File 7165

Chapter 01: Public Health Nursing and Population Health
Stanhope: Foundations for Population Health in Community/Public Health Nursing, 6th Edition
MULTIPLE CHOICE
1. Which statement best describes community-based nursing?

a. A practice in which care is provided for individuals and families.
b. Providing care with a focus on the group’s needs.
c. Giving care with a focus on the aggregate’s needs.
d. A value system in which all clients receive optimal care.
ANS: A
By definition, community-based nursing is a setting-specific practice in which care is provided for “sick” individuals and families
where they live, work, and attend school. The emphasis is on acute and chronic care and the provision of comprehensive,
coordinated, and continuous care. These nurses may be generalists or specialists in maternal–infant, pediatric, adult, or psychiatric
mental health nursing. Community-based nursing emphasizes acute and chronic care to individuals and families, rather than
focusing on groups, aggregates, or systems.
2. Which statement best describes the goal of community-oriented nursing?

a. Providing care to individuals and families
b. Providing care to manage acute or chronic conditions
c. Giving direct care to ill individuals within their family setting
d. To preserve, protect, promote, or maintain health and prevent disease
ANS: D
By definition, community-oriented nursing has the goal of preserving, protecting, or maintaining health and preventing disease to
promote the quality of life. All nurses may focus on individuals and families, give direct care to ill persons within their family
setting, and help manage acute or chronic conditions. These definitions are not specific to community-oriented nursing.
3. Which of the following is the primary focus of public health nursing?

a. Families and groups
b. Illness-oriented care
c. Individuals within the family unit
d. Health care of communities and populations
ANS: D
In public health nursing, the primary focus is on the health care of communities and populations rather than on individuals, groups,
and families. The goal is to prevent disease and preserve, promote, restore, and protect health for the community and the population
within it. Community-based nurses deal primarily with illness-oriented care of individuals and families across the life span. The
aim is to manage acute and chronic health conditions in the community, and the focus of practice is on individual or
family-centered illness care.
4. Which of the following is responsible for the dramatic increase in life expectancy during the 20th century?
a. Technology increases in the field of medical laboratory research
b. Advances in surgical techniques and procedures
c. Sanitation and other population-based prevention programs
d. Use of antibiotics to fight infections
ANS: C
There has to be indisputable evidence collected over time that public health policies and programs were primarily responsible for
increasing the average life span from 47 in 1900 to 78.6 years in 2017, an increase of approximately 60% in just over a century plus
through improvements in (1) sanitation, (2) clean water supplies, (3) making workplaces safer, (4) improving food and drug safety,
(5) immunizing children, and (6) improving nutrition, hygiene, and housing. Although people are excited when a new drug is
discovered that cures a disease or when a new way to transplant organs is perfected, it is important to know about the significant
gains in the health of populations that have come largely from public health accomplishments.
5. A nurse is developing a plan to decrease the number of premature deaths in the community. Which of the following interventions
would most likely be implemented by the nurse?
a. Provide free health care to all citizens
b. To increase the number of individuals with access to effective health care benefits
c. Lower the cost of health care to the American population
d. To lessen the governmental burden of providing health care to Americans
ANS: B
The central feature in the Patient Protection and Affordable Care Act (ACA) of 2010 are the mechanisms to increase the number of
people with health insurance. The care provided is not necessarily free. While the cost of health care and the burden it places on the
American government are serious concerns, they are not the primary focus of ACA.
Copyright © 2022, Elsevier Inc. All rights reserved. 1

6. What is the basic assumption stated by Healthy People 2010 as it relates to public health efforts?
a. Health disparities among any groups are morally and legally wrong.
b. Health care is the most important priority in government planning and funding.
c. The health of individuals cannot be separated from the health of the community.
d. The government is responsible for lengthening the life span of Americans.
ANS: C
The major premise of Healthy People 2010 was that the health of the individual cannot be entirely separate from the health of the
larger community. Public health practice focuses on the community as a whole, and the effect of the community’s health status
(resources) on the health of individuals, families, and groups. The goal is to prevent disease and disability and promote and protect
the health of the community as a whole. Public health can be described as what society collectively does to ensure that conditions
exist in which people can be healthy. The basic assumptions of public health do not judge the morality of health disparities. The
focus is on prevention of illness not on spending more on illness care. Additionally, individual responsibility for making healthy
choices is the directive for lengthening life span not the role of the government.
7. Which of the following actions would most likely be performed by a public health nurse?
a. Asking community leaders what interventions should be chosen
b. Assessing the community and deciding on appropriate interventions
c. Using data from the main health care institutions in the community to determine
needed health services
d. Working with community groups to create policies to improve the environment
ANS: D
Although the public health nurse might engage in any of the tasks listed, he or she works primarily with members of the community
to carry out core public health functions, including assessment of the population as a whole and engaging in promoting health and
improving the environment. The interventions of asking community leaders which interventions should be chosen, assessing the
community and deciding on appropriate interventions, and using data from health care institutions do not demonstrate the
engagement of the community when making decisions about what the community actually wants and needs.
8. Which public health nurse most clearly fulfills the responsibilities of this role?
a. The nurse who met with several groups to discuss community recreation issues
b. The nurse who spent the day attending meetings of various health agencies
c. The nurse who talked to several people about their particular health concerns
d. The nurse who watched the city council meeting on local cable television
ANS: B
Any of these descriptions might represent a nurse communicating, cooperating, or collaborating with community residents or
groups about health concerns. A major challenge for the future is the need for public health nursing specialists to be more
aggressive in working collaboratively with various groups in the community as well as professional colleagues in institutional
settings to deal with barriers to health. However, the nurse who spent the day attending meetings of various health agencies is the
most representative, because in public health, concerns are addressed from a broader perspective. In public health, broad concerns
of the community should be addressed. Concerns are broader than recreation, individual concerns are not as important as aggregate
priorities, and watching television (a one-way form of communication) is less effective than interacting with others.
9. Which of the following best defines aggregate?

a. A large group of persons
b. A collection of individuals and families
c. A collection of people who share one or more characteristics
d. Another name for demographic group
ANS: C
An aggregate is defined a collection of people who share one or more personal or environmental characteristics. Members of a
community can be defined in terms of either geography (e.g., a county, a group of counties, or a state) or a special interest (e.g.,
children attending a particular school). These members make up a population. The term population may be used interchangeably
with the term aggregate. A large group of persons, a collection of individuals and families, and another name for demographic
group are not accurate definitions of the term aggregate.
10. Which question asked by a novice nurse would be the most reflective of an understanding of the role of a public health nurse?
a. “Which groups are at the greatest risk for problems?”
b. “Which patients should I see first as I begin my day?”
c. “With which physicians will I be most closely collaborating?”
d. “With which nursing assistants will I partner the most?”
ANS: A
Asking which groups are at greatest risk reflects a community-oriented perspective. The incorrect responses reflect a focus on
individuals rather than a community-oriented perspective.
11. Making sure that essential community-oriented health services are available defines which of the core public health functions?
a. Policy development
b. Assessment
c. Assurance
d. Scientific knowledge-based care
ANS: C
Assurance includes making sure that essential community-oriented health services are available in the community. The definition
does not fit the terms assessment, policy development. Scientific knowledge-based care is not a core function of public health.
Assessment is systematic data collection on the population, monitoring the population’s health status, and making information
available about the health of the community. Policy development refers to efforts to develop policies that support the health of the
population, including using a scientific knowledge base to make policy decisions.

