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Chapter 16 A nurse in community health has determined that there is a need for a program for teenage fathers who

want to learn about childcare. The next step in the program management process would be to: A) Conduct a survey to determine how many children the fathers have B) Determine whether the fathers have benefited from this type of program before C) Meet with community members to form a planning body D) Provide the fathers with community resources Feedback: CORRECT The program management process is like the nursing process. One is applied to a program, whereas the other is applied to clients. Following the assessment, planning for the program should occur.

2. The nurse in community health is meeting with staff to systematically plan for a new outreach program. Doing so helps them to: A) Assess the needs of potential outreach clients B) Recognize the special needs of vulnerable people in the area C) Identify how the problems of similar programs will not be repeated D) Identify the resources and activities that will help them meet their program objectives Feedback: CORRECT Systematic planning for meeting client needs assists in identifying the resources and activities that are needed to meet the objectives of client services. 3. A 3-year smoking cessation program for teens has just concluded. The type of evaluation the staff will conduct is: A) A formative evaluation B) An informal evaluation C) An ongoing evaluation D) A summative evaluation Feedback: CORRECT Summative evaluations assess program outcomes or are a follow-up of the results of the program activities. 4. The nurse engaging in formative program evaluation would most likely:

A) Conduct medical record audits for quality assurance B) Make a home visit before a client is discharged from the program C) Participate in new client evaluation D) Write policy for risk management Feedback: CORRECT Quality assurance audits are prime examples of formative program evaluation in health care delivery. 5. The major evaluation source for a nurse to use to determine the effectiveness of a teen driver safety program is: A) Centers for Disease Control and Prevention (CDC) reports B) Community health indexes C) Recent census data D) Voter registration records Feedback: CORRECT A community health index is a summary of the health indicators of a community, such as mortality and morbidity data, that is probably cited more frequently than any other single index for program evaluation at a community level. 6. A nurse in community health becomes aware that a teen smoking cessation program offered at the health department is a demonstration project. In evaluating this program, the nurse would be concerned with the program's: A) Efficiency B) Impact C) Relevance D) Sustainability A program can be continued if there are resources for it. Programs funded as a demonstration project or through outside sources will require ongoing funding to survive after the initial funding or timeframe for the demonstration project has ended. 7. Local officials have requested a program evaluation of a comprehensive teen sex education program offered in the local schools in preparation for potential budget discussions. A nurse in community health conducts a program evaluation and determines that the teen pregnancy rate has gradually declined over the years that the program has been in place. The community is measuring the program's: A) Efficiency B) Progress

C) Relevance D) Sustainability A program evaluation may be able to determine whether a program provides better benefits at a lower cost than does a similar program or whether the benefits to the clients or number of clients served justifies the costs of the program. This is a measure of the efficiency of a program. A reduction in teen pregnancies can represent significant cost savings to the overall health of the community. 8. A nurse in community health is participating on a community service board strategic team that is currently assessing the community's strengths, the local public mental health system, the community's mental health status, and other variables. This best describes what strategic program planning model used today in the public health arena? A) Assessment Protocol for Excellence in Public Health (APEXPH) B) Health Evaluation Data Information System (HEDIS) C) Mobilizing for Action Through Planning and Partnership (MAPP) D) Planning Approach to Community Health (PATCH) MAPP is the newer approach to program planning in the public health arena. It is a strategic planning model that helps the community health workers be facilitators, as communities establish priorities in their public health issues and identify resources to address the issues. 9. A nurse in community health seeks a low-cost evaluation method to learn the perspectives of the largest number of persons regarding a proposed local safe haven program for unwanted infants. The best evaluation method to meet the criteria would be: A) Community forums B) Focus groups C) Key informants D) Surveys Community forums have the advantage of being low in cost and capturing the perspectives of a large number of persons. Focus groups and key informant methods limit the number of persons expressing their perspectives. Surveys are expensive and technically demanding. 10. The major sources of information for program evaluation are (select all that apply): A) Community indicators B) Media reports C) Program clients D) Program providers E) Program records

Major sources of information for program evaluation are program clients, program records, and community indicators. Chapter 17 A state health department wants to ensure that the local health departments are delivering quality client care and can demonstrate the degree of excellence attained. The principle that is best defined by this statement is: A) Continuous quality improvement (CQI) B) Quality assurance (QA) C) Risk management D) Total quality management (TQM) Quality assurance has two goals: (1) to ensure the delivery of quality client care and (2) to demonstrate the efforts of the health care provider to deliver quality care. CQI is the use of scientific process analysis methods to achieve QA. TQM is a structured management approach to quality assurance. 2. Given recent vaccine shortages for the flu, the local nurses in community health form a group to evaluate the process of scheduling and operating flu vaccination clinics in the community and review the community's complaints from the previous season. The activity best represents the principle of: A) Total quality management (TQM) to achieve continuous quality improvement (CQI) B) Quality assurance (QA) to achieve continuous quality improvement (CQI) C) Risk management to achieve quality D) Continuous quality improvement (CQI) to achieve total quality management (TQM) TQM is a process-driven and customer-oriented philosophy of management that embodies leadership, teamwork, employee empowerment, individual responsibility, and continuous improvement of the system processes that lead to improved outcomes and greater customer satisfaction.

