she is told.
b. The nurse allows time for the partner to ask questions.
c. The nurse allows the mother and father to make choices when possible.
d. The nurse informs the family about what is going to happen.
e.
The nurse tells the patient’s sister, who is a nurse, that she cannot be in the room during the
delivery.
ANS: B, C
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Including the partner in the care process and allowing the couple to make choices are
important elements of family-centered care. The nurse should never tell the mother
what to do. Family-centered care involves collaboration between the health care team
and the client. Unless an institutional policy limits the number of attendants at a
delivery, the client should be allowed to have whomever she wants present (except
when the situation is an emergency and guests are asked to leave).
PTS: 1 DIF: Cognitive Level: Analysis REF: 8
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
MATCHING
Medical errors are a leading cause of death in the United States. The National
Quality Forum has recommended numerous safe practices that nursing can promote
to reduce errors. Match each safe practice with the correct statement.
a. Ask the patient to “teach back.”
b. Comply with CDC guidelines.
c. Ensure that information is documented in a timely manner.
d. Promote interventions that will reduce patient risk.
e. Reduce exposure to radiation.
27. Hand hygiene
28. Informed consent
29. Culture measurement, feedback, and intervention
30. Pediatric imaging
31. Patient care information
27. ANS: B PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
28. ANS: A PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
important elements of family-centered care. The nurse should never tell the mother
what to do. Family-centered care involves collaboration between the health care team
and the client. Unless an institutional policy limits the number of attendants at a
delivery, the client should be allowed to have whomever she wants present (except
when the situation is an emergency and guests are asked to leave).
PTS: 1 DIF: Cognitive Level: Analysis REF: 8
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
MATCHING
Medical errors are a leading cause of death in the United States. The National
Quality Forum has recommended numerous safe practices that nursing can promote
to reduce errors. Match each safe practice with the correct statement.
a. Ask the patient to “teach back.”
b. Comply with CDC guidelines.
c. Ensure that information is documented in a timely manner.
d. Promote interventions that will reduce patient risk.
e. Reduce exposure to radiation.
27. Hand hygiene
28. Informed consent
29. Culture measurement, feedback, and intervention
30. Pediatric imaging
31. Patient care information
27. ANS: B PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
28. ANS: A PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
Loading page 15...
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
29. ANS: D PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
30. ANS: E PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
31. ANS: C PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
Chapter 02: Community Care: The Family and
Culture
Chapter 02: Community Care: The Family and Culture
MULTIPLE CHOICE
1. A married couple lives in a single-family house with their newborn son and the
husband’s daughter from a previous marriage. On the basis of the information given,
what family form best describes this family?
a. Married-blended family c. Nuclear family
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
29. ANS: D PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
30. ANS: E PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
31. ANS: C PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in
2010, outlining 24 safe practices that should be used in all health care settings to reduce the risk
of harm from the environment of care, processes, and systems. These are only a few of the
recommended practices; however, nurses should be familiar with these guidelines.
Chapter 02: Community Care: The Family and
Culture
Chapter 02: Community Care: The Family and Culture
MULTIPLE CHOICE
1. A married couple lives in a single-family house with their newborn son and the
husband’s daughter from a previous marriage. On the basis of the information given,
what family form best describes this family?
a. Married-blended family c. Nuclear family
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b. Extended family d. Same-sex family
ANS: A
Married-blended families are formed as the result of divorce and remarriage.
Unrelated family members join together to create a new household. Members of an
extended 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 female
partners and the children resulting from that union. A same-sex family is a family
with homosexual partners who cohabit with or without children.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 18
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
2. In what form do families tend to be most socially vulnerable?
a. Married-blended family c. Nuclear family
b. Extended family d. Single-parent family
ANS: D
The single-parent family tends to be vulnerable economically and socially, creating an
unstable and deprived environment for the growth potential of children. The married-
blended family, the extended family, and the nuclear family are not the most socially
vulnerable.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 18
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
3. Health care functions carried out by families to meet their members’ needs include:
a. Developing family budgets.
b. Socializing children.
c. Meeting nutritional requirements.
d. Teaching family members about birth control.
ANS: C
Meeting nutritional requirements is a fundamental health promotion behavior.
Although creating a family budget may be helpful, it does not indicate that funds will
be allotted to meet health needs if money is scarce. Often families cannot afford
preventive 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 health
care of individuals in a family unit. Birth control may be important, but it is not a
basic survival health care function.
ANS: A
Married-blended families are formed as the result of divorce and remarriage.
Unrelated family members join together to create a new household. Members of an
extended 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 female
partners and the children resulting from that union. A same-sex family is a family
with homosexual partners who cohabit with or without children.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 18
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
2. In what form do families tend to be most socially vulnerable?
a. Married-blended family c. Nuclear family
b. Extended family d. Single-parent family
ANS: D
The single-parent family tends to be vulnerable economically and socially, creating an
unstable and deprived environment for the growth potential of children. The married-
blended family, the extended family, and the nuclear family are not the most socially
vulnerable.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 18
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
3. Health care functions carried out by families to meet their members’ needs include:
a. Developing family budgets.
b. Socializing children.
c. Meeting nutritional requirements.
d. Teaching family members about birth control.