12. When talking to a women’s group at the senior citizens’ center, the nurse reminded them that the only way the center would be able
to afford to provide transportation services for them would be for them to continue to write letters to their local city council
representatives requesting funding for such a service. What was the nurse trying to accomplish through this action?
a. Ensure that the women did not expect the nurse to solve their problem.
b. Demonstrate that the nurse understood the women’s concerns and needs.
c. Express empathy, support, and concern.
d. Help the women engage in political action.
ANS: D
Public health nurses engage themselves and others in policy development and encourage and assist persons to communicate their
needs to those with the power to take action. The nurse is demonstrating the role of advocate through this action, it goes beyond
merely understanding the women’s concern, and instead mobilizes them to take action. This action does not demonstrate the nurse
showing empathy rather the nurse is empowering these women.
13. The public health nurse has a clear vision of what needs to be done and where to begin to improve the health of the community.
Why would the nurse spend time meeting with community groups to discuss the most important task to be addressed first?
a. To increase the group’s self-esteem
b. To maintain communication links with the groups
c. To make the groups feel good about their contribution
d. To work with the groups, not for the groups
ANS: D
Historically, health care providers have been accused of providing care for or to people without actually involving the recipients in
the decisions. Public health nursing is a “with the people”—not a “to the people” or “for the people”—approach to planning. There
is an imperative to work with members of the community to carry out core public health functions. The purpose of meeting with
community groups is not to increase their self-esteem or make them feel good about their contribution, rather it is to allow them to
act for themselves to solve the problems they are facing. The first task of working with the group should occur before addressing
maintaining communication links.
14. The nurse often has to make resource allocation decisions. Which of the following best describes the criterion the nurse should use
in such cases?
a. The specific moral or ethical principle related to the situation
b. The cheapest, most economical approach
c. The most rational probable outcome
d. The needs of the aggregate rather than a few individuals
ANS: D
The dominant needs of the population outweigh the expressed needs of one or a few people. All of the choices represent
components of a decision that the nurse might consider in determining the needs of the aggregate.
15. Which of the following actions best represents public health nursing?
a. Assessing the effectiveness of the high school health clinic
b. Caring for clients in their home following their outpatient surgeries
c. Providing care to children and their families at the school clinic
d. Administering follow-up care for pediatric clients at an outpatient clinic
ANS: A
A public health or population-focused approach would look at the entire group of children being served to determine whether
available services are effective in achieving the goal of improving the health of the school population. Caring for clients and their
families focuses on individuals and families and not on the entire population. Public health focuses on care of populations.
16. Two nurses plan to walk under a huge downtown bridge where various homeless persons live. Why would the nurses go to such an
unsafe area?
a. To assess the needs of the homeless who live there
b. To demonstrate their courage and commitment
c. To distribute some of their own surplus clothes to those who can use them
d. To share with various churches and other charities what is needed
ANS: A
In most nursing practices, the client seeks out and requests assistance. In public health nursing, the nurse often reaches out to those
who might benefit from a service or intervention, beginning with assessment of needs. The other answers reflect responses where
the nurse is trying to give assistance to this population that may or may not be helpful or welcomed.
MULTIPLE RESPONSE
1. Which of the following variables have led to a stronger commitment to population-focused services? (Select all that apply.)
a. Economic turmoil and demand for high-technology care
b. Emergence of new or drug-resistant infectious diseases
c. Emphasis on overall health care needs rather than only on acute care treatment
d. Threat of bioterrorism
ANS: B, C, D
As overall health needs become the focus of care in the United States, a stronger commitment to population-focused services is
emerging. Threats of bioterrorism, anthrax scares, and the emergence of modern-day epidemics have drawn attention to
population-focused safety and services. Economic turmoil and demand for high-technology care have not contributed to a stronger
commitment to population-focused services, rather it has occurred as overall health needs have become the focus of care.

2. Which of the following actions demonstrate effective public health nursing practice in the community? (Select all that apply.)
a. Epidemiologic investigations examine the environment for health hazards.
b. New services are organized where particular vulnerable populations live.
c. Partnerships are established with community coalitions.
d. Staff members at the public health agency continue to increase in number.
e. Staffing walk in clinics for low income families
ANS: A, B, C
Evidence that public health nurses are practicing effectively in the community would include organizing services where people
live, work, play, and learn; working in partnerships and with coalitions; and participating in epidemiologic studies. Neither
increasing the number of staff nor acting as staff in the delivery of acute and/or chronic care has a relationship to the effectiveness
of public health nursing practice.
3. Why are nurses increasingly providing care in clients’ homes rather than in hospitals? (Select all that apply.)
a. Home care is less expensive.
b. It is much more efficient to give care in the home.
c. Nurses prefer to give home care with individual attention.
d. People prefer to receive care in their homes rather than in hospitals.
ANS: A, D
An increasing number of clients are receiving care in the home because it is less expensive and clients prefer to receive care in
familiar and comfortable settings. It is not more efficient nor more convenient, since travel time has to be considered. Nurses differ
as to their preferred employment setting.

Chapter 02: The History of Public Health and Public and Community Health Nursing
MULTIPLE CHOICE
1. A nurse is considering applying for a position as a public health nurse. Which of the following would be a reason this position
would be appealing?
a. Its autonomy and independence
b. Its focus on acute care and immediately visible outcomes
c. Its collaboration with other health care professionals
d. Its flexibility and higher wages
ANS: A
Public health nursing is known for its autonomy and independence. In many instances, there are limited other health care
professionals and staff with whom to interact. In-patient acute care nurses focus on acute care with outcomes known fairly quickly.
Acute care nurses collaborate frequently with other health care professionals. Depending on the position there may be more
flexibility, but typically public health nurses do not receive higher wages.
2. The Elizabethan Poor Law of 1601 is similar to which current law?

a. Welfare
b. Food stamps
c. Medicaid
d. Medicare
ANS: C
The Elizabethan Poor Law guaranteed medical care for poor, blind, and “lame” individuals. This minimal care was generally
provided in almshouses supported by local government similar to Medicaid assistance. Welfare and food stamps do not provide for
medical care. Medicare provides medical care to primarily the elderly population.
3. How did the Industrial Revolution result in previous caregiving approaches, such as care by families, friends, and neighbors,
becoming inadequate?
a. Economic and political wars resulted in frequent death and injuries.
b. Incredible plagues consistently and constantly swept the European continent.
c. Migration and urbanization resulted in increased demand for care.
d. Caregivers could easily find other employment, so they demanded to be paid.
ANS: C
Care became inadequate because of the social changes in Europe, with great advances in transportation, communication, and other
technologies. The increased mobility led to migration and urbanization, which in turn led to increased need for care. The Industrial
Revolution was a time of great advances in technology, transportation, and communication, not a time of economic and political
unrest or a time where incredible plagues occurred in Europe. Caregivers during this time period were typically poorly educated
and untrained, so there was not an issue related to wages or employment.
4. A colonist is working in the public health sector in early colonial America. Which of the following activities would have likely
been completed?
a. Establishing schools of nursing
b. Developing vaccines to administer to large numbers of people
c. Collecting vital statistics and improving sanitation
d. Developing public housing and almshouses
ANS: C
Collecting vital statistics and improving sanitation are examples of activities from the early colonial America. Establishing schools
of nursing, developing vaccines to administer to large numbers of people, and developing public housing and almshouses all
happened after the colonial period.
5. Why did American citizens become interested in establishing government-sponsored boards of health?
a. They were afraid of infectious diseases such as yellow fever.
b. The government could force the poverty-stricken to accept care.
c. Such boards could tax and thereby ensure adequate funds to pay for care.
d. Such a system would allow for accurate records of births and deaths.
ANS: A
Threat of disease, especially yellow fever, led to public interest in establishing government-sponsored, or official, boards of health.
The threat of disease was the impetus for creation of the boards of establishing boards of health. The primary interest of the boards
of health was to provide public health services for the entire population and not only those who were poverty-stricken. The primary
purpose of the boards of health was not to collect accurate vital statistics or receive tax dollars rather its purpose was to ensure the
health of the population.

6. A nurse was employed by the Marine Hospital Service in 1800. Which of the following interventions would the nurse most likely
have implemented?
a. Setting policy on quarantine legislation for immigrants
b. Establishing hospital-based programs to care for the sick at home
c. Identifying and improving environmental conditions
d. Providing health care for merchant seamen
ANS: D
Providing health care to seamen was an early effort by the federal government to improve public health. The purpose of the Marine
Hospital Service was to secure its maritime trade and seacoast cities. Quarantine legislation was enacted by legislation during this
time period, but the nurse would not have been responsible for setting these policies. Nursing care for clients in the home began in
the first half of the 1800s through a variety of agencies including the Ladies’ Benevolent Society of Charleston South Carolina.
Identifying and improving environmental conditions was a focus of the public boards of health, not necessarily specifically a role
of the nurse.
7. What was the outcome of the Shattuck Report?

a. Efforts to control alcohol and drug abuse, as well as tobacco use, were initiated.
b. Environmental sanitation efforts became an immediate priority.
c. Guidelines for modern public health organizations were eventually developed.
d. Local and state governments established boards of health after its publication.
ANS: C
It took 19 years for the first of Shattuck’s recommendations to be implemented, but his report was the first effort to create a modern
public health organization. This report called for broad changes to improve the public’s health to take place; however, these
changes did not happen immediately after publication. They took 19 years to be implemented in the first state of Massachusetts.
The report included establishment of a state health department and local health boards in every town, sanitary surveys, and food,
drug, and communicable disease control, but none of these changes happened quickly.
8. Which nurse is famous for creating public health nursing in the United States?
a. Florence Nightingale
b. Frances Root
c. Lillian Wald
d. Mrs. Solomon Loeb
ANS: C
Lillian Wald established the Henry Street Settlement and later emerged as the established leader of public health nursing during its
early decades. Mrs. Solomon Loeb was a wealthy layperson who assisted Mary Brewster in the establishment of the Henry Street
Nurses Settlement. Francis Root was the first trained nurse in the United States who was salaried as a visiting nurse. Florence
Nightingale had many accomplishments, but none of these occurred in the United States.
9. Which of the following would have been the focus of a school nurse in the early 20th century?
a. Investigating causes of absenteeism
b. Teaching school as well as being a nurse
c. Promoting nursing as an autonomous practice
d. Providing medical treatment to enable children to return to school
ANS: A
Early school nursing focused on investigating causes of absenteeism. Providing medical treatment was the responsibility of
physicians. School nurses did not teach in the schools nor were they part of an autonomous practice during this time period.
10. A nurse is reviewing the original work of the National Organization for Public Health Nursing. Which accomplishments of today
were started within this organization?
a. Requiring that public health nurses have a baccalaureate degree in nursing
b. Standardizing public health nursing education
c. Developing public health nursing competencies
d. Opening the Henry Street Settlement
ANS: B
The National Organization for Public Health Nursing sought to improve the educational and services standards of public health
nursing. The Henry Street Settlement was already in existence and was opened by Lillian Wald and Mary Brewster. The
baccalaureate degree in nursing was not developed yet. Public health nursing competencies were developed by the Quad Council.
11. Why were nurses so unprepared for public health nursing in the early 20th century?
a. Public health nursing had not yet been created as a field.
b. No one would teach the nurses how to engage in public health activities.
c. Nightingale’s textbook did not include content on public health nursing.
d. Nurses were educated in diploma schools, which emphasized care of hospital
clients.
ANS: D
Nursing school courses taught in diploma schools of nursing emphasized hospital care of patients; thus, nurses were unprepared for
home visiting. The specialty of public health nursing practice was developed in the early 1800s. There was not a lack of teachers
for this activity, rather the focus of nursing care was in the acute care setting and not in the community. Nightingale did not have a
published textbook.

