Nursing 1205 Unit I

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  1. What level of prevention includes receiving vaccines?
  2. What level of prevention includes a diabetic patient trying to prevent blindness?
  3. Having knee surgery would fall under what level of prevention?
  4. Having a routine check up would fall under what level of prevention?
  5. Health promotion is disease oriented. True or False
    False, Health promotion is not disease oriented. p. 281 Kozier & Erbs. Box 16-4
  6. What are the stages of health behavior change?
    • Precontemplation
    • Contemplation
    • Preoperation
    • Action
    • Maintenance
    • Termination
  7. What are the four main characteristics of homeostatic mechanisms?
    • 1. Self regulating
    • 2. Compensatory
    • 3. Tend to be regulated by neg. feedback system.
    • 4. They may require several feedback mechanisms to correct only one physiological imbalance.
  8. When someone's peripheral blood vessels constrict, thereby divertiing most of the blood internally, and increased muscular activity and shivering occur to create heat. What characteristic of physiologic homeiostasis is this?

    1. Neg. Feedback.
    2. Self-Regulating
    3. Compensatory
    3. Compensatory

    Homeostatic mechanisms are compensaory (counterbalancing) because they tend to counteract conditions that are abnormal for the peroson. pp. 276 K&E
  9. What are they psychological needs that each person needs in order to maintain psychological homeostasis?
    Love, security, and self-esteem
  10. Which stage of health behavior change occurs when the person intends to take action in the immediate future?
    Preperation Stage.

    pp. 285 K&E
  11. Which stage of health behavior change occurs when the person actively implements behavioral and cognitive strategies of the action plan to interrupt previous health risk behaviors and adopt new ones?
    Action Stage

    pp. 285 K&E
  12. Which stage of health behavior is when the person acknowledges having a problem, seriously considers changing a specific behavior actively gathers information and verbalizes plans to change the behavior in the near future?
    Contemplation Stage

    pp. 285 K&E
  13. What stage of health behavior occurs when the person doesn't think about changing his or her behavior in the next 6 months?
    Precontemplation Stage

    pp. 285 K&E
  14. What stage of health behavior occurs when the person stirives to prevent relapse by integrating newly adopted behaviors into his or her lifestyle. This stage lasts until the person no longer experiences temptation to return to previous unhealth behaviors.
    Maintenance Stage pp. 285
  15. What stage is the ultimate goal where the individual has complete confidence that the problem is no longer a temptation or threat?
    Termination Stage. pp. 285
  16. What is the ability to devlop one's inner nature to its fullest potential?
    Spiritual Health. pp. 288
  17. Health promotion plans need to be developed according to the needs, desires, and priorities of the client.

    True or False?
    True. pp. 295
  18. A nurse and aprimary care provider inform a client that chemotherapy yis recommended for a diagnosis of cancer. .Which nursing action is most representative of the concept of holism?

    1. Offer to come to the client's home to provide needed pysical care.
    2. Contact the client's spiritual advisor.
    3. Inquire how this will affect other aspects of the client's life.
    4. Provide the client with information about how to join a support group.
    Answer 3: Holism implies consideration of all aspects of the client's life. The client is the best source of information regarding personal needs. Assessment should always precede intervention.

    pp. 1522 K&E
  19. A cleint is admitted for heart failure. The nurse assessses that the client's blood pressure is below normal range and the apical pulse is 110. The nurse knows that the increase in the client's pulse illustrates which aspect of the client's homeostatic mechanism?

    1. Compensation.
    2. Decompensation
    3. Self-Regulation
    4. Equilibrium
    Answer 1: The compensatory mechanism of increasing the heart rate is the body's way of trying to balance an ineffective cardiac output since the BP has decreased. Decompensation occurs when the compensatory mechanism is ineffective. Self-regulation refers to the homeostatic mechanisms that come into play automatically in the healthy person.
  20. The nurse who is assisting a client in the action stage of change would use which strategy?
    Answer 1: Option 2 is a strategy for the contemplation stage, option 3 is a strategt for the preoperation stage, and option 4 is a straegy for the maintenace stage.
  21. When writing a patient outcome, what components must the goal have?
    The goal must be Smart, Measurable, Attainable, Reasonable, Timed.
  22. What stage in Erickson's Psychosocial Development phase does a child feel as though they can take on adultlike responsibility of adults or internalize prohibitions and limitations of parents. They are either adventerous or guilty.
    • Initiative vs. Guilt
    • Ages 3 to 6 Years
  23. What stage in Erickson's Psychosocial Development do infants either trust caretake to give care, feed or devlop mistrust about receiving care?
    • Trust vs. Mistrust
    • Birth to 1 Year
  24. What stage in Erickson's Psychosocial Development does the individual struggle with "Who Am I" and experience difficulty with role identity.
    • Adolescense
    • Identity vs. Role Confusion
  25. What is defined as the desire to learn?
  26. What are three major develpmental stage factors associated with the leaner readiness?
    • Physical, Cognitive, and Psychosocial Maturation
    • pp. 495
  27. What is known as the "feeling" domain? It includes emotional and social goals such as feelings, interest, atitutudes, and appreciateions.
    Affective Domain
  28. What is known as the skill domain. It includes fine and gross motor abilities such as gving an injection.
    Psychomotor Domain. pp. 494
  29. Which learning activity reflects Bloom's affective domain?
    1. Adminstering an injection
    2. Accepting the loss of a limb.
    3. Inserting a catheter.
    4. Learning how to read.
    Answer 2. pp. 1531
  30. Which is the best method of helping a client newly diagnosed with diabetes to learn the dietary requirements associated with the disesase?