ANS: C
Meeting nutritional requirements is a fundamental health promotion behavior.
Although creating a family budget may be helpful, it does not indicate that funds will
be allotted to meet health needs if money is scarce. Often families cannot afford
preventive 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 health
care of individuals in a family unit. Birth control may be important, but it is not a
basic survival health care function.
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PTS: 1 DIF: Cognitive Level: Comprehension REF: 28
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
4. The nurse should be aware that the criteria used to make decisions and solve
problems within families are based primarily on family:
a. Rituals and customs. c. Boundaries and channels.
b. Values and beliefs. d. Socialization processes.
ANS: B
Values 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 action
taken by family members. Boundaries and channels affect the relationship between
the family members and the health care team, not the decisions within the family.
Socialization processes may help families with interactions with the community, but
they are not the criteria used for decision making within the family.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 25
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
5. Using the family stress theory as an intervention approach for working with families
experiencing parenting, the nurse can help the family change internal context factors.
These include:
a. Biologic and genetic makeup.
b. Maturation of family members.
c. The family’s perception of the event.
d. The prevailing cultural beliefs of society.
ANS: C
The family stress theory is concerned with the family’s reaction to stressful events;
internal context factors include elements that a family can control such as psychologic
defenses. It is not concerned with biologic and genetic makeup, maturation of family
members, or the prevailing cultural beliefs of society.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 20
OBJ: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity
6. 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 the
interventions will be most influenced by:
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
4. The nurse should be aware that the criteria used to make decisions and solve
problems within families are based primarily on family:
a. Rituals and customs. c. Boundaries and channels.
b. Values and beliefs. d. Socialization processes.
ANS: B
Values 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 action
taken by family members. Boundaries and channels affect the relationship between
the family members and the health care team, not the decisions within the family.
Socialization processes may help families with interactions with the community, but
they are not the criteria used for decision making within the family.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 25
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
5. Using the family stress theory as an intervention approach for working with families
experiencing parenting, the nurse can help the family change internal context factors.
These include:
a. Biologic and genetic makeup.
b. Maturation of family members.
c. The family’s perception of the event.
d. The prevailing cultural beliefs of society.
ANS: C
The family stress theory is concerned with the family’s reaction to stressful events;
internal context factors include elements that a family can control such as psychologic
defenses. It is not concerned with biologic and genetic makeup, maturation of family
members, or the prevailing cultural beliefs of society.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 20
OBJ: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity
6. 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 the
interventions will be most influenced by:
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a. Educational achievement. c. Subcultural group.
b. Income level. d. Individual beliefs.
ANS: D
The patient’s beliefs are ultimately the key to acceptance of health care interventions.
However, these beliefs may be influenced by factors such as educational level, income
level, and ethnic background. Educational achievement, income level, and subcultural
group all are important factors. However, the nurse must understand that a woman’s
concerns from her own point of view will have the most influence on her compliance.
PTS: 1 DIF: Cognitive Level: Application REF: 22
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
7. The nurse’s care of a Hispanic family includes teaching about infant care. When
developing a plan of care, the nurse bases interventions on the knowledge that in
traditional Hispanic families:
a. Breastfeeding is encouraged immediately after birth.
b. Male infants typically are circumcised.
c. The maternal grandmother participates in the care of the mother and her infant.
d. Special herbs mixed in water are used to stimulate the passage of meconium.
ANS: C
In Hispanic families, the expectant mother is influenced strongly by her mother or
mother-in-law. Breastfeeding often is delayed until the third postpartum day. Hispanic
male infants usually are not circumcised. Olive or castor oil may be given to stimulate
the passage of meconium.
PTS: 1 DIF: Cognitive Level: Application REF: 26
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
8. The woman’s family members are present when the home care maternal-child nurse
arrives for a postpartum and newborn visit. What should the nurse do?
a. Observe the family members’ interactions with the newborn and one another.
b. Ask the woman to meet with her and the baby alone.
c. Do a brief assessment on all family members present.
d. Reschedule the visit for another time so that the mother and infant can be assessed privately
ANS: A
b. Income level. d. Individual beliefs.
ANS: D
The patient’s beliefs are ultimately the key to acceptance of health care interventions.
However, these beliefs may be influenced by factors such as educational level, income
level, and ethnic background. Educational achievement, income level, and subcultural
group all are important factors. However, the nurse must understand that a woman’s
concerns from her own point of view will have the most influence on her compliance.