12. A nurse is considering joining the American Public Health Association (APHA). What information about this organization should
be considered when making this decision?
a. APHA focuses on the public health concerns of the medical profession.
b. APHA represents concerns of nursing specialty practices.
c. APHA provides a national forum for nurses to discuss their public health
concerns.
d. APHA focuses on providing health promotion education to the public.
ANS: C
APHA was formed to facilitate interprofessional efforts and promote the “practical application of public hygiene.” The Public
Health Nursing Section within APHA provides nurses with a national forum to discuss their concerns and strategies within the
larger context of the major public health organization. It also serves as a focus of leadership and policy development for
community/public health nursing. The focus of public health concerns of the APHA is broader than only the medical profession.
The APHA focuses on concerns of public health nurses, not all nursing specialty practice. The APHA focuses on practical
application of public hygiene, which is broader than only health promotion education.
13. Why did the Metropolitan Life Insurance Company establish and retain for several years the first community nursing health
program for policyholders?
a. Creating such a service was the morally correct thing to do
b. Employing nurses directly was less expensive than paying taxes to the city for the
same purpose
c. Having the company’s nurses make home visits increased worker morale
d. Public health nurses visits led to fewer policyholder deaths and lowers company
costs
ANS: D
Metropolitan Life saw an average decline of 7% in the mortality rate of policyholders and almost a 20% decline in the deaths of
children under the age of 3 years. The insurance company attributed this improvement and the associated reduced costs to the work
of visiting nurses. There was limited funding in the early 20th century to extending nursing services in the community; thus, home
visiting was a very expensive service to provide. Although Metropolitan Life Insurance Company may have increased worker
morale that was not the primary reason for continuation of the program.
14. Which client would have been most likely to receive care from the Frontier Nursing Service?
a. An injured soldier
b. A homebound, elderly male
c. A woman in labor
d. A child with a broken femur
ANS: C
The Frontier Nursing Service nurses were trained in nursing, public health, and midwifery and provided care to rural and
inaccessible areas, which led to reduced mortality. Care for soldiers, elderly, and children was not the focus of the care provided by
the Frontier Nursing Service.
15. A public health nurse is determining what type of programming should be developed for the community. Which of the following is
the most crucial factor that will influence program development?
a. Comprehensive assessment and planning done in the community
b. Documented needs of the local community
c. Federal funding for priority diseases or groups
d. Nursing staff’s expertise and skills
ANS: C
Programs are designed to fit funding priorities; thus, the areas supported by Congress determine the categories in which most effort
is focused locally. A need in the community may be identified through community assessment, planning, and looking at needs in
the community; however, without funding there will not be a way to create necessary programming. The expertise of the staff
should not be the determining factor when deciding on programming in the community.
16. A nursing student during World War II would likely join which group?
a. The US Public Health Service
b. The Marine Nurse Corps
c. The Frontier Nursing Service
d. The Cadet Nurse Corps
ANS: D
The Bolton Act of 1943 established the Cadet Nurse Corps during World War II, which increased enrollment in schools of nursing
at undergraduate and graduate levels. The U.S. Public Health Service began to use nurses during World War I to establish a public
health nursing program for military outposts. The Marine Hospital Service was established well before World War II in 1798. The
Frontier Nursing Service was established by Mary Breckinridge in 1925 and provided health care to the rural and often inaccessible
populations in the Appalachian region of southeastern Kentucky.
17. A public health nurse is compiling information about how to promote early detection of breast cancer in women. Which document
would most likely provide useful information about this topic?
a. The Future of Public Health
b. Healthy People 2020
c. Patient Protection and Affordable Care Act
d. Scope and Standards of Public Health Nursing Practice
ANS: B
The Healthy People 2020 documents propose a national strategy to significantly improve the health of Americans by preventing or
delaying the onset of major chronic illnesses, injuries, and infectious diseases. The disarray resulting from reduced political
support, financing, and effectiveness is described in The Future of Public Health. The Scope and Standards of Public Health
Nursing Practice describes the processes of assessment, analysis, and planning that are carried out by the public health nurse. The
Patient Protection and Affordable Care Act improved access to health insurance for Americans.

18. A public health nurse is involved in health care reform. Which of the following best explains why the nurse is involved in these
efforts?
a. To promote the nursing profession
b. To increase funding for public health nursing
c. To address the concerns of nurses
d. To help improve health care access
ANS: D
Public health nurses have been involved in health care reform for several years. An emphasis of reform is that health promotion and
disease prevention appear to yield reduction in costs and illness/injury incidence while increasing years of healthy life. Health care
reform has a larger scope than only the profession of nursing and public health nursing. It addresses the concerns of nurses as well
as many other health care professions.
MULTIPLE RESPONSE
1. How did Florence Nightingale help bring about community health nursing? (Select all that apply.)
a. She convinced socially prominent wealthy women to volunteer to give care.
b. She focused on all soldiers and their environment.
c. She interacted with each individual person, assessing his or her needs and acting
to meet those needs.
d. She kept careful records on what was done and what were the results.
ANS: B, D
Nightingale progressively improved the soldiers’ health using a population-based approach that improved both environmental
conditions and nursing care. Using simple epidemiology measures, she documented a decreased mortality rate to demonstrate the
outcomes. While Nightingale was part of a wealthy family, the role of nurses during this time period was typically fulfilled by poor
women. The focus of Nightingale’s care was to identify health care needs and interventions that influenced the health of the entire
population, not individuals.
2. A nurse working with Mary Breckinridge would have likely assisted in what activity? (Select all that apply.)
a. Establishing the Henry Street Settlement
b. Developing health programs geared toward improving the health care of the rural
populations
c. Blazing a nursing trail through the Rockies, providing nursing care to miners and
their families
d. Ensuring positive outcomes for pregnancies among women in the Appalachian
region
ANS: B, D
Mary Breckinridge developed health programs geared toward improving the health care of the rural and often inaccessible
populations in the Appalachian regions of the Southern Kentucky. Breckinridge introduced the first nurse-midwives into the United
States when she deployed FNS nurses trained in nursing, public health, and midwifery. Their efforts led to reduced pregnancy
complications and maternal mortality, and to one-third fewer stillbirths and infant deaths in an area of 700 square miles. Lillian
Wald established the Henry Street Settlement. Mary Breckinridge developed health programs geared toward improving the health
care of the rural and often inaccessible populations in the Appalachian regions of southern Kentucky, not the Rockies.
3. How did nursing education change in the 1950s? (Select all that apply.)
a. Baccalaureate nursing programs typically included public health nursing
concepts.
b. Diploma schools of nursing continued to expand their student numbers.
c. Junior and community colleges began offering nursing programs.
d. Nurses were strongly encouraged to have a scientific basis for their practice.
e. Post diploma training was initiated nationwide.
ANS: A, C
In the 1950s, public health nursing became a required part of most baccalaureate nursing education programs. In 1952, nursing
education programs began in junior and community colleges. Associate degree programs began to expand their enrollments, not
diploma schools. The need for evidence-based practice continues to grow but was not a change in the 1950s. In 1914 Mary
Adelaide Nutting, working with the Henry Street Settlement, began the first course for post-diploma school training in public
health nursing at Teachers College in New York City.
4. How did health care and its delivery change during the 1980s? (Select all that apply.)
a. Funding to public health increased as funding for acute hospital care decreased.
b. Laws began to be passed that discouraged the use of alcohol, drugs, and tobacco.
c. Nurse practitioners were increasingly used to provide care.
d. Public health programs suffered reduced political support, financing, and
effectiveness.
ANS: B, C, D
During the 1980s funding began to shift to meet the costs of acute hospital care, medical procedures, and institutional long-term
care. The use of health maintenance organizations was encouraged, and the use of nurse practitioners increased. Consumer and
professional advocacy groups urged the passage of laws to prohibit unhealthy practices such as smoking and driving under the
influence of alcohol. By the late 1980s, public health had declined in political support, financing, and effectiveness.