3. A general approach to quality improvement where a qualified agent designates formal recognition to individuals or institutions that have met minimum standards of performance is best described as: A) Accreditation B) Charter C) Credentialing D) Licensing General approaches to quality improvement seek to protect the public by ensuring a level of competency among health care professionals. Examples are credentialing, licensure, accreditation, certification, charter, recognition, academic degrees.

Credentialing is defined as the formal recognition by which individuals or institutions are designated by a qualified agent as having met minimum standards of performance. Licensure is typically viewed as recognition that a person has met a minimal set of standards to practice. 4. The general approach to quality improvement known as licensure that grants control over who can enter into and who exists in a profession can best be described as a contract between the: A) Consumers and the profession B) Legislature and the state board C) Profession and the state D) Public and the professional associations Individual licensure is a contract between the profession and the state whereby the profession (i.e., State Board of Nursing) is granted control over who can enter into and who exists in the profession. It requires written regulations to define the scope and limits of the profession's practice. 5. One specific approach to quality assurance is the use of Total Quality Management (TQM). A district public health department uses this approach and gives much attention to ensuring that studies are used to improve processes, remove management by objectives, and promote self-improvement. The major TQM guideline that would summarize these efforts would be: A) Create, publish, and distribute aims and purposes B) Drive out fear and create trust C) Eliminate barriers to pride of work/performance D) Understand the purpose of inspection Deming identified 14 guidelines for ensuring quality using a TQM approach. One major guideline is to drive out fear and create trust. This allows organizations to integrate quality into the culture every day in every way. It ensures that employees integrate continuous process improvement to improve outcomes, productivity, and customer/employee satisfaction. 6. A government agency is conducting an audit of all active clients in the local hospice program to ensure that hospice criteria for care are being applied appropriately. The type of tool being used in this specific approach to quality assurance is: A) Concurrent audit B) Outcome audit C) Retrospective audit D) Peer review Staff/peer review processes are a specific approach to quality assurance that often use audit tools to determine quality of care. The concurrent audit is a process of audit that evaluates the quality of ongoing care by looking at the nursing process. A retrospective or outcome audit evaluates quality of care following the discharge of a client. 7.

A multidisciplinary quality assurance team has reviewed an organization's stated philosophy and objectives and developed a conceptual model for appraisal that integrates peer review and client satisfaction. The quality assurance program component that should be addressed next would be: A) Action B) Process C) Structure D) Outcome The components of a quality assurance program are 1. structure, 2. process, 3. outcome, - Outcome is the most important ingredient of a program, since it is the key to evaluation of providers and agencies by external agents. 4. evaluation, 5. interpretation, and 6. action. 8. The purpose of record keeping in public health agencies is to maintain complete information on clients served and the extent and quality of service provided to those clients. The records also provide information for education and research. Another important use of the records is to: A) Determine raises for personnel B) Explain cost overruns C) Foster independence in clinical practice D) Resolve legal issues in malpractice suits Records provide complete information about the client, indicate the extent and quality of services provided, resolve legal issues in malpractice suits, and provide information for education and research. 9. The Omaha System is a client classification system developed by the Visiting Nurses Association of Omaha, Nebraska, that has the potential to improve the delivery of care by: A) Improving the description of care B) Minimizing the assessment required C) Predicting the outcome D) Decreasing the communication needs The Omaha System is a comprehensive method for evaluating client care. The components include a classification system for assessing and categorizing client problems, a database, a nursing problem list, and anticipated outcome criteria for the classified problems. It has the potential to improve the delivery of nursing care, documentation, and the descriptions of client care that will enhance nursing assessment, planning, implementation, and evaluation of client care and allow the

collection of more pertinent client information (relevant, consistent, measurable) for more effective and efficient nurse productivity and communication. 10. Identification of the discrepancies between the quality standards of the agency and the actual practice of the health care professionals is part of the interpretation component of quality assurance programs. Other factors addressed during this stage are (select all that apply): A) Choices of possible courses of action B) Follow-up evaluation C) Strengths and weaknesses D) Taking action Feedback: CORRECT The identification component of a quality assurance program addresses the discrepancies between the quality standards of the agency and the actual practices of the providers, identification of strengths and weaknesses, and identification of possible choices of action to address weaknesses or enhance strengths based on significance, economic benefit, and timeliness.