PTS: 1 DIF: Cognitive Level: Application REF: 22
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
7. The nurse’s care of a Hispanic family includes teaching about infant care. When
developing a plan of care, the nurse bases interventions on the knowledge that in
traditional Hispanic families:
a. Breastfeeding is encouraged immediately after birth.
b. Male infants typically are circumcised.
c. The maternal grandmother participates in the care of the mother and her infant.
d. Special herbs mixed in water are used to stimulate the passage of meconium.
ANS: C
In Hispanic families, the expectant mother is influenced strongly by her mother or
mother-in-law. Breastfeeding often is delayed until the third postpartum day. Hispanic
male infants usually are not circumcised. Olive or castor oil may be given to stimulate
the passage of meconium.
PTS: 1 DIF: Cognitive Level: Application REF: 26
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
8. The woman’s family members are present when the home care maternal-child nurse
arrives for a postpartum and newborn visit. What should the nurse do?
a. Observe the family members’ interactions with the newborn and one another.
b. Ask the woman to meet with her and the baby alone.
c. Do a brief assessment on all family members present.
d. Reschedule the visit for another time so that the mother and infant can be assessed privately
ANS: A
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The nurse should introduce herself to the patient and the other family members
present. Family members in the home may be providing care and assistance to the
mother 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 new
postpartum mother and her infant, not to all family members. The nurse can politely
ask about the other people in the home and their relationships with the woman. Unless
an indication is given that the woman would prefer privacy, the visit may continue.
PTS: 1 DIF: Cognitive Level: Analysis REF: 33
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
9. The nurse should be aware that during the childbearing experience an African-
American woman is most likely to:
a. Seek prenatal care early in her pregnancy.
b. Avoid self-treatment of pregnancy-related discomfort.
c. Request liver in the postpartum period to prevent anemia.
d. Arrive at the hospital in advanced labor.
ANS: D
African-American women often arrive at the hospital in far-advanced labor. These
women may view pregnancy as a state of wellness, which is often the reason for delay
in seeking prenatal care. African-American women practice many self-treatment
options for various discomforts of pregnancy, and they may request liver in the
postpartum period, but this is based on a belief that the liver has a high blood content.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 26
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
10. To provide competent care to an Asian-American family, the nurse should include
which of the following questions during the assessment interview?
a. “Do you prefer hot or cold beverages?”
b. “Do you want milk to drink?”
c. “Do you want music playing while you are in labor?”
d. “Do you have a name selected for the baby?”
ANS: A
present. Family members in the home may be providing care and assistance to the
mother 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 new
postpartum mother and her infant, not to all family members. The nurse can politely
ask about the other people in the home and their relationships with the woman. Unless
an indication is given that the woman would prefer privacy, the visit may continue.
PTS: 1 DIF: Cognitive Level: Analysis REF: 33
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
9. The nurse should be aware that during the childbearing experience an African-
American woman is most likely to:
a. Seek prenatal care early in her pregnancy.
b. Avoid self-treatment of pregnancy-related discomfort.
c. Request liver in the postpartum period to prevent anemia.
d. Arrive at the hospital in advanced labor.
ANS: D
African-American women often arrive at the hospital in far-advanced labor. These
women may view pregnancy as a state of wellness, which is often the reason for delay
in seeking prenatal care. African-American women practice many self-treatment
options for various discomforts of pregnancy, and they may request liver in the
postpartum period, but this is based on a belief that the liver has a high blood content.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 26
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
10. To provide competent care to an Asian-American family, the nurse should include
which of the following questions during the assessment interview?
a. “Do you prefer hot or cold beverages?”
b. “Do you want milk to drink?”
c. “Do you want music playing while you are in labor?”
d. “Do you have a name selected for the baby?”
ANS: A
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Asian-Americans often prefer warm beverages. Milk usually is excluded from the diet
of 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: 27
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
11. The patient’s family is important to the maternity nurse because:
a. They pay the bills.
b. The nurse will know which family member to avoid.
c. The nurse will know which mothers will really care for their children.
d. The family culture and structure will influence nursing care decisions.
ANS: D
Family structure and culture influence the health decisions of mothers.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 17
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
12. A mother’s household consists of her husband, his mother, and another child. She
is living in a(n):
a. Extended family. c. Married-blended family.
b. Single-parent family. d. Nuclear family.
ANS: A
An extended family includes blood relatives living with the nuclear family. Both
parents and a grandparent are living in this extended family. Single-parent families
comprise an unmarried biologic or adoptive parent who may or may not be living with
other adults. Married-blended refers to families reconstructed after divorce. A nuclear
family is where male and female partners and their children live as an independent
unit.
PTS: 1 DIF: Cognitive Level: Application REF: 17
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
13. A traditional family structure in which male and female partners and their children
live as an independent unit is known as a(n):
a. Extended family. c. Nuclear family.
b. Binuclear family. d. Blended family.
ANS: C
of 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: 27
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
11. The patient’s family is important to the maternity nurse because:
a. They pay the bills.
b. The nurse will know which family member to avoid.
c. The nurse will know which mothers will really care for their children.
d. The family culture and structure will influence nursing care decisions.