Chapter 03: US and Global Health Care
MULTIPLE CHOICE
1. A public health agency is planning to implement the electronic health record. (Which is a benefit of this choice?
a. Facilitation of interprofessional care
b. Improved client compliance with medical regimens
c. Cost savings to the agency
d. Compliance with JCAHO standards
ANS: A
The electronic medical record facilitates interprofessional care in chronic disease management and coordination of referrals;
24-hour availability of records with downloaded laboratory results and up-to-date assessments; incorporation of protocol reminders
for prevention, screening, and management of chronic disease; improvement of quality measurement and monitoring; increased
client safety; and decline in medication errors. There is no evidence that an electronic health record improves client compliance
with medical regimens. Electronic health records can increase costs to an agency. JCAHO does not accredit public health agencies.
2. Which statement best describes the cost of health care in the United States?
a. Health care costs are kept low, and the indicators of health are among the best
worldwide.
b. Health care costs are low which has resulted in poor health outcomes.
c. Health care costs are the highest in the world, but the indicators of health are not
the best worldwide.
d. Health care costs and indicators of health are the highest in the world.
ANS: C
Health care costs in the United States are the highest in the world and comprise the greatest percentage of the gross domestic
product, the indicators of what constitutes good health do not document that Americans are really getting their money’s worth.
Health care costs are not low in comparison to the rest of the world. The health outcomes in the United States are poor in
comparison to other countries who spend less money on health care.
3. A nurse is explaining the health care system in the United States to a group of health care providers visiting from South America.
How would the nurse best describe the current health care system?
a. “It is a logical, rational approach to meeting expressed needs while still trying to
control costs.”
b. “It is a centralized system that provides care in hospitals.”
c. “It is divided primarily into two components: private health care and public health
care.”
d. “It is the best in the world with outstanding research and high-technology care
available to all.”
ANS: C
Health care in the United States consists of a private or personal care system and a public health system, with overlap between the
two. The United States health care system is one of the most expensive systems in the world that does not do a good job at
controlling costs. Care is provided through an enormous range of facilities and providers, including hospitals, physicians’ and
dentists’ offices, nursing homes, mental health facilities, ambulatory care centers, and freestanding clinics. Although there is great
research and high-technology care in the United States, the health care outcomes of the country do not reflect this. Health care
disparities exist among multiple populations making this system not available to all.
4. Which statement best describes ideal primary health care?

a. Based on a multidisciplinary group of health care providers that work as a team
b. Essential care available to all community members, which encourages
self-management
c. Focused on health promotion and disease prevention for everyone enrolled in the
health center
d. Local efforts to meet the Declaration of Alma Ata principles
ANS: B
Primary health care is generally defined as essential care made universally accessible to individuals, families, and the community.
Health care is made available to them with their full participation and is provided at a cost that the community and country can
afford. Public health is described as organized and multidisciplinary efforts aimed at preventing disease and promoting health, not
primary care. Primary care provides for the integration of health promotion, disease prevention, with curative and rehabilitative
services. The Declaration of Alma Ata was aimed at a world-wide, not local goal, to attain a level of health that permitted all
citizens of the world to live socially and economically productive lives.

5. How does managed care (MC) attempt to control costs of care?
a. By encouraging families to use the point of service list of individual practice
associates
b. By requiring families to choose a care provider from the MC network and not
allowing access to other services without their provider’s permission
c. By moving Medicaid-eligible families onto state Medicare enrollment
d. By refusing permission for families to use urgent care or emergency department
services
ANS: B
Managed care is a system in which care is delivered by a specific network of providers. Each provider serves as a gatekeeper who
controls access to other providers and services. Cost is reduced because members cannot use specialists or seek hospital or other
care without permission from their primary-care providers. Thus, those enrolled in Medicaid managed care have restrictions that
help keep costs down for government (and for taxpayers). Managed care provides care through a specific network of providers who
agree to comply with the care approaches established through a case management approach, not through a point of service list of
individual practice associates. Medicaid and Medicare programs are not interchangeable, these programs serve different
populations. Managed care does not refuse permission for certain services such as urgent care or emergency department, rather a
case management approach is used to control costs.
6. An 80-year-old woman comes to the community health care facility with a large bag of medications. She tells the nurse she can no
longer afford these medications because her only income is Social Security. Which statement is the best response by the nurse?
a. “Let’s go through these medications and see which ones we can delete.”
b. “You can get these medicines at this clinic for free.”
c. “Let’s see if we can get some help from Medicare to help you pay for these
medications.”
d. “These medications are important. Do your best to pay for them.”
ANS: C
This elderly patient probably is eligible for benefits through Medicare Part D. Medicare Part D has been added to Medicare to help
cover the cost of prescriptions. The role of the nurse would not be to delete medications for the patient or to tell the patient to figure
it out on her own. Because of the age of the patient, the nurse should see if options exist under the Medicare system before looking
into receiving the medications for free as there may be other barriers which limit the abilities to get these medications at a
discounted cost.
7. A nurse is determining which health care services must be offered at a local public health clinic. Which factor is most important for
the nurse to consider?
a. Data available from the most recent community assessment
b. Suggestions from community members about what is needed
c. Recommendations from Healthy People 2020
d. Services mandated by the state government
ANS: D
At the local level, health departments provide care that is mandated by state and federal regulations. Data available from the most
recent community assessment, suggestions from community members about need, and recommendations from Healthy People 2020
could all be used. However, funding for these types of programs may not be available. The services that are mandated by the state
government will be funded and allow the clinic to be able to provide these services.
8. A public health nurse is working with a low-income population in Massachusetts. Which of the following assumptions can the
nurse make about this population?
a. They have difficulty accessing health care due to a shortage of primary-care
providers.
b. They most likely receive health insurance through Medicare.
c. They are unable to access health care due to the implementation of the Affordable
Care Act.
d. They have access to affordable health care insurance.
ANS: D
Massachusetts began an experiment in health reform in 2006. Two years after health reform legislation became effective, only
2.6% were uninsured, the lowest percentage ever recorded in any state. The shortage of primary care providers is not significantly
different in Massachusetts than in other areas of the country. Low-income populations are eligible for Medicaid services, not
Medicare. The program in Massachusetts became a model for the Affordable Care Act.
9. A public health nurse is working with a client who does not have health insurance. Where will the nurse most likely direct the
client to in order to receive care?
a. Managed care
b. Community health center
c. Emergency department
d. Physician office
ANS: B
There is a safety net for the uninsured or underinsured. These are the federally funded community health centers which provide a
broad range of health and social services, using nurse practitioners and RNs, physician assistants, physicians, social workers, and
dentists. Community health centers serve primarily in medically underserved areas which can be rural or urban as well as people of
all ages, races, and ethnicities, with or without health insurance. Managed care is a system in which care is delivered by a specific
network of providers who agree to comply with the care approach, not a place to refer a client without health insurance. Emergency
departments and physician offices are not the best place for an individual without health insurance to receive care. Both are
expensive and do not provide the necessary resources for the individual to possibly receive health insurance.

10. Which of the following best describes why local, state, and federal governmental agencies have started to cooperate and collaborate
more closely in the last few years?
a. Increased administrative pressures to demonstrate outcomes
b. Increased focus on emergency preparedness and response
c. Increased taxpayers’ complaints and general unhappiness
d. Increased pressure to decrease overlap in services
ANS: B
Since the tragedy of September 11, 2001, health departments have increasingly focused on emergency preparedness and response.
In case of an emergency event, state and local health departments in the affected area will be expected to collect data and accurately
report the situation, to respond appropriately to any type of emergency, and to ensure the safety of the residents of the immediate
area, while protecting those just outside the danger zone. This goal—to enable public health agencies to anticipate, prepare for,
recognize, and respond to terrorist threats or natural disasters—has required an unprecedented level of interstate and f ederal-local
planning and cooperation among these agencies. Demonstrating outcomes and decreasing overlap of services are both important
factors to consider; however, this is not the reason why increased collaboration has occurred. There has not been an increase in
taxpayer complaints or unhappiness that has caused these changes to occur.
11. Minority nurses represented about 30.1 percent of the RN population. What is this an example of?
a. Projection
b. Disparity
c. Racism
d. A sentinel event
ANS: B
Disparities are racial or ethnic differences in the quality of health care or representation of a faction of the population, not based on
access or clinical needs, preferences, or appropriateness of an intervention. Projection is an estimate or forecast of a future situation
based on current trends. Racism is a prejudice that exists against someone of a different race based on the belief that one’s own race
is superior. A sentinel event is an unanticipated event in health care that results in death or serious injury to the pa tient.
MULTIPLE RESPONSE
1. A public health agency is in the process of obtaining accreditation. Which of the following best describes why the agency would
want to achieve accreditation? (Select all that apply.)
a. To improve health programming and services
b. To improve community relationships
c. To improve performance and quality
d. To improve management
e. To decrease cost of health care
ANS: B, C, D
The purpose of accreditation for public health departments is to assist and identify quality health department performance and
quality, and it develops leadership, improve management, and improve community relationships. Neither the improvement of
health care programming and services nor minimizing health care costs is a reason why a public health agency would want to
achieve accreditation.
2. What do demographic figures suggest about the ways in which the population of the United States is changing? (Select all that
apply.)
a. Foreign-born immigrant population is increasing.
b. Hispanics are the largest minority group population.
c. Leading causes of death are from infectious diseases.
d. Mortality for both genders in all age groups declined.
e. Unintentional injuries are among the top 10 causes of death.
ANS: A, B, D, E
The nation’s foreign-born population is growing, and it is projected that from now until 2050 the largest population growth will be
due to immigrants and their children. Although African Americans used to be the largest minority group, Hispanics now have that
distinction. The population of the United States continues to increase, and mortality for both genders from all age groups has
declined. The leading causes of death have changed from infectious diseases to chronic and degenerative diseases with
unintentional injuries being among the top 10.
3. Which of the following statements is accurate descriptions of current social and economic trends in the United States? (Select all
that apply.)
a. Citizens are appreciating the quality of life enjoyed in the United States.
b. Enjoying life is not as important as the need to take care of oneself.
c. People often spend a considerable amount of their own money on complementary
therapies.
d. The gap between the richest and poorest is widening.
e. The composition of families and living patterns are changing.
ANS: A, C, D, E
Several social trends that influence health care include changing lifestyles, a growing appreciation of the quality of life, the
changing composition of families and living patterns, changing household incomes, and a revised definition of quality health care.
People often spend a considerable amount of their own money for these types of therapies because few are covered by insurance. It
is obvious that the gap between the richest and poorest is widening because of the percent wage increase in the higher income
levels. Americans spend considerable money on health care, nutrition, and fitness, because health is seen as an irreplaceable
commodity. To be healthy, people must take care of themselves.