Chapter 21
1. A city uses the local media (radio, television, and newspapers) to post ratings of air quality on days when the air quality is poor. This notification is directed toward older adults, very young members of the community, and those with chronic breathing problems. These groups are an example of: A) Disenfranchised populations B) Disadvantaged populations C) Vulnerability D) Vulnerable populations Vulnerable populations are those groups who have an increased risk to develop adverse outcomes. A vulnerable population group is a subgroup of the population, more likely to develop health problems as a result of exposure to risk or to have worse outcomes from a health problem than is the rest of the population. The risks are often cumulative risks from environmental hazards, personal behavior, or biological or genetic makeup. 2. A poor older Native Alaskan woman lives in a small remote village near the Canadian border. She has been diagnosed with hypertension and diabetes but rarely makes it to the regional clinic in a distant town for checkups. This woman is most at risk for: A) Disenfranchisement B) Health disparities

C) Loss of independence D) Resilience Vulnerable populations often are more likely than the general population to suffer from health disparities (i.e., wide variations in health services and health status among certain population groups). The less than adequate care experienced by these groups can be defined by age, gender, race or ethnicity, education or income, disability, geography, or sexual orientation. Racial or ethnic minority populations that have been targeted for initiatives to reduce their higher than average burden from poor health are African-Americans, Hispanics, Native Americans, Native Alaskans, and Asian-Pacific Islanders. Race and ethnicity are not thought to be causes of disparities at this time, but poverty and low education levels are more likely to contribute to health disparities. 3. A young adult with a history of prior parental abuse has recently been diagnosed with a stress-related illness. The individual works at a local convenience store, earning a little more than the federal poverty level, but receives no health benefits. This individual is predisposed to the development of: A) Poverty B) Resilience C) Risk D) Vulnerability Some predisposing factors to the development of vulnerability are poverty, being uninsured or underinsured, age (both ends of the age continuum), changes in normal physiology, and life experiences, especially early life experiences. 4. A nurse participates with a community planning board addressing housing strategies and future community needs. The nurse is aware that the community has a population of homeless families served by local churches. The nurse is also aware that this agricultural community relies on migrant workers during seasonal harvesting of local produce. The nurse is concerned that these disenfranchised populations may be: A) Complicated to address B) Costly to serve C) Invisible to the community D) Resilient to the community Disenfranchisement refers to a feeling of separation from mainstream society. Groups such as the poor, the homeless, and migrant workers are "invisible" to society as a whole and forgotten in health and social planning. Vulnerable populations are at risk for disenfranchisement because their social supports are generally weak, as are their links with formal community organizations. 5. A nurse volunteering at the free clinic in her community informs a client seeking treatment for hypertension that the family's children may qualify for enrollment in the State Children's Health Insurance Program (SCHIP). The nurse's intervention can reduce health disparities for these vulnerable children by making a referral to a program that provides: A) Direct financial subsidies for children B) Funds to insure currently uninsured children

C) Outreach efforts to enroll eligible children in Medicaid D) Prospective payments for child services Title XXI of the Social Security Act provides for the State Children's Health Insurance Program (SCHIP) to provide funds to insure currently uninsured children. Individuals receiving services at a free clinic are typically the uninsured working poor. Children in these families may qualify for the SCHIP benefits. This program addresses health disparities. 6. The Medicare Prescription Drug Improvement and Modernization Act of 2003 creates a prescription drug benefit as Part D of Medicare that will be purchased through private companies with their own formularies. This design benefits individuals in the low-income category but may only provide limited relief for individuals earning more than the lowincome level. This new benefit is decreasing health disparities by addressing the predisposing vulnerability factor of: A) Disadvantaged populations B) Disenfranchised populations C) Resilience D) Underserved populations Medicare Part D insurance will be purchased through private companies, each with their own formulary. People in the low-income category will receive clear benefits (no premium or deductible and very limited copayment). This will assist about 13 million people that fall into this poverty category. Those earning above the poverty level will receive some (75%) coverage to $2,250 in annual drug costs. There is no coverage between $2,251 and $5,100 in annual drug costs. Annual costs in excess of $5,100 are covered at 95%. The insurance provides the most relief for those individuals with the most limited resources (poverty category) who are considered disadvantaged. This reduces health disparities. 7. The most critical strategy that can be used by nurses in community health to improve the health status of migrant workers that spend only a few months in a geographic location is to: A) Conduct a comprehensive assessment and formulate a plan for treatment B) Establish a long-term trust relationship to prevent disappointment C) Schedule appointments for appropriate immunizations for the children D) Use every opportunity to teach about preventive health care Focus on prevention. Use every opportunity to teach about preventive health care.

8. A nurse in community health directly contacts a mammography clinic to arrange an appointment for a female migrant worker with limited English language abilities. The nurse communicates with the client through an interpreter to ensure that the client's appointment is scheduled to meet her needs and that the client understands the procedure to be performed. This strategy used with vulnerable populations can best be described as: A) Advocacy B) Culturally competent care

C) Partnership D) Social justice Advocacy refers to those actions one undertakes on behalf of another. Vulnerable populations may require the active participation of the nurse to ensure access to available services. Vulnerable populations already face numerous stressors, and their vulnerability may increase as they try to negotiate the maze of local health care services. Nurses should support vulnerable populations to increase these populations' resilience. 9. Health education is often used as a strategy in working with vulnerable populations. The benefits of health education can be greatly affected by: A) Dependency cycle B) Health literacy C) Income level D) Race and ethnicity A new concern for public nurses and nurses in community health is whether the populations with whom they work have adequate health literacy to benefit from health education. It may be necessary to collaborate with an educator, an interpreter, or an expert in health communications to design messages that vulnerable individuals and groups can understand and use. 10. Which of the following are factors that may contribute to vulnerability? Select all that apply. A) Exercise habits B) Crime C) Peeling lead paint D) Social isolation E) Illiteracy Individual and social factors may contribute to vulnerability. Risks come from the environment, personal behaviors, or biological or genetic makeup. Some risks are related to social factors like homelessness, neighborhood crime, abuse, and violence. Others are related to isolation, geography, and language and education barriers.