ANS: D
Family structure and culture influence the health decisions of mothers.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 17
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
12. A mother’s household consists of her husband, his mother, and another child. She
is living in a(n):
a. Extended family. c. Married-blended family.
b. Single-parent family. d. Nuclear family.
ANS: A
An extended family includes blood relatives living with the nuclear family. Both
parents and a grandparent are living in this extended family. Single-parent families
comprise an unmarried biologic or adoptive parent who may or may not be living with
other adults. Married-blended refers to families reconstructed after divorce. A nuclear
family is where male and female partners and their children live as an independent
unit.
PTS: 1 DIF: Cognitive Level: Application REF: 17
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
13. A traditional family structure in which male and female partners and their children
live as an independent unit is known as a(n):
a. Extended family. c. Nuclear family.
b. Binuclear family. d. Blended family.
ANS: C
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About two thirds of U.S. households meet the definition of a nuclear family. Extended
families include additional blood relatives other than the parents. A binuclear family
involves two households. A blended family is reconstructed after divorce and involves
the merger of two families.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 17
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
14. Which statement about family systems theory is inaccurate?
a. A family system is part of a larger suprasystem.
b. A family as a whole is equal to the sum of the individual members.
c. A change in one family member affects all family members.
d. The family is able to create a balance between change and stability.
ANS: B
A family as a whole is greater than the sum of its parts. The other statements are
characteristics of a system that states that a family is greater than the sum of its parts.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 20
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
15. A pictorial tool that can assist the nurse in assessing aspects of family life related
to health care is the:
a. Genogram. c. Life cycle model.
b. Family values construct. d. Human development wheel.
ANS: A
A genogram depicts the relationships of family members over generations.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 19
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
16. The process by which people retain some of their own culture while adopting the
practices of the dominant society is known as:
a. Acculturation. c. Ethnocentrism.
b. Assimilation. d. Cultural relativism.
ANS: A
Acculturation is the process by which people retain some of their own culture while
adopting the practices of the dominant society. This process takes place over the
course of generations. Assimilation is a loss of cultural identity. Acculturation
families include additional blood relatives other than the parents. A binuclear family
involves two households. A blended family is reconstructed after divorce and involves
the merger of two families.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 17
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
14. Which statement about family systems theory is inaccurate?
a. A family system is part of a larger suprasystem.
b. A family as a whole is equal to the sum of the individual members.
c. A change in one family member affects all family members.
d. The family is able to create a balance between change and stability.
ANS: B
A family as a whole is greater than the sum of its parts. The other statements are
characteristics of a system that states that a family is greater than the sum of its parts.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 20
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
15. A pictorial tool that can assist the nurse in assessing aspects of family life related
to health care is the:
a. Genogram. c. Life cycle model.
b. Family values construct. d. Human development wheel.
ANS: A
A genogram depicts the relationships of family members over generations.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 19
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
16. The process by which people retain some of their own culture while adopting the
practices of the dominant society is known as:
a. Acculturation. c. Ethnocentrism.
b. Assimilation. d. Cultural relativism.
ANS: A
Acculturation is the process by which people retain some of their own culture while
adopting the practices of the dominant society. This process takes place over the
course 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 adopting
the practices of the dominant society. Ethnocentrism is the belief in the superiority of
one’s own culture over the cultures of others. Acculturation describes the process by
which people retain some of their own culture while adopting the practices of the
dominant society. Cultural relativism recognizes the roles of different cultures.
Acculturation describes the process by which people retain some of their own culture
while adopting the practices of the dominant society.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 22
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
17. When attempting to communicate with a patient who speaks a different language,
the nurse should:
a. Respond promptly and positively to project authority.
b. Never use a family member as an interpreter.
c. Talk to the interpreter to avoid confusing the patient.
d. Provide as much privacy as possible.
ANS: D
Providing privacy creates an atmosphere of respect and puts the patient at ease. The
nurse should not rush to judgment and should make sure that he or she understands
the patient’s message clearly. In crisis situations, the nurse may need to use a family
member or neighbor as a translator. The nurse should talk directly to the patient to
create an atmosphere of respect.
PTS: 1 DIF: Cognitive Level: Application REF: 23
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
18. In which culture is the father more likely to be expected to participate in the labor
and delivery?
a. Asian-American c. European-American
b. African-American d. Hispanic
ANS: C
European-Americans expect the father to take a more active role in the labor and
delivery than the other cultures.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 26
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
19. Which statement about cultural competence is not accurate?
the practices of the dominant society. Ethnocentrism is the belief in the superiority of
one’s own culture over the cultures of others. Acculturation describes the process by
which people retain some of their own culture while adopting the practices of the
dominant society. Cultural relativism recognizes the roles of different cultures.
Acculturation describes the process by which people retain some of their own culture
while adopting the practices of the dominant society.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 22
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
17. When attempting to communicate with a patient who speaks a different language,
the nurse should:
a. Respond promptly and positively to project authority.
b. Never use a family member as an interpreter.
c. Talk to the interpreter to avoid confusing the patient.
d. Provide as much privacy as possible.