4. Which of the following provides evidence that the US health care system is in crisis? (Select all that apply.)
a. Health insurance is an expensive benefit for employers to provide.
b. Incompetent or negligent nurses are an ongoing source of medical errors.
c. Long work hours and provider fatigue are a major factor in medical errors.
d. More punitive measures must be taken to decrease provider errors.
e. Consumers want lower costs and high-quality health care without limits.
ANS: A, C, E
Consumers want lower costs and high-quality health care without limits and with an improved ability to choose providers and
services of their choice while employers are typically the purchasers of health care; they want to be able to obtain basic health care
plans at reasonable costs for their employees. Many employers have seen their profits diminish as they put more money into
providing adequate health care coverage for employees. Nurses working long hours pose a serious threat to patient safety because
fatigue slows reaction time, saps energy, and diminishes attention to detail. The Institute of Medicine’s (IOM) report To Err Is
Human recommends that we stop blaming and punishing individuals for errors and instead begin identifying and correcting system
failures by designing safety into the process of care. The report makes it clear that the majority of medical errors today were not
produced by provider negligence, lack of education, or lack of training.
5. A nurse is working at a state health department. Which of the following duties would most likely be completed in this setting?
(Select all that apply.)
a. Administering the Medicaid program
b. Assessing the health needs of the state’s citizens
c. Employing and supervising school health nurses
d. Establishing and maintaining child immunization clinics
e. Providing education regarding established health codes
ANS: A, B, E
State health departments try to prevent and respond to infectious disease outbreaks. They also are responsible for health care
financing and administering Medicaid, providing mental health and professional education, establishing health codes, licensing
facilities and personnel, and regulating the insurance industry. State health departments also give direct assistance to local health
departments in areas such as ongoing assessment of health needs. Employing and supervising school health nurses occur at the
local level, and many times within a specific school. Provision of child immunization clinics occurs at the local level.

Chapter 04: Government, the Law, and Policy Activism
MULTIPLE CHOICE
1. Which of the following best defines the word politics?

a. The art of influencing others
b. The outcome of governmental policies
c. A provision of power for making decisions
d. The result of legislative action
ANS: A
Politics is the art of influencing others to accept a specific course of action. Political action results in governmental policies and
legislation. The result of legislative action typically is done in the form of laws and policies. The provision of power for making
decisions is typically assumed by the government.
2. Which of the following activities is completed by the executive branch of the federal government?
a. Administration of policy
b. Interpretation of policy
c. Proposal of policy
d. Passage of policy
ANS: A
The executive branch administers and regulates policy. The legislative branch proposes policy (as bills) and passes policy (as laws).
The judicial branch interprets laws.
3. A nurse meets with a senator to lobby for passage of a bill to increase funding for interpreter services. With which of the following
branches of the government is the nurse working?
a. Constitutional branch of government
b. Executive branch of government
c. Legislative branch of government
d. Judicial branch of government
ANS: C
The legislative branch of government is composed of the Senate and the House of Representatives. The legislative branch identifies
problems and proposes and then debates, passes, and modifies laws to address those problems. There is not a constitutional branch
of the government. The executive branch administers and regulates policy. The judicial branch interprets laws.
4. Which of the following statements best describes why the federal government has become involved in health care?
a. The states asked the federal level to become involved.
b. Because of rising costs to the states, the federal budget needed to be used to pay
for necessary services.
c. The Constitution gives the federal government the power to promote the general
welfare.
d. This step was necessary to standardize care on a national level.
ANS: C
One of the first constitutional challenges to a federal law passed by Congress was in the area of health and welfare in 1937. The
Supreme Court (judicial branch) reviewed the legislation in question and determined, through interpretation of the Constitution,
that such federal governmental action was within the powers of Congress to promote the general welfare. According to Article I,
Section 8 of the US Constitution Congress has multiple roles in relation to health care: provide for the general welfare, regulate
commerce among the states, raise funds to support the military, and provide spending power. Thus, Congress was within its role to
become involved in health care and was not asked to do so by the states or used to standardize care on the national level.
5. A client states to the nurse, “I have heard the Affordable Care Act is supposed to help improve the health care I receive, but so far I
have seen no benefits from this legislation.” Which of the following statements would be the best reply by the nurse?
a. “Maybe you have not directly seen the changes; however, several things have
changed in health care because of this bill.”
b. “It will take years to see any effects from the act because of the delays in
implementation of the changes.”
c. “This legislation will primarily improve care for the elderly and poor populations,
so this is why you may not have seen any benefits.”
d. “The way health care operates at the federal and state levels has changed, so most
individuals will not see any direct impact.”
ANS: A
It is possible that unless one has been in a situation where changes have been made, that one may not realize any of the effects of
this law. The goal of the Affordable Care Act was to improve the health of the nation and access care. Several changes to health
care have already been made because of this legislation, and more changes will continue in the future. Multiple provisions of the
act will affect individuals and families.

6. What was the significance of the 1979 Surgeon General’s report?
a. It planned the goals and priorities for the entire Veterans Administration medical
system.
b. It vastly increased funding for health promotion activities.
c. It identified the use of tobacco as a cause of lung cancer.
d. It created national goals for promoting health and preventing disease.
ANS: D
The 1979 Surgeon General’s report began a focus on preventing disease and promoting health for all Americans. It was a national
effort with all levels of government, as well as other interested parties, involved. The 1979 report did not plan goals and priorities
for the Veterans Administration medical system; rather it looked at health of all Americans. There was no funding associated with
the report. It addressed prevention of disease and promotion of health for multiple diseases, not just lung cancer.
7. A nurse is advocating for the public health department to increase the number of public health nurses that it employs. Which of the
following factors should the nurse emphasize?
a. Providing disease investigation training
b. Providing research opportunities
c. Providing leadership experiences
d. Providing salaries commensurate with responsibilities
ANS: D
Through the input of the Division of Nursing’s National Advisory Council for Nursing Education and Practice (NACNEP), the
Division of Nursing sets policy for nursing nationally. A few of the factors indicated by the NACNEP that need to be in place to
support the public health nurse role are competitive salaries commensurate with responsibilities, experience in health promotion
and prevention, long-term trusting relationships in the community, and a commitment to social justice and eliminating health
disparities. The Division of Nursing’s National Advisory Council for Nursing Education and Practice (NACNEP) did not
emphasize the importance of providing disease investigation training, research opportunities, or leadership experiences.
8. A nurse is determining whether a hospital has the right to require infected patients to be isolated against their will. To which type of
law will the nurse refer?
a. Common law
b. Constitutional law
c. Legislation and regulation
d. Judicial law
ANS: B
Constitutional law provides the right to intervene in a reasonable manner to protect the health, safety, and welfare of the citizenry.
State power concerning health care is called police power. This power allows states to act to protect the health, safety, and welfare
of their citizens. The state must show that it has a compelling interest in taking actions, especially actions that might infringe on
individual rights. The state can isolate an individual to prevent an epidemic, even though this infringes on individual rights. The
community’s rights are deemed more important than the individual’s rights when there is a threat to the health of the public.
Judicial law, based on court and jury decisions, and the principles of common law (precedent, justice, fairness, respect for an
individual’s autonomy, and self-determination) are both used by court’s as the basis to make a decision and do not relate to having
the right to isolate a patient. Legislation is law that comes from the legislative branches of the government and regulations are
specific statements of law related to defining or implanting individual pieces of legislation. Neither are as important in this case as
the constitutional law of the police power of the states in regards to isolation of a patient.
9. Who is responsible for determining the scope of practice for registered nurses?
a. American Nurses Association
b. Federal legislators
c. State legislators
d. US Department of Health and Human Services
ANS: C
Health care practitioners are subject to the laws of the state in which they practice. The state nurse practice acts define the practice
of professional nursing, identify the scope of nursing practice, set educational qualifications, and determine legal titles. The nurse
practice act is governed by legislators in each state. The American Nurses Association, US Department of Health and Human
Services, and federal government do not determine the scope of practice for nurses; this responsibility is the role of state
governments. The US Department of Health and Human Services is the agency most heavily involved with the health and welfare
of US citizens.
10. Which of the following statements by a client indicates a lack of understanding regarding an appropriate reason to sue for
professional negligence?
a. “Because the health care workers didn’t turn my mother every 2 hours, she
developed bedsores.”
b. “I received permanent nerve damage because they would not remove a cast that
was too tight.”
c. “My daughter wasn’t given a call light, and for a whole shift no one checked on
her condition.”
d. “They amputated the wrong leg during surgery.”
ANS: C
Professional negligence, or malpractice, is defined as an act (or failure to act) that leads to injury. All of the choices specify an
injury, except for “My daughter wasn’t given a call light, and for a whole shift no one checked on her condition,” in which case the
care was substandard but no injury resulted. The incorrect responses all specify an injury whereas professional negligence, or
malpractice, is defined as an act (or failure to act) that leads to injury.