Chapter 22: Rural Health and Migrant Health

1. When determining whether a geographic area is rural or urban, the nurse should recognize that: A) Rural and urban areas, by relative nature, occur on a continuum B) Rural regions have fewer than six persons per square mile

C) Rural residents feel isolated D) Rural areas are recreational, retirement, or resort communities Rural and urban residencies are not opposing lifestyles. Rather, they are a rural-urban continuum ranging from living on a remote farm, to a village or small town, to a larger town or city, to a large metropolitan area with a core inner city. Although some communities may seem geographically remote, the residents who live there may not feel isolated. For the more affluent, rural may bring to mind recreational, retirement, and resort communities located in the mountains, near the seashore, or in lake country. For the less affluent, it may mean an impoverished Indian reservation or migrant labor camp. Therefore rural may be a state of mind. 2. A nurse in community health is working in a rural setting. In planning for programs to address the population's needs, the nurse should be aware that, in general, rural populations: A) Engage in physical activity during leisure time B) Engage in preventive behaviors C) Perceive their overall health as less favorable D) Use seat belts In general, people in rural areas have a poorer perception of their overall health and functional status than do urban residents. 3. When using the health measure of death rates for working-age adults, the nurse could expect to find the highest rates in which areas? A) Large metropolitan areas B) Most rural and highly populated urban areas C) Most rural and suburban areas D) Small suburban and all urban areas Death rates for working-age adults are higher in the most rural and the most highly populated urban areas. 4. Within a state, counties designated as Health Professional Shortage Areas (HPSAs) tend to have a high proportion of racial minorities and fewer specialists. This factor may explain conflicting data within a state related to: A) Adult immunization rates B) Chronic respiratory illness rates C) Maternal/infant morbidity rates D) Obesity rates HPSAs tend to have a high proportion of racial minorities and fewer specialists, such as pediatricians, obstetricians, and gynecologists. 5.

A nurse in community health located in Virginia is conducting an assessment on a Hispanic worker currently working in a local apple orchard for the season. The nurse determines that the worker originates from Florida and is living in temporary housing with other orchard workers. Based on this information, the nurse should integrate the special needs of what vulnerable population? A) Migrant farmworkers B) Seasonal farmworkers C) Underinsured D) Undocumented aliens A migrant farmworker is a person whose principal employment is in agriculture on a seasonal basis, who has been employed within the last 24 months, and who establishes for the purpose of such employment a temporary abode. Most are either American citizens or are authorized to work in the United States. Seasonal farmworkers work cyclically in agriculture but do not migrate. 6. The local hospital emergency department has recently experienced an increase in gastroenteritis cases among migrant farmworkers. The local health department is informed of this rise in cases and schedules a case mapping of local: A) Bars frequented by migrant workers B) Farm fields employing migrant workers C) Housing for migrant workers D) Restaurants frequented by migrant workers Housing conditions greatly vary among states and localities. When housing costs are high, 50 farmworkers may live in one house, or three families may share one trailer. Some may live in cars or tents if necessary. Housing may lack individual sanitation, bathing, or laundry facilities. Poor-quality and crowded housing can contribute to such health problems as tuberculosis (TB), gastroenteritis, and hepatitis.

7. An undocumented migrant farmworker has been diagnosed with tuberculosis (TB). The local health department initiates treatment by dispensing the first month's supply of medication and educates the client on the need to continue treatment for 6 to 12 months. A major challenge that the client may face related to ongoing treatment for TB is: A) Affordable care B) Discrimination C) Fragmented services D) Language barriers While migrant workers move from job to job, their health care records typically do not go with them. This leads to fragmented services in such areas as TB treatment, chronic illness management, and immunization. 8. A school nurse is asked to assess a 13-year-old child because of excessive drowsiness and inattention in class. The nurse determines that this is a child of migrant workers on a local produce farm. Based on the nurse's knowledge of migrant worker families, the nurse should first explore the child's potential involvement in:

A) Delinquent behavior B) Drug use C) Field work D) Migrant Education Program Children of migrant farmworkers may need to work for the family's economic survival. Federal law does not protect children from overworking or from the time of day they work outside of school. Therefore children may work until late in the evening or very early in the morning every day of the week. These children may experience constant fatigue and are set up for failure in school. 9. A district health nurse is assigned to two rural counties in the state. To achieve the best outcomes possible in reducing the health disparities for the large number of frail older clients in the two counties, the nurse should consider using what community-oriented nursing skill? A) Assessment B) Case management C) Geriatrics D) Tertiary prevention Nurses working in rural areas, including those working with migrant farmworkers, have opportunities to use many skills of nursing in community health. One of the first and most important is that of prevention. Given the barriers to receiving health care in rural areas, the ideal situation is to prevent health disruptions whenever possible. Case management and community-oriented primary health care are two effective models to address some of those deficits and resolve rural health disparities. 10. Rural residents appear to have a more persistent, endemic level of depression. The factors that may contribute to this level of depression may be related to which of the following? Select all that apply. A) Crisis intervention B) Gaps in continuum of mental health services C) Sufficient number of mental health services D) Tolerance for destructive coping behaviors E) Trust in the health care professionals There appears to be a more persistent, endemic level of depression among rural residents. Factors that relate to this level of depression are high rate of poverty, economic difficulties, economic recession, geographic isolation, insufficient number of mental health professionals, delays in seeking treatment, tolerance of destructive coping behaviors, lack of trust in mental health professionals, and gaps in the continuum of mental health services. Chapter 23: Homelessness, Poverty, Mental Illness, and Teen Pregnancy
The educator role uses teaching-learning principles to increase understanding about mental illness and mental health. The educator role is foundational to health maintenance, health promotion, and community action.

Teaching clients about illness symptoms and the benefits of medication promotes health maintenance and may reduce the risk for illness relapse. Factors that influence community services include (1) the scope of emotional and mental disorders, (2) the uncertainty about specific cause, cure, and treatment for most severe mental disorders, (3) the severe chronic disabling nature of some mental disorders, and (4) the complexity of the community mental health services sector. Possible self-help and community sources are Alcoholics Anonymous, Al-Anon, American Anorexia/Bulimia Association, American Association of Suicidology, Anxiety Disorders Association of America, Attention Deficit Information Network, Children and Adults with Attention Deficit Disorders, Depressive/Manic Depressive Association, Gamblers Anonymous, National Center for Post-Traumatic Stress Disorder, National Center for Learning Disabilities, Obsessive-Compulsive Foundation, Overeaters Anonymous, Schizophrenics Anonymous.

1. A recent movie release portrays a criminal as a black female drug user whose abusive boyfriend has two children by different women, living in the riot-torn inner city of a large metropolitan area with high levels of poverty and unemployment. This best demonstrates what type of factor that influences poverty? A) Cultural B) Environmental C) Political D) Social Cultural attitudes are the beliefs and perspectives that a society values. Perspectives about individual responsibility for health and well-being are influenced by the prevailing cultural attitudes. The media communicate thoughts and attitudes through literature, film, art, television, and newspapers. 2. A nurse in community health working in an inner city clinic with high poverty and unemployment rates recognizes the need for programs for pregnant women because these women often receive late or no prenatal care and deliver: A) At home B) Full term C) Identical twins or triplets D) Low-birthweight babies Poor pregnant women are more likely than other women to receive late or no prenatal care and to deliver low-birthweight babies, premature babies, or babies with birth defects. 3. A case management nurse for a locally funded program for special-needs children is increasingly concerned about a recent referral for a 1-year-old child with a congenital illness that is residing in poverty-stricken community. The nurse knows that this child may be at higher risk for the most harmful effects of poverty including: A) Developmental delays B) Ear infections C) Frequent colds and infections D) Irritability

Young children (newborn to age 5 years) are at greater risk for the most harmful effects of poverty, especially in regard to adequate nutrition and brain development. 4. For the homeless, health care is usually crisis oriented and sought in emergency departments. The most difficult challenge for nurses treating this vulnerable population is to recognize the client's: A) Limitations in following treatment protocols B) Limited number of transient treatment facilities C) Transition to persistent poverty D) Use and abuse of tobacco, alcohol, and illicit drugs Homeless people devote a large portion of their time to just trying to survive. Health care is usually crisis oriented and sought in emergency departments. Those who access health care have a hard time following prescribed treatment regimes such as prescribed diets, purchasing prescriptions, or health-promotion or symptom-relief measures. 5. The nurse must ask about violence at each prenatal and postpartum visit, especially with vulnerable populations such as teenagers, as well as observe for signs of violence on each visit. The nurse should be aware that the peak for postpartum intimate partner violence may be observed at various times according to ethnic group, such as: A) 6 months for white mothers B) 10 months for white mothers C) 3 months for African-American and Hispanic/Latino mothers D) 12 months for African-American and Hispanic/Latino mothers Violence that begins in pregnancy may continue for several years after, with increasing severity. Variations by ethnicity have also been observed during this postpartum period: intimate partner violence may peak at 3 months postpartum among African-American and Hispanic/Latino new mothers and at 18 months for white mothers. 6. A nurse in community health is following a pregnant teenager that attends school. The nurse plans to discuss self-care activities that will be important for the teen during her pregnancy. The discussion should include: A) Carrying heavy book bags B) Changing to home education C) Decreasing fluid intake to avoid nausea D) Keeping up her grades If teens return to school, it is important for the nurse to discuss these needs: (1) using the bathroom frequently, (2) carrying and drinking more fluids or snacks to relieve nausea, (3) climbing stairs and carrying heavy book bags, and (4) fitting comfortably behind stationary desks. 7. The goal of deinstitutionalization was to improve the quality of life for people with mental disorders by providing services in the communities where they lived rather than in large institutions. At what program level did this change in locus of care fail?