ANS: D
Providing privacy creates an atmosphere of respect and puts the patient at ease. The
nurse should not rush to judgment and should make sure that he or she understands
the patient’s message clearly. In crisis situations, the nurse may need to use a family
member or neighbor as a translator. The nurse should talk directly to the patient to
create an atmosphere of respect.
PTS: 1 DIF: Cognitive Level: Application REF: 23
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
18. In which culture is the father more likely to be expected to participate in the labor
and delivery?
a. Asian-American c. European-American
b. African-American d. Hispanic
ANS: C
European-Americans expect the father to take a more active role in the labor and
delivery than the other cultures.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 26
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
19. Which statement about cultural competence is not accurate?
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a.
Local health care workers and community advocates can help extend health care to underse
populations.
b.
Nursing care is delivered in the context of the client’s culture but not in the context of the n
culture.
c. Nurses must develop an awareness of and sensitivity to various cultures.
d. A culture’s economic, religious, and political structures influence practices that affect child
ANS: B
The cultural context of the nurse also affects nursing care. The work of local health
care workers and community advocates is part of cultural competence; the nurse’s
cultural context is also important. Developing sensitivity to various cultures is part of
cultural competence, but the nurse’s cultural context is also important. The impact of
economic, religious, and political structures is part of cultural competence; the nurse’s
cultural context is also important.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 25
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
20. The nurse is preparing for a home visit to complete a newborn wellness checkup.
The neighborhood has a reputation for being dangerous. Identify which precautions
the nurse should take to ensure her safety (Select all that apply).
a. Having access to a cell phone at all times.
b. Visiting alone due to the agency’s staffing model.
c. Carrying an extra set of car keys.
d. Avoiding groups of strangers hanging out in doorways.
e. Wearing her usual amount of jewelry.
ANS: A, C, D
Nurse safety is an important component of home care. The nurse should be fully
aware of the home environment and the neighborhood in which the home care is being
provided. In this situation, nurses should visit in pairs, have access to a cell phone at
all times, and wear a limited amount of jewelry. The car should be parked in a well-lit
area and locked at all times. An extra set of keys kept in the nursing home care bag
avoids 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.
Local health care workers and community advocates can help extend health care to underse
populations.
b.
Nursing care is delivered in the context of the client’s culture but not in the context of the n
culture.
c. Nurses must develop an awareness of and sensitivity to various cultures.
d. A culture’s economic, religious, and political structures influence practices that affect child
ANS: B
The cultural context of the nurse also affects nursing care. The work of local health
care workers and community advocates is part of cultural competence; the nurse’s
cultural context is also important. Developing sensitivity to various cultures is part of
cultural competence, but the nurse’s cultural context is also important. The impact of
economic, religious, and political structures is part of cultural competence; the nurse’s
cultural context is also important.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 25
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
20. The nurse is preparing for a home visit to complete a newborn wellness checkup.
The neighborhood has a reputation for being dangerous. Identify which precautions
the nurse should take to ensure her safety (Select all that apply).
a. Having access to a cell phone at all times.
b. Visiting alone due to the agency’s staffing model.
c. Carrying an extra set of car keys.
d. Avoiding groups of strangers hanging out in doorways.
e. Wearing her usual amount of jewelry.
ANS: A, C, D
Nurse safety is an important component of home care. The nurse should be fully
aware of the home environment and the neighborhood in which the home care is being
provided. In this situation, nurses should visit in pairs, have access to a cell phone at
all times, and wear a limited amount of jewelry. The car should be parked in a well-lit
area and locked at all times. An extra set of keys kept in the nursing home care bag
avoids 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.
Loading page 24...
PTS: 1 DIF: Cognitive Level: Application REF: 33
OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
MATCHING
You 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 assist
you 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. Introduce yourself to the interpreter and converse informally.
b. Outline your statements and questions, listing the key pieces of information you need to kno
c. Make sure the interpreter is comfortable with technical terms.
d. Learn something about the culture of the patient.
e. Make notes on what you learned for future reference.
f. Stop every now and then and ask the interpreter “How is it going?”
21. Step One
22. Step Two
23. Step Three
24. Step Four
25. Step Five
26. Step Six
21. ANS: B PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
22. ANS: D PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
OBJ: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
MATCHING
You 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 assist
you 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. Introduce yourself to the interpreter and converse informally.
b. Outline your statements and questions, listing the key pieces of information you need to kno
c. Make sure the interpreter is comfortable with technical terms.
d. Learn something about the culture of the patient.
e. Make notes on what you learned for future reference.
f. Stop every now and then and ask the interpreter “How is it going?”
21. Step One
22. Step Two
23. Step Three
24. Step Four
25. Step Five
26. Step Six
21. ANS: B PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
22. ANS: D PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
Loading page 25...