11. Which of the following statements best describes the law in relation to clinical practice by nursing students?
a. Students are considered certified until licensure is obtained.
b. Students are expected to meet the same standard of care as the professional nurse.
c. Students are not legally liable for errors because they practice under the license of
their instructor.
d. Students have a scope of practice determined by the nurse practice act.
ANS: B
Nursing students need to be aware that the same laws and rules that govern the professional nurse apply to them as well. Students
are expected to meet the same standard of care as that met by any licensed nurse practicing under the same or similar
circumstances. Although it is true that students cannot practice outside the scope of practice determined by the nurse practice act,
they also cannot perform the tasks and responsibilities of the licensed practitioner within the scope of practice until they have
received adequate knowledge; therefore, the scope of practice for the student is determined by the instructor, based on the student’s
level of education.
12. A nurse wishes to see a bill passed to support funding for the use of interpreters for clients with limited English proficiency. Which
of the following would be the best time for the nurse to request support from the local senator, who is not on the committee that is
reviewing this bill?
a. When the bill is first assigned to a committee.
b. When the bill is discussed and debated within the committee.
c. When the bill moves out of committee to be heard by the entire Senate.
d. When the bill passes the Senate and moves to the House of Representatives.
ANS: C
Once the bill is passed by committee and moves out of committee to be heard by all senators, it will be important to contact this
senator, who will then be in a position to act on it. To contact the senator when the bill is first assigned to the committee or is being
discussed and debated within the committee is too early to effectively influence the individual senators. The nurse would not want
to wait until after the vote has been taken in the Senate because it would then be too late for the senator to act.
13. The state board of nursing has written new regulations to clarify in a more concrete manner what the nurse practice act allows and
requires. Which of the following effects will this change have on nurses in this state?
a. None, because they are just helpful guidelines for maximum safety.
b. None, because they just give specifics that may change over time.
c. Major, because prudent nurses would follow such regulations.
d. Major, because these rules and regulations have the effect of law and must be
obeyed.
ANS: D
When the legislature passes a law and delegates its oversight to an agency, it gives that agency the power to make regulations.
Because regulations flow from legislation, they have the force of law. Whether prudent or not, nurses are obligated to practice
consistent with these regulations. All nurses have the responsibility to follow the changes that are in place by legislation. They are
laws that must be followed, not guidelines.
14. A bill with the potential to decrease health care services is passed by Congress. Which of the following actions should the nurse
take to influence the bill’s implications?
a. Exercise veto power by calling for petitions from health care agencies.
b. Contact the regulatory agency and participate in public hearings.
c. Call members of congress to request that they rescind the legislation that was
passed.
d. Discuss the change in services with the administrators at the hospital.
ANS: B
Once a bill is passed and becomes law, it is too late to influence congressional members to change their vote; however, it is not too
late to influence the outcome of the vote because the nurse can influence how the law is regulated. An agency typically writes the
regulations that control how the law is implemented in more specific detail. Often this process can be just as important as lobbying
against a bill because it shapes the final implementation of the law. Health care agencies do not have the ability to veto a bill. After
a bill has been passed, it is too late to contact members of congress. Calling the hospital will not change the implications of the bill.
Contact must be made with the regulatory agency in order to influence how the law is regulated.
15. Which of the following agencies has the most influence on the health and welfare of US citizens?
a. Agency for Healthcare Research and Quality (AHRQ)
b. Centers for Disease Control and Prevention (CDC)
c. US Department of Health and Human Services (USDHHS)
d. World Health Organization (WHO)
ANS: C
As the agency to which most health care legislation is delegated, the USDHHS is the agency most heavily involved with the health
and welfare of citizens. The AHRQ and CDC are divisions of the USDHHS. WHO’s policy-making body provides policy options
and guides but not laws. In the textbook, only the USDHHS is discussed regarding its responsibility for Medicare and Medicaid
through the Centers for Medicare and Medicaid Services (CMS).

16. Which of the following laws established programs for provision of health services for women and children and supported
community-oriented nursing practice?
a. Early Periodic Screening and Developmental Testing (EPSDT) Initiative
b. Healthy People 2000 Initiative
c. Sheppard-Towner Act
d. State Child Health Improvement Act (SCHIP)
ANS: C
The Sheppard-Towner Act of 1921 played an important role in the development of public health policy, public health nursing, and
social welfare policy. Of particular importance was the fact that it established standards for programs to serve women and children
and made nurses available to provide these services in the community setting. Within the Sheppard-Towner Act was a provision to
start the EPSDT initiative. SCHIP provides insurance for children and families who cannot otherwise afford health insurance.
Healthy People 2000 focuses on promoting health and preventing disease for all Americans.
MULTIPLE RESPONSE
1. Which of the following describes the significance of the passage of The Public Health Threats and Emergencies Act? (Select all
that apply.)
a. It funded ongoing activities of the public health system.
b. It led to improved water quality and food safety guidelines.
c. It included funding for public health activities.
d. It validated that the public health system was prepared for terrorism.
e. Expanded the role of Secretary of HHS to include aspects of public health
emergencies.
ANS: B, C
The Public Health Threats and Emergencies Act was the first federal law to comprehensively address the public health system’s
preparedness for bioterrorism and other infectious disease outbreaks and signaled the beginning of renewed interest in public health
as the protector for entire communities. The focus of this law was to address emerging threats to the public’s health and authorize
the Secretary of HHS to take appropriate response actions during a public health emergency, including investigations, treatment,
and prevention. A focus was the improvement of water quality and food safety. It did not support the ongoing activities of public
health. It did not validate the public health system was prepared for terrorism.
2. Which of the following best describes the importance of the World Health Organization (WHO) to the United States? (Select all
that apply.)
a. Provides daily information on disease occurrences.
b. Establishes international standards for antibiotics and vaccines.
c. Creates international legislation regarding international cooperation.
d. Supports national programs to fight disease when asked to do so.
e. Monitors for adverse drug reactions.
ANS: A, B, D, E
Some WHO services that benefit all countries (including the United States) are providing day-to-day information service on the
occurrence of internationally important diseases; publishing the international list of causes of disease, injury, and death; monitoring
adverse reactions to drugs; and establishing international standards for antibiotics and vaccines. Individual countries can request
assistance with strengthening the delivery of health services, supporting national programs to fight disease, and training health
workers—which the United States does not. WHO can suggest but cannot legislate to individual countries.
3. Which of the following activities is the responsibilities of the Centers for Disease Control and Prevention (CDC)? (Select all that
apply.)
a. Conduct research to enhance disease prevention.
b. Detect and investigate infectious disease problems.
c. Develop public health policies.
d. Publish national goals for promoting health and preventing disease.
e. Serves as an advocate of public health polices
ANS: A, B, C, E
The mission of the CDC is to promote health and quality of life by preventing and controlling disease, injury, and disability. To
monitor health, the CDC will detect and investigate health problems, conduct research that will enhance prevention, and develop
and advocate sound public health policies and other prevention strategies. The safety and health of the workplace is the specific
responsibility of OSHA. The CDC cannot write or pass legislation. The USDHHS published national health goals in Healthy
People 2020.
4. A nurse is visiting a state legislator to encourage the legislator to vote for a particular health bill that the state n urses association has
endorsed. Which of the following actions would be most important for the nurse to complete? (Select all that apply.)
a. Encourage the legislator or staff to ask relevant questions.
b. Be friendly and engage in small talk so that rapport can be established.
c. Be aware that legislators are well informed; don’t insult the legislator by stating
information that is obvious.
d. Have a handout that summarizes all the major points in support of the bill.
ANS: A, D
Legislators might not be well informed about every issue, so they need and want important information. The nurse should allow
time for questions or clarifications of information shared and have the material on a handout for the legislator’s convenience. It is
also helpful to invite the legislator to attend nursing conferences or meetings where health issues will be discussed. The nurse
should not waste time with small talk but briefly present his or her stand, emphasizing other nurses who support the bill, because
numbers count. Legislators might not be well informed about every issue, so they need and want important information that the
nurse can provide.