A) Assessment level B) Design level C) Evaluation level D) Implementation level Although deinstitutionalization was noble in conception, it was bankrupt in implementation. Families and communities were not prepared to take on the treatment responsibilities they had to assume, and little education was available. Either care settings such as nursing homes, personal care settings, supervised apartments, rooming houses, single-occupancy hotels, and other similar settings were not available, or people were not educated or prepared to deal with this population. 8. A hospice nurse is working with a cancer client and his family. The client's 7-year-old son has developed recent school and peer problems. Understanding the risk for disruption of normal development, the nurse plans to first screen the child for: A) Developmental disorders B) Mental health problems C) Parental neglect D) Violence potential Children are at risk for disruption of normal development by biological, environmental, and psychosocial factors that impair their mental health, interfere with their education and social interactions, and keep them from realizing their full potential as adults. Children can develop depression or behavior problems in response to an actual or potential loss. 9. A nurse in community health conducts quarterly mental health-promotion and depression-screening programs at the local senior center. The nurse is aware that older adults are at increased risk for developing depression. Using such an intervention also addresses the older adults': A) Dependence on their primary care provider B) Normal sensory losses C) Reduced social contacts D) Underutilization of the mental health system Older adults underutilize the mental health system and are more likely to be seen in primary care or to be the recipient of care in institutions. The nurse can reach them by organizing health-promotion programs through senior settings or other community-based settings. 10. It is estimated that one in 15 males becomes a father during his teen years. The nurse should be aware that many young men facing paternity have specific challenges such as (select all that apply): A) Acting as though they are interested when they are disinterested B) Avoiding prenatal care involvement C) Desiring and needing to be involved with their children

D) Being rejected by the young womans family E) Rejecting their role as a father Nurses can acknowledge and support the young man as he develops in the role of father. Young men react differently when they learn that their partner is pregnant, and it often depends on the nature of the relationship before pregnancy. Many young men will accompany the young woman to a health care center for pregnancy diagnosis and counseling. A large percentage of young men will continue to accompany the young woman to some prenatal visits and may even attend the delivery. These young men may also want to and need to be involved with their children regardless of changes in the relationship with the teen mother. It is not unusual for a young man to be excluded or even rejected by the young woman's family. He may then begin to act as if he is disinterested when he may really feel that he cannot provide resources for his child or know how to take care of the child. Chapter 24 Alcohol, Tobacco, & Other Drug Problems in Community
1. For a nurse to develop a therapeutic attitude toward the treatment of alcohol, tobacco, and other drug (ATOD) problems in the community, the nurse must realize drug addiction can be successfully treated, anyone may develop drug dependence, and:

A) Any drug can be abused B) Illegal drugs are the category of abused drugs C) Prescription drugs rarely cause dependence D) Over-the-counter (OTC) drugs are good drugs A health care approach to ATOD problems is the harm reduction model. This is a new public health model that nurses can use to treat individuals, families, and communities. To develop a therapeutic attitude, the nurse must realize that any drug can be abused, anyone may develop drug dependence, and drug addiction can be successfully treated. 2. A long-distance truck driver being assessed by a nurse in a community-based clinic states, "I smoke 3 packs of cigarettes a day. I use coffee and diet pills from the drug store to stay awake on the road. That makes it difficult to sleep when I do pull over, so I use a prescription sleeping pill from my doctor to sleep for 4 hours. It's giving me palpitations." The nurse's assessment should include a diagnosis of:

A) Drug abuse B) Drug addiction C) Substance abuse D) Adverse drug reaction Substance abuse is the use of any substance that threatens a person's health or impairs social or economic functioning. This definition is more objective and universal than the government's definition of drug abuse, which is the use of a drug without a prescription or any use of an illegal drug.

3. The nurse is evaluating a new home health client for ongoing management at home following back surgery for a traumatic injury. The client has been receiving a morphine-based drug for long-term pain management over the past 6 months. The nurse's assessment should include a plan for addressing the client's:

A) Drug dependence B) Drug addiction C) Substance abuse D) Opiate addiction Drug dependence is a state of neuroadaptation caused by the chronic, regular administration of a drug. This is a physiological change in the central nervous system; therefore the drug must be continued to prevent withdrawal symptoms. The morphine should be gradually tapered rather than abruptly stopped to prevent withdrawal symptoms. 4. An eighth-grader is brought to the emergency department by a parent for unusual skin blistering and discoloration around the nose and lips. The parent states that the child will not say what caused the injury. The nurse should consider the possible use of:

A) Crystallized methamphetamine B) Inhalants C) MDMA (Ecstasy) D) PCP (phencyclidine) Inhalants are often among the first drugs that young children use. Recent surveys show that about 6% of American children have tried inhalants by the fourth grade, with use peaking around the eighth grade. Dangers with administration of gases increase when inhaling from pressurized tanks, because the gas is very cold and can cause frostbite to the nose, lips, and vocal cords. 5. The harm reduction approach to substance abuse focuses on health promotion and disease prevention. A primary prevention strategy that can be used by the nurse to address substance abuse under this approach is to:

A) Assess for recreational drug use B) Destroy the myth of good drugs versus bad drugs C) Encourage children to just say no D) Refer to an addiction treatment program

Nurses are experts in medication administration and understand the potential dangers of indiscriminate drug use and the inherent inability of drugs to cure problems. Nurses can influence the health of clients by destroying the "good drugs versus bad drugs" myth. This means (1) teaching clients that no drug is completely safe and that any drug can be abused, and (2) helping persons learn how to make informed decisions about their drug use to minimize potential harm. 6. A client is back for his follow-up appointment and says to the nurse, "I know. I know. I drink too much, but the job is so stressful that I need to find a way to unwind at the end of the day. You would too!" The nurse should recognize that this is a primary symptom of addiction known as:

A) Denial B) Social drug use patterns C) Setting variable D) Coping The role of the nurse in secondary prevention is to accurately assess the client to identify substance abuse and plan appropriate interventions. A progression in drug-use patterns and related problems warns about the possibility of addiction. Denial is a primary symptom of addiction and can be demonstrated by the following: lying about use; minimizing use patterns; blaming or rationalizing; intellectualizing; changing the subject; using anger or humor; and "going with the flow" (agreeing that a problem exists, stating behavior will change, but not demonstrating any behavior change). 7. Methadone maintenance for heroin addiction is a harm reduction strategy because it reduces deviant behavior and:

A) Avoids costly residential programs B) Introduces addicted persons to the health care system C) Prevents relapse D) Provides total abstinence Methadone maintenance is a harm reduction intervention because it reduces deviant behavior (needle-sharing practices) and introduces addicted persons to the health care system. This may ultimately lead to total abstinence. The advantages of methadone are that it is long acting, effective orally, and inexpensive with few known side effects. 8. Indiscriminate use of "good drugs" has caused more health problems from adverse reactions, drug interactions, dependence, addiction, and overdoses than has the use of "bad drugs." The high-risk population group that most experiences the negative consequences identified above is:

A) Adolescents B) Injection drug users C) Older adults D) Pregnant women Older adults consume more prescribed and OTC medications than does any other age-group. Problems with alcohol consumption, including interactions with prescribed and OTC drugs, far outnumber any other substance-abuse problem among older adults. Factors such as slowed metabolic turnover of drugs, age-related organ changes, enhanced drug sensitivities, a tendency to use drugs over longer periods, and a more frequent use of multiple drugs all contribute to greater negative consequences from drug use among older adults. 9. A nurse in community health is following an older woman who complains frequently of migraine headaches, backaches, and GI disturbances. During a recent visit, the woman states that her adult son now lives with her. He was recently let go from his job. He enjoys hanging out with his old buddies. When he feels better he will look for a new job. Despite the added burden she really enjoys having her son around again. The nurse should explore this further to determine whether the family is:

A) Abusive B) Codependent C) Coping D) Estranged Drug addiction is often a family disease. People in close relationship with the addict often develop unhealthy coping mechanisms to continue the relationship. This is known as codependency, a stress-induced preoccupation with the addicted person's life, leading to extreme and excessive concern with the addict. Codependents try to meet the addict's needs at the expense of their own. Codependency may underlie medical complaints and emotional stress seen by health care providers such as ulcers, skin disorders, migraine headaches, chronic colds, and backaches. 10. Marijuana (Cannabis sativa or C. indica) is the most widely used illicit drug in the United States. The nurse should be aware that marijuana has which of the following characteristics? Select all that apply.

A) Decreases appetite B) May lead to tolerance C) Is highly toxic

D) Has little quality control E) Is a safe therapeutic agent Compared with the other psychoactive drugs, marijuana has little toxicity and is one of the safest therapeutic agents known. However, because of its illegal status, there is little quality control, and a user may consume contaminated marijuana that may cause problems. Tolerance can develop, as well as physical dependence; however, withdrawal is benign.

Primary prevention of violence: provide education on the developmental stages and needs of children, teach parenting skills, and teach stress-reduction techniques. Secondary prevention of violence: conduct assessment during routine examination, assess for marital discord, counsel for at-risk parents, and assist with controlling anger. (See the Levels of Prevention box in Chapter 25 in your textbook. 1. Violence is a major public health problem in our communities that causes premature mortality and lifelong disability. Violence-related morbidity is a significant factor in: A) Community deterioration B) Health care costs C) Juvenile delinquency D) Population density Violence is a public health problem that has both emotional and physical effects. Violence is the major cause of premature mortality and lifelong disability, and violence-related morbidity is a significant factor in health care costs. Violent behavior is predictable, and therefore it is preventable, especially with community action. 2. A large industrial plant has recently laid off a significant portion of its workforce because of scalebacks in production. The occupational health nurse proposes education sessions with the remaining employees about effective strategies for managing stress during economic downturns. This suggestion to management is based on the nurse's understanding that increases in aggression and violence at home and work may be triggered by: A) Competition B) Unemployment C) Survivor guilt D) Work-related stress 3. A nurse in community health is working with a parent whose spouse has been called up for active duty in the military reserve. The family is experiencing financial strain due to decreased income. The extended family lives at a distance. The parent is struggling to manage the family in the spouse's absence. The family consists of four children (three preschool and one preteen). The preteen is very bright in school and actively involved in community and school activities. In this situation, it would be important for the nurse to further explore the potential for:

Chapter 25 Violence and Human Abuse

A) Child abuse B) Depression C) Intimate partner abuse D) Parents resentment of the preteen Parents with low social support, a tendency toward depression, multiple stress factors, or a history of abuse are at risk for abusing their children. 4. A nurse in community health conducting a home visit notices a 4-year-old girl sitting on a stool in an adjoining room. The girl is quiet and withdrawn, rarely makes eye contact, and does not leave the room. The nurse proceeds to ask about the child and attempts to engage the child in conversation. The nurse is assessing for what indicators of child abuse? A) Emotional abuse B) Emotional neglect C) Physical abuse D) Physical neglect Neglect is more difficult to assess than is abuse. Emotional neglect is the omission of basic nurturing, acceptance, and caring essential for healthy personal development. These children are largely ignored or in many cases treated as a nonperson. It is difficult for a neglected child to feel a great deal of self-worth because the parents have not demonstrated that they value the child. Astute observations of children, their homes, and the way they relate to their caregivers can provide clues of neglect. 5. A father brings his stepdaughter to the family clinic for an immunization update prior to the new school year. The nurse notices the interaction between the young girl and her stepfather. The child appears tense and cautious and wraps her arms around herself in a protective manner. The child startles when touched by the stepfather and pulls away. The stepfather is overheard saying, "I'll leave you here if you don't behave and act nice." In this scenario, it would be important for the nurse to explore in her assessment the possibility of: A) Child neglect B) Family secrets C) Father-daughter incest D) Impaired family functioning Incest occurs in all races, religious groups, and socioeconomic classes. A typical pattern is as follows: The daughter involved in the parental incest is usually 9 years of age at the onset and is often the oldest or only daughter. The father seldom uses force. He is more likely to use threats, bribes, intimidations, or misrepresentation of moral standards. These children may have difficulty in social situations and demonstrate avoidance behaviors. They may also attempt to cover or protect their bodies. Therefore the nurse must be aware of these indicators in order to conduct an appropriate assessment and plan appropriate interventions. 6. All adults should be assessed for violence in their primary intimate relationships. The abuse of female partners has the most serious community health ramifications because of the greater prevalence, the more serious long-term emotional and physical consequences, and the greater potential for:

A) Fleeing to a shelter B) Homicide C) Possessive behavior D) Spontaneous abortion The abuse of female partners has the most serious community health ramifications because of the greater prevalence, the greater potential for homicide, the effects on the children in the household, and the more serious long-term emotional and physical consequences. As a woman tries to leave the abusive relationship, the risk for homicide increases, creating a catch-22 scenario. A nurse encountering evidence of severe abuse needs to consider the safety of the woman and her children as the priority. 7. The nurse at the adult day care center notices bruises on the wrists of a 90-year-old client. Besides the physical assessment of the client, the nurse should: A) Confront the daughter when she arrives to pick the father up B) Discuss the findings with the caregivers to determine the cause of the injuries C) Educate the staff about indications of elder abuse D) Make a referral to the primary care provider for follow-up Rough handling by caregivers can lead to bruises and bleeding into body tissues because of the fragility of older adult clients' skin and vascular systems. It is often difficult to determine whether the injuries of older adults result from abuse, falls, or other natural causes. Careful assessment through both observation and discussion can help determine the cause of injuries so that proper plans for interventions can be made. 8. In giving care to the survivors of violence, the nurse should demonstrate respect and caring for all family members, insist that safety is the first priority, and demonstrate intolerance for violent behavior. Additionally, the nurse should be: A) Absolutely honest about what will be reported and what the family can expect B) Authoritarian in approaching the problem C) Cautious in reporting unconfirmed reports of violence D) Sincere in concern for the victims The principles of giving care to families who have experienced violence include the following: 1. intolerance of the violence, 2. respect and caring for all family members, 3. safety as the first priority, 4. absolute honesty, and 5. empowerment. The nurse must use a nurse-family partnership rather than a paternalistic or authoritarian approach. 9. A nurse new to the community evaluates the resources available to a father that has sought help with his escalating abuse and threats of violence to his family. After making the referral, the nurse approaches the local newspaper about running a series on the nature and extent of human abuse in the community. This strategy would:

A) Advocate for government programs to treat survivors B) Demonstrate the providers commitment to address the need for services C) Increase awareness of community resources to address violence and abuse D) Increase the number of individuals identified as perpetrators Referral is an important component of tertiary prevention. Nurses should know about available community resources for abuse victims and perpetrators. If attitudes and resources are inadequate, it is often helpful to work with local radio and television stations and newspapers to provide information about the nature and extent of human abuse as a community health problem. People often do not seek services early in an abusive situation because they simply do not know what is available to them.

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