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
23. ANS: A PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
24. ANS: C PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
25. ANS: F PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
26. ANS: E PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
23. ANS: A PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
24. ANS: C PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
25. ANS: F PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
26. ANS: E PTS: 1 DIF: Cognitive Level: Application
REF: 24 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four
categories. These include actions that are necessary before the interview, meeting with the
interpreter, during the interview, and after the interview. The nurse must be sensitive to cultural
Loading page 26...
and situational differences (e.g., a woman from the Middle East may not wish to have a male
interpreter present).
Chapter 03: Assessment and Health
Promotion
Chapter 03: Assessment and Health Promotion
MULTIPLE CHOICE
1. The two primary functions of the ovary are:
a. Normal female development and sex hormone release.
b. Ovulation and internal pelvic support.
c. Sexual response and ovulation.
d. Ovulation and hormone production.
ANS: D
The two functions of the ovaries are ovulation and hormone production. The presence
of ovaries does not guarantee normal female development. The ovaries produce
estrogen, progesterone, and androgen. Ovulation is the release of a mature ovum from
the ovary; the ovaries are not responsible for internal pelvic support. Sexual response
is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and the
ovaries. Ovulation does occur in the ovaries.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 42
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
2. The uterus is a muscular, pear-shaped organ that is responsible for:
a. Cyclic menstruation. c. Fertilization.
b. Sex hormone production. d. Sexual arousal.
ANS: A
The uterus is an organ for reception, implantation, retention, and nutrition of the
fertilized ovum; it also is responsible for cyclic menstruation. Hormone production
and fertilization occur in the ovaries. Sexual arousal is a feedback mechanism
involving the hypothalamus, the pituitary gland, and the ovaries.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 40-41
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. Unique muscle fibers make the uterine myometrium ideally suited for:
a. Menstruation. c. Ovulation.
interpreter present).
Chapter 03: Assessment and Health
Promotion
Chapter 03: Assessment and Health Promotion
MULTIPLE CHOICE
1. The two primary functions of the ovary are:
a. Normal female development and sex hormone release.
b. Ovulation and internal pelvic support.
c. Sexual response and ovulation.
d. Ovulation and hormone production.
ANS: D
The two functions of the ovaries are ovulation and hormone production. The presence
of ovaries does not guarantee normal female development. The ovaries produce
estrogen, progesterone, and androgen. Ovulation is the release of a mature ovum from
the ovary; the ovaries are not responsible for internal pelvic support. Sexual response
is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and the
ovaries. Ovulation does occur in the ovaries.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 42
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
2. The uterus is a muscular, pear-shaped organ that is responsible for:
a. Cyclic menstruation. c. Fertilization.
b. Sex hormone production. d. Sexual arousal.
ANS: A
The uterus is an organ for reception, implantation, retention, and nutrition of the
fertilized ovum; it also is responsible for cyclic menstruation. Hormone production
and fertilization occur in the ovaries. Sexual arousal is a feedback mechanism
involving the hypothalamus, the pituitary gland, and the ovaries.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 40-41
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
3. Unique muscle fibers make the uterine myometrium ideally suited for:
a. Menstruation. c. Ovulation.
Loading page 27...
b. The birth process. d. Fertilization.
ANS: B
The myometrium is made up of layers of smooth muscle that extend in three
directions. These muscles assist in the birth process by expelling the fetus, ligating
blood vessels after birth, and controlling the opening of the cervical os.
PTS: 1 DIF: Cognitive Level: Application REF: 41
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
4. The hormone responsible for maturation of mammary gland tissue is:
a. Estrogen. c. Prolactin.
b. Testosterone. d. Progesterone.
ANS: D
Progesterone causes maturation of the mammary gland tissue, specifically acinar
structures of the lobules. Estrogen increases the vascularity of the breast tissue.
Testosterone has no bearing on breast development. Prolactin is produced after birth
and released from the pituitary gland. It is produced in response to infant suckling and
emptying of the breasts.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 43
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
5. Because of the effect of cyclic ovarian changes on the breast, the best time for
breast self-examination (BSE) is:
a. 5 to 7 days after menses ceases. c. Midmenstrual cycle.
b. Day 1 of the endometrial cycle. d. Any time during a shower or bath.
ANS: A
The physiologic alterations in breast size and activity reach their minimal level about
5 to 7 days after menstruation stops. All women should perform BSE during this
phase of the menstrual cycle.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 44
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
6. Menstruation is periodic uterine bleeding:
a. That occurs every 28 days.
b. In which the entire uterine lining is shed.
c. That is regulated by ovarian hormones.
ANS: B
The myometrium is made up of layers of smooth muscle that extend in three
directions. These muscles assist in the birth process by expelling the fetus, ligating
blood vessels after birth, and controlling the opening of the cervical os.
PTS: 1 DIF: Cognitive Level: Application REF: 41
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
4. The hormone responsible for maturation of mammary gland tissue is:
a. Estrogen. c. Prolactin.
b. Testosterone. d. Progesterone.