5. A nurse would like to become involved in political action. Which of the following actions would be most appropriate for the nurse
to accomplish this goal? (Select all that apply.)
a. Become a member of the state nurses association.
b. Be friendly with everyone, whether supportive or not of your ideas.
c. Focus on being appointed to the state level committees.
d. Focus all your efforts on your specialty practice area and your employment site.
e. Volunteer to serve on relevant committees.
ANS: A, B
A nurse wishing to become politically involved should begin by joining the state nurses association, networking with others
involved, and volunteering to serve on committees or in offices. Be friendly and network to increase your knowledge beyond your
own workplace or specialty and seek opportunities to share expertise with others. Becoming involved locally is a good opportunity
to start becoming involved in political action and allows for networking at the local level. Seeking opportunities beyond one’s
workplace or specialty area allows the nurse to gain additional knowledge and share expertise in specialty area with others.
6. A nurse is testifying at a committee meeting about a health bill. Which of the following actions should be taken by the nurse?
a. Briefly describe professional education.
b. Discuss how the bill affects more than just nurses.
c. Include factual data and, if possible, statistical information in visual form.
d. Provide written proof of personal and professional qualifications
e. Provide information about relevant expertise and related experience.
ANS: A, B, C, E
Language must be simple and carefully chosen to convey information to listeners and to avoid professional jargon. The nurse must
share a bit of personal education, experience, and expertise to be seen as a credible source, but written proof of credentials is not
necessary unless specifically requested. The testimony must go beyond just nursing’s interest and include accurate, credible data.
The data must be accurate and credible which may not be the case when getting names from the media.

Chapter 06: Ethics in Public and Community Health Nursing Practice
MULTIPLE CHOICE
1. Which of the following is generally considered to be nursing’s first code of ethics?

a. Nightingale Pledge
b. Code for Professional Nurses
c. Code of Ethics for Nurses
d. Principles of the Ethical Practice of Public Health
ANS: A
The Nightingale Pledge is generally considered to be nursing’s first code of ethics. After the Nightingale Pledge, the Code for
Professional Nurses was formally adopted by the ANA House of Delegates in 1950. It was amended and revised five more times,
until, in 2001 the ANA House of Delegates adopted the Code of Ethics for Nurses with Interpretive Statements. The Principles of
the Ethical Practice of Public Health was approved in 2002.
2. A nurse didn’t know what to do when faced with a particular ethical dilemma because an option that would have a good outcome
didn’t seem possible. The nurse decided to talk to the agency supervisor and decide what action to take. Which of the following
best describes the nurse’s actions?
a. Appropriate, because the supervisor is responsible for the nurse’s choices.
b. Intelligent, because the supervisor has access to resource persons (clergy,
physicians, administrators) who might know of options the nurse hadn’t
considered.
c. Justified, because this provides an opportunity to discuss the issue but the nurse
maintains responsibility for the decision.
d. Wise, because the supervisor would be more knowledgeable concerning agency
priorities and traditional practices.
ANS: C
Ethically, each nurse is responsible for his or her own decisions and cannot avoid ethical accountability by relying on obedience to
a supervisor or any external rule or policy. The supervisor is not responsible for the nurse’s choices, the nurse must maintain
responsibility for his/her own decisions. The nurse should have access to the same resources as the supervisor and should have
similar knowledge as the supervisor.
3. Which of the following is the first and most crucial step in a generic ethical decision-making process?
a. Assess the context or environment in which the decision must be made.
b. Consider the various ethical principles or theories.
c. Identify the ethical issues and dilemmas.
d. Make a decision and act on it.
ANS: C
The first step in the ethical decision-making framework is to identify the ethical issue or dilemma. After the first step of identifying
the ethical concern, the following steps are: (2) place the ethical issue or dilemma within a meaningful context, (3) obtain all
relevant facts, (4) reformulate ethical issues or dilemmas, if needed, (5) consider appropriate approaches to action or options, (6)
make the decision and take action, and (7) evaluate the decision and action.
4. A nurse is asked to meet with a family who recently immigrated from Botswana (Africa). After the physician tells the husband the
wife’s diagnosis of breast cancer, the family thanks the physician and starts to leave. Ethically, which of the following is the
nurse’s most important action?
a. Emphasizing that the family must set up a surgical appointment for the wife
immediately
b. Assessing the family’s current living situation, including insurance and other
assets
c. Educating the family concerning the usual treatment and the prognosis of breast
cancer
d. Interviewing the family concerning their perspective of the threat to the family’s
well-being
ANS: D
The United States is a multicultural nation with diverse ethnic groups and diverse values. Before any intervention can be made, the
health care professionals must understand the family’s cultural, psychological, social, communal, and environmental contexts,
because these contexts affect the way issues are formulated and decisions are made. Consequently, it is crucial to interview the
family to determine their understanding of the situation before deciding what, if any, intervention must be made. In many cultures,
the family, rather than the individual, is the unit of primary concern. Setting up a surgical appointment immediately would not be
an appropriate action for the nurse to take as this would be a premature action for anyone who has just been told that she has
cancer. Assessing the family’s current living situation would not be the first concern of the nurse; the first concern should focus on
the family’s well-being. After assessing the family’s well-being, the next action of the nurse may be to educate the family about the
treatment and prognosis of breast cancer.

5. The nurse learns that a family has declined an elective medical intervention for a health care problem because paying for the care
would drastically reduce the family’s resources and ability to meet the needs of other family members. Ethically, which of the
following actions should be taken by the nurse?
a. Appreciate that the family has made the decision that it feels is best and take no
further action if it is clear the family has made an informed choice.
b. Stress that each individual in society has a right to health care and the family will
have to create some way to raise funds for the needed treatment.
c. Talk to the media to see whether a campaign to raise funds for the family can be
created.
d. Try to convince the agency to give the care for free, even if it means economic
stress for the agency, because the medical need is obvious.
ANS: A
According to Callahan, although the nurse may attempt moral persuasion to change the family’s values, in the absence of
immediate and grievous harm, no ethical requirement exists to interfere with the family’s values. Because there is no immediate or
grievous harm, it is not in the best interest of the nurse to interfere with the family’s decision. Thus, the other answers are not an
appropriate action for the nurse to take.
6. Some nurses are debating about the appropriate action to take in relation to a particular family. The father is ill, and the other
family members have chosen to continue working rather than take time off to care for the ill family member. One nurse states, “It is
a wife’s responsibility to care for an ill husband.” Which of the following ethical approaches is being used by this nurse?
a. Consequentialism
b. Communitarianism
c. Deontological ethics
d. Principlism
ANS: C
The nurse is focusing on duty, which is a deontological approach based on the moral obligation to engage in certain actions. The
nurse is focusing on duty, which is a deontological approach based on the moral obligation to engage in certain actions. Based upon
this understanding, none of the other options correctly describes the nurse’s statement.
7. Some nurses are debating about the appropriate action to take in relation to a particular family. One member of the family is ill, and
the other family members have chosen to continue working rather than take time off to care for the ill family member. One nurse
states, “The whole family is being affected and will fall apart if they don’t focus on their family’s needs first before anything else.”
Which of the following ethical approaches is being used by this nurse?
a. Communitarianism
b. Deontology
c. Principlism
d. Utilitarianism
ANS: D
By focusing on the whole family, not individual members, and the consequences or outcomes for the whole family during this time
of stress, the nurse is taking a utilitarian approach. Principlism relies on these ethical principles to guide decision-making.
Communitarianism is similar to virtue ethics and looks at the relationship and responsibility between the individual and the
community. The ethical approach of deontology describes adhering to moral rules or duty rather than to the consequences of the
actions.
states, “But it doesn’t have to be an either/or situation. Perhaps each family member could take a turn calling in sick just 2 or 3
days. That way they could all take a turn at helping and yet not upset their employers. Wouldn’t that be fair?” Which of the
following ethical approaches is being used by this nurse?
a. Communitarianism
b. Deontology
c. Principlism
d. Utilitarianism
ANS: C
The nurse is focusing on ethical principles—in this case, beneficence (do good for the ill family member), nonmaleficence (do no
harm, even to the employer), and justice (everyone takes a turn and shares equally). Communitarianism is similar to virtue ethics
and looks at the relationship and responsibility between the individual and the community. The ethical approach of deontology
describes adhering to moral rules or duty rather than to the consequences of the actions. Utilitarianism is a consequentialist ethical
theory associated with outcomes or consequences in determining which choice to make.
states, “It’s not up to us; it’s the family’s decision. They know what is best for them.” Which of the following ethical approaches is
being used by this nurse?
a. Communitarianism
b. Deontology
c. Principlism
d. Utilitarianism
ANS: C
The nurse is using an ethical principle, namely autonomy, in which each person or group can choose those actions that fulfill its
values and goals. Therefore, the nurse is using Principlism—that is, basic principles are the basis of the nurse’s actions.
Communitarianism is similar to virtue ethics and looks at the relationship and responsibility between the individual and the
community. The ethical approach of deontology describes adhering to moral rules or duty rather than to the consequences of the
actions. Utilitarianism is a consequentialist ethical theory associated with outcomes or consequences in determining which choice
to make.