    1. Provide a videotape that addresses the dietary requirements associated with the disease.
    2. Ask the nutritionist to visit the client to present information and handouts about the diabetic diet.
    3. Ask the client to make a list of her favorite foods and how to work them into her diet.
    4. Have the client attend a group meeting for clients with diabetes to discuss their adaptation to this hronic health condition.
    Answer 3. Options 1 and 2 are passive learning strategies.
  31. A nurse is scheduling a teaching situation. Which client is most ready to learn?
    1. A 45 year old man whose doctor just informed him that he has cancer.
    2. A 3 year old child whose parents are reading a story book about going to the hospital.
    3. A 60 year old female who received medication 5 minutes ago for relief of abdominal pain.
    4. A 70 year old man, recovering from a stroke, who has returned from physical therapy.
    Answer 2. The client most ready to learn is experiencing or has recently experienced the least amount of stress or is the least preoccupied with other concerns.
  32. How can the nurse best assess a client's style of learning?
    1. Ask the client how he or she learns best.
    2. Use a variety of teacing strategies.
    3. Observe the client's interactions with others.
    4. Ask family members.
    Answer 1: Ind. learn in various ways, such as visually, group learning, auditory and participatory. The ind. knows ow learning has occured in the past.
  33. A 74 year old client who takes multiple medications tells the nurse, "I have no idea what that little yellow pill is for". What is the best nursing diagnosis for this client?

    1. Deficient Knowledge
    2. Health-Seeking Behavior
    3. Deficient Knowledge (Med Information)
    4. Noncompliance

    Answer 3
  34. A client is scheduled to have a diagnostic procedure. Which questions by the nurse will most likely produce a "teachable moment"? Select all that apply.
    1. "Have you ever had this procedure today?"
    2. "What are your concerns about this procedure?"
    3. What would you like to know about the procedure?"
    4. "Are you prepared for this procedure?"
    5. "What have you heard or read about the procedure?"
    2, 3, 5

    They are open-ended quesitons that will give the cleint the opportunity to provice information that will help the nurse asses level of knowledge and subsequently provide/discuss needed information with the client.
  35. A client needs to learn to self-administer insulin injections. Which statements reflect possible low literacy skills? Select all that apply.

    1. "I will read the information later_I'm too tired right now"
    2. "I've watched my brother give his own shots. I know how to do it."
    3. "Just show my wife".
    4. "I don't understand this one section in the handout".
    1, 2, 3, 4. All of thse statements could indicate a low literacy skill. The nurse will need to assess which teaching strategies will be most appropriate and will also need to carefully evaluate if the client has learned the skill and necessary information.
  36. A primary care provider admitted a client experiencing hypertensive crisis because of the failure to take his prescribed medications. To determine learning needs, which client assessment by the nurse would have the highest priority.
    1. Age.
    2. Perception of the effects of hypertension.
    3. Ability to purchase needed medications.
    4. Support system
    Answer 3. All are important factors to assess. The priority; however, would be the potential economic factorbecause the meds can be very expensicve and the client may not take them if he or she cannot afford them.
  37. A client has a learning outcome of "Select foods that are low in fat content". Which statement reflects that the client has met this learning outcome?
    1. "I understand the importance of maintaining a low-fat diet.
    2. "I feel beter about myself now."
    3. See how I revised my favorite recipe to be lower in fat."
    4. "Since changing my diet, my husband is also losing weight."
    Answer 3: This option is the easiest for the nurse to evaluate.
  38. A client's learning outcome is "Client will verbalize medication name, purpose, and appropriate precaustions". Which documented statement reflects evidence of learning?
    1. Taught name, purpose and precaustions for the new cardiac medication, seemed to understand.
    2. Written information about the medication provided and reviewed, correct resonses were given to follow-up questions.
    3. Written information read to client, stated he would read it when he got home.
    4. Asked questions about the new cardiac medication, satisfied with the information.
    Answer 2: This is the only option that clarly reflects the teacing process, evaluation method, and the response of the client indicating evidence of learning.
  39. What stage of Erickson's is when an adult of 25 to 65 years displays concern for others.
    Adulthood. pp. 358
  40. Describe the state of Intimacy vs. Isolation
    Intimate relationship with another person, Impersonal relationships. Avoidance of relationship, career, or lifestyle commitments.
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Nursing 1205 Unit I
Nursing 1205 Unit I
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