ANS: D
Progesterone causes maturation of the mammary gland tissue, specifically acinar
structures of the lobules. Estrogen increases the vascularity of the breast tissue.
Testosterone has no bearing on breast development. Prolactin is produced after birth
and released from the pituitary gland. It is produced in response to infant suckling and
emptying of the breasts.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 43
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
5. Because of the effect of cyclic ovarian changes on the breast, the best time for
breast self-examination (BSE) is:
a. 5 to 7 days after menses ceases. c. Midmenstrual cycle.
b. Day 1 of the endometrial cycle. d. Any time during a shower or bath.
ANS: A
The physiologic alterations in breast size and activity reach their minimal level about
5 to 7 days after menstruation stops. All women should perform BSE during this
phase of the menstrual cycle.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 44
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
6. Menstruation is periodic uterine bleeding:
a. That occurs every 28 days.
b. In which the entire uterine lining is shed.
c. That is regulated by ovarian hormones.
Loading page 28...
d. That leads to fertilization.
ANS: C
Menstruation is periodic uterine bleeding that is controlled by a feedback system
involving three cycles: endometrial, hypothalamic-pituitary, and ovarian. The average
length of a menstrual cycle is 28 days, but variations are normal. During the
endometrial cycle, the functional two thirds of the endometrium is shed. Lack of
fertilization leads to menstruation.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 45
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
7. Individual irregularities in the ovarian (menstrual) cycle are most often caused by:
a. Variations in the follicular (preovulatory) phase.
b. An intact hypothalamic-pituitary feedback mechanism.
c. A functioning corpus luteum.
d. A prolonged ischemic phase.
ANS: A
Almost all variations in the length of the ovarian cycle are the result of variations in
the length of the follicular phase. An intact hypothalamic-pituitary feedback
mechanism is regular, not irregular. The luteal phase begins after ovulation. The
corpus luteum depends on the ovulatory phase and fertilization. During the ischemic
phase, the blood supply to the functional endometrium is blocked, and necrosis
develops. The functional layer separates from the basal layer, and menstrual bleeding
begins.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 45
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
8. Prostaglandins are produced in most organs of the body, including the uterus. Other
source(s) of prostaglandins is/are:
a. Ovaries. c. Menstrual blood.
b. Breast milk. d. The vagina.
ANS: C
Menstrual blood is a potent source of prostaglandins. Prostaglandins are produced in
most organs of the body and in menstrual blood. The ovaries, breast milk, and vagina
are neither organs nor a source of prostaglandins.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 47
ANS: C
Menstruation is periodic uterine bleeding that is controlled by a feedback system
involving three cycles: endometrial, hypothalamic-pituitary, and ovarian. The average
length of a menstrual cycle is 28 days, but variations are normal. During the
endometrial cycle, the functional two thirds of the endometrium is shed. Lack of
fertilization leads to menstruation.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 45
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
7. Individual irregularities in the ovarian (menstrual) cycle are most often caused by:
a. Variations in the follicular (preovulatory) phase.
b. An intact hypothalamic-pituitary feedback mechanism.
c. A functioning corpus luteum.
d. A prolonged ischemic phase.
ANS: A
Almost all variations in the length of the ovarian cycle are the result of variations in
the length of the follicular phase. An intact hypothalamic-pituitary feedback
mechanism is regular, not irregular. The luteal phase begins after ovulation. The
corpus luteum depends on the ovulatory phase and fertilization. During the ischemic
phase, the blood supply to the functional endometrium is blocked, and necrosis
develops. The functional layer separates from the basal layer, and menstrual bleeding
begins.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 45
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
8. Prostaglandins are produced in most organs of the body, including the uterus. Other
source(s) of prostaglandins is/are:
a. Ovaries. c. Menstrual blood.
b. Breast milk. d. The vagina.
ANS: C
Menstrual blood is a potent source of prostaglandins. Prostaglandins are produced in
most organs of the body and in menstrual blood. The ovaries, breast milk, and vagina
are neither organs nor a source of prostaglandins.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 47
Loading page 29...
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
9. Physiologically, sexual response can be characterized by:
a. Coitus, masturbation, and fantasy. c. Erection and orgasm.
b. Myotonia and vasocongestion. d. Excitement, plateau, and orgasm.
ANS: B
Physiologically, according to Masters (1992), sexual response can be analyzed in
terms of two processes: vasocongestion and myotonia. Coitus, masturbation, and
fantasy 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 response
cycle.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 47
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
10. The long-term treatment plan for an adolescent with an eating disorder focuses on:
a. Managing the effects of malnutrition.
b. Establishing sufficient caloric intake.
c. Improving family dynamics.
d. Restructuring perception of body image.
ANS: D
The treatment of eating disorders is initially focused on reestablishing physiologic
homeostasis. Once body systems are stabilized, the next goal of treatment for eating
disorders is maintaining adequate caloric intake. Although family therapy is indicated
when dysfunctional family relationships exist, the primary focus of therapy for eating
disorders is to help the adolescent cope with complex issues. The focus of treatment in
individual therapy for an eating disorder involves restructuring cognitive perceptions
about the individual’s body image.
PTS: 1 DIF: Cognitive Level: Application REF: 54
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
11. The nurse guides a woman to the examination room and asks her to remove her
clothes and put on an examination gown with the front open. The woman states, “I
have special undergarments that I do not remove for religious reasons.” The most
appropriate response from the nurse would be:
a. “You can’t have an examination without removing all your clothes.”
9. Physiologically, sexual response can be characterized by:
a. Coitus, masturbation, and fantasy. c. Erection and orgasm.
b. Myotonia and vasocongestion. d. Excitement, plateau, and orgasm.
ANS: B
Physiologically, according to Masters (1992), sexual response can be analyzed in
terms of two processes: vasocongestion and myotonia. Coitus, masturbation, and
fantasy 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 response
cycle.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 47
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
10. The long-term treatment plan for an adolescent with an eating disorder focuses on:
a. Managing the effects of malnutrition.
b. Establishing sufficient caloric intake.
c. Improving family dynamics.
d. Restructuring perception of body image.
ANS: D
The treatment of eating disorders is initially focused on reestablishing physiologic
homeostasis. Once body systems are stabilized, the next goal of treatment for eating
disorders is maintaining adequate caloric intake. Although family therapy is indicated
when dysfunctional family relationships exist, the primary focus of therapy for eating
disorders is to help the adolescent cope with complex issues. The focus of treatment in
individual therapy for an eating disorder involves restructuring cognitive perceptions
about the individual’s body image.
PTS: 1 DIF: Cognitive Level: Application REF: 54
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
11. The nurse guides a woman to the examination room and asks her to remove her
clothes and put on an examination gown with the front open. The woman states, “I
have special undergarments that I do not remove for religious reasons.” The most
appropriate response from the nurse would be:
a. “You can’t have an examination without removing all your clothes.”
Loading page 30...
b. “I’ll ask the doctor to modify the examination.”
c.
“Tell me about your undergarments. I’ll explain the examination procedure, and then we ca
discuss how you can have your examination comfortably.”
d. “What? I’ve never heard of such a thing! That sounds different and strange.”
ANS: C
This statement reflects cultural competence by the nurse and shows respect for the
woman’s religious practices. The nurse must respect the rich and unique qualities that
cultural 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: 48-49
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
12. A 62-year-old woman has not been to the clinic for an annual examination for 5
years. 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 the women’s health nurse
practitioner for her visit. To facilitate a positive health care experience, the nurse
should:
a.
Remind the woman that she is long overdue for her examination and that she should come i
annually.
b. Listen carefully and allow extra time for this woman’s health history interview.
c. Reassure the woman that a nurse practitioner is just as good as her old doctor.
d. Encourage the woman to talk about the death of her husband and her fears about her own de
ANS: B
The nurse has an opportunity to use reflection and empathy while listening and to
ensure open and caring communication. Scheduling a longer appointment time may be
necessary because older women may have longer histories or may need to talk. A
respectful and reassuring approach to caring for women older than age 50 can help
ensure that they continue to seek health care. Reminding the woman about her
overdue examination, reassuring the woman that she has a good practitioner, and
encouraging conversation about the death of her husband and her own death are not
the best approaches with women in this age group.
PTS: 1 DIF: Cognitive Level: Application REF: 62
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
c.
“Tell me about your undergarments. I’ll explain the examination procedure, and then we ca
discuss how you can have your examination comfortably.”
d. “What? I’ve never heard of such a thing! That sounds different and strange.”
ANS: C
This statement reflects cultural competence by the nurse and shows respect for the
woman’s religious practices. The nurse must respect the rich and unique qualities that
cultural 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: 48-49
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
12. A 62-year-old woman has not been to the clinic for an annual examination for 5
years. 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 the women’s health nurse
practitioner for her visit. To facilitate a positive health care experience, the nurse
should:
a.
Remind the woman that she is long overdue for her examination and that she should come i
annually.
b. Listen carefully and allow extra time for this woman’s health history interview.
c. Reassure the woman that a nurse practitioner is just as good as her old doctor.
d. Encourage the woman to talk about the death of her husband and her fears about her own de
ANS: B
The nurse has an opportunity to use reflection and empathy while listening and to
ensure open and caring communication. Scheduling a longer appointment time may be
necessary because older women may have longer histories or may need to talk. A
respectful and reassuring approach to caring for women older than age 50 can help
ensure that they continue to seek health care. Reminding the woman about her
overdue examination, reassuring the woman that she has a good practitioner, and
encouraging conversation about the death of her husband and her own death are not
the best approaches with women in this age group.
PTS: 1 DIF: Cognitive Level: Application REF: 62
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
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Subject
Nursing