10. Which of the following is the dominant issue in ethical debate around an issue such as continuing or withdrawing treatment in acute
health care?
a. Doing what is best for the community
b. Doing what is best for the family
c. Obeying legal mandates
d. Upholding ethical principles
ANS: D
In acute care settings with a single localized issue, the primary ethical principles are usually applied, with patient a utonomy being
the dominant or most crucial principle. Upholding ethical principles should be the first consideration before obeying legal mandates
or doing what is best for the community or family.
11. The staff cannot reach an agreement on what is the right thing to do in relation to a specific patient. Which of the following
approaches should the nurse use in personally deciding what is right?
a. Do whatever will not get the nurse in trouble with employer.
b. Do whatever is supported by an ethical expert, such as the hospital chaplain.
c. Do whatever the nurse would recommend to anyone in a similar situation.
d. Do whatever the nurse supervisor would feel comfortable reporting to
administration.
ANS: C
One of the rules in deontological decision-making is to determine whether the proposed actions can be generalized so that all
persons in similar situations are treated similarly. In the same way, Principlism suggests the nurse examine the context and make
the decision that can be morally justified within that context. In order to apply the deontological ethics decision process, the nurse
must first determine the moral rules that serve as standards by which individuals can perform their moral obligations, examine their
own personal motives, and then determine whether the proposed actions can be generalized. Doing whatever will not get the nurse
in trouble, whatever is supported by an ethical expert, or whatever the nurse supervisor feels comfortable with is not an appropriate
way to make an ethical decision.
12. A man entered the emergency department bleeding profusely and screaming, “I’ve got to see a doctor right now! I’ve got a right to
see a doctor! I’m hurt. You have to take care of me!” Which of the following premises would ethically justify such a demand for
immediate attention?
a. All hospitals receive federal money and all capable employed adults pay taxes, so
all adults have a right to what their tax money has purchased.
b. Saving an individual’s life improves society and upholds tradition.
c. Our society believes that all persons should be treated equally and that basic
needs, such as not dying if death can be avoided, should be met.
d. The man has a property right to his own body, and the government is responsible
to ensure that property rights are protected.
ANS: C
The ethical theory of egalitarianism suggests that everyone is entitled to equal rights, equal treatment, and an equal share of the
goods of society—and that the government’s role is to ensure this happens, at least on a basic level. Therefore, the man has a right
to emergency care. Hospital funding and use of taxpayer money does not demonstrate the use of an ethical principle. Saving an
individual’s life may or may not improve society. There is not an ethical principle that states that the man has a property right to his
own body.
13. From an ethical standpoint, what is the problem with the belief that everyone should receive his or her fair share, that life should
always be fair, and that everyone should make his or her own decisions?
a. With this belief, the needs of society as a whole are ignored.
b. Insufficient resources exist to give everyone a fair share.
c. This belief leads to a propensity for some people to like to be taken care of.
d. Some people think they deserve more than others.
ANS: A
All principles of justice focus on the individual, which ignores the needs of society as a whole. The rights of an individual may
conflict with the rights of the community as a whole. It is recognized that distribution should be based on what needs and deserves
there is considerable disagreement that exists when considering what these terms mean in the context of fairness.
14. A health care provider refuses to order pain medication for a drug addict who has been severely injured in a car accident. When
reminded by nurses that pain medication has not been ordered, the provider merely replies that the patient’s suffering from the pain
of his injuries will build character and that the addicted patient needs to get off drugs. Which of the following ethical theories is
being using (or misusing)?
a. Consequentialism
b. Communitarianism
c. Deontological ethics
d. Virtue ethics
ANS: D
Virtue ethics emphasizes practical reasoning applied to character development. Although such action by a care provider is
paternalistic and unethical on many grounds, the physician may truly be concerned with enabling the injured addict to learn from
his experience and possibly develop into a drug-free person. Communitarianism is similar to virtue ethics and looks at the
relationship and responsibility between the individual and the community. When decisions are based on outcomes or consequences,
it is known as consequentialism. The ethical approach of deontology describes adhering to moral rules or duty rather than to the
consequences of the actions.

15. Which of the following is considered the most important goal in nursing today?
a. Adapting to technological advances such as electronic medical records
b. Demonstrating caring as the basis of nursing practice
c. Distinguishing nursing care from medical care
d. Seeking evidence-based outcomes to demonstrate nursing’s contribution to care
ANS: B
Since the mid-1980s, nurses have written about caring as the essence of nursing and as the ethical and moral ideal of nursing
practice. Caring is part of the core values of public health nursing and addresses the importance of the fiduciary relationship
between the patient and the care provider. The primary goal of nursing is not to adapt to technological advances, distinguish
nursing from medical care, or seek evidence-based outcomes; rather, the goal of nursing is to implement caring which has been the
moral ideal of nursing for many years.
16. With which of the following ethical approaches are Gilligan and Noddings associated?
a. Distributive justice approach
b. Feminine ethic
c. Principlism approach
d. Virtue ethics
ANS: B
Gilligan and Noddings are associated with the approach known as the feminine ethic, which focuses on the morality of
responsibility in relationships that emphasize connection and caring as a moral imperative. Distributive justice (fair distribution of
the benefits and burdens of society), Principlism (relying on ethical principles for decision- making), and virtue ethics (seeking to
enable persons to flourish as human beings) were not developed by Gilligan and Noddings.
17. How are ethics and public policies similar?

a. Both are abstract principles that often differ in actual practice.
b. Both are best achieved by persons in high political office who can effect change.
c. Both strive for the public good.
d. Both use general principles in making decisions.
ANS: C
An important goal of both policy and ethics is to achieve the public good, and both are involved in good citizenship. Ethics
involves the application of specific principles when making decisions. There is nothing that supports that ethics and public policies
are better achieved by those in high political office.
18. A new nurse states to a nursing colleague, “But why do I have to be involved in politics? I just want to be the very best clinical
nurse I can.” Which of the following would be the best response from the nursing colleague?
a. “As long as you pay your membership fee to the American Nurses Association,
you have participated in the profession’s political endeavors.”
b. “Political action is the way you try to fulfill your ethical responsibilities to
clients.”
c. “You’re absolutely right; if you are good clinically, you have fulfilled your
obligation.”
d. “When you’ve completed your clinical orientation, then you’ll have time to be
involved in politics.”
ANS: B
To be a good clinical nurse, the nurse needs resources and supportive policies that can be obtained only through political action to
ensure those very resources and policies. Many clients are members of vulnerable groups who have often previously lacked access
to quality care at an affordable cost. The American Nurses Association Code of Ethics for Nurses emphasizes political action as the
mechanism to affect social justice and reform regarding homelessness, violence, and stigmatization. Nurses need to be involved in
the political process in more ways than only being a dues paying member to the American Nurses Association. Clinical practice is
not the same as political involvement; political involvement is necessary to achieve the advocacy role of the nurse. Nurses must
make a conscious effort to be involved in political action.
19. Which of the following would confirm that the nurse’s advocacy has been truly successful or effective?
a. Audiences agree with the nurse who is serving as advocate.
b. Legislators discuss appropriate legislation to better allocate resources.
c. People verbalize that the disenfranchised should be better treated.
d. Systematic social changes are made to improve quality of life.
ANS: D
Advocacy is the application of information and resources to effect systematic changes that shape the way people in a community
live to reduce death and disability and improve quality of life in the community. Only when systematic social changes are made to
improve quality of life can advocacy be considered truly effective. Systematic change encompasses the complete role of the nurse
as an advocate. Audiences do not necessarily have to agree with the nurse who is serving as advocate as different populations may
have different views than the nurse. Advocacy goes beyond only working with legislators to allocate resources. Serving those who
are disenfranchised is only one part of the advocacy role.
20. How can nurses know whether they have been effective in assessing the community and planning and implementing appropriate
interventions?
a. Ask community leaders for their opinion of the interventions.
b. Examine the morbidity and mortality rate of the community.
c. Reassess the community to determine whether obvious needs have been met.
d. Systematically survey community residents regarding their perception.
ANS: B
The end products of appropriate advocacy are decreased morbidity and mortality. In other words if advocacy has been effective,
public health problems will be decreased. Effectiveness cannot be assessed accurately by asking community leaders for their
opinions, reassessing the community, or surveying community members regarding their perception; data must be collected to
determine results.

21. How can ethics be applied to public health nursing practice?
a. Ethics and actual nursing practice are not related.
b. Knowing ethics allows nurse to recognize the source of most problems.
c. Ethics is constantly involved in nurses’ clinical decisions.
d. Although ethics is important, political and legal responsibilities are more
important in practice.
ANS: C
Ethical problems in public health nursing include inequities in power, unacceptable practices, inequitable resource allocation,
conflict between ethics and law, and inadequate systems support for nursing. Therefore, ethics permeates every aspect of public
health nursing as nurses attempt to meet the needs of the community. Ethical principles are applied in nursing practice on a regular
basis and assist with problem-solving. The use of ethics does not allow the nurse to recognize the source of most problems. The
used of ethics is more important than political and legal responsibilities in practice.
MULTIPLE RESPONSE
1. Three nurses disagree over the appropriate treatment for a woman who is an excellent candidate for hospice care. The first nurse
believes that deciding on care rather than cure is the woman’s decision and no one else can decide for her. The second nurse says
that it is the responsibility of the health care team to do good for the woman, and if the physician thinks there is still a possibility of
cure, then the nurses should do everything they can to implement the treatment plan. The third nurse states that it isn’t fair for the
family members to expend all their resources on the woman, who is probably going to die anyway. Which of the following
conclusions can be drawn from this dispute? (Select all that apply.)
a. Ethical principles can conflict with one another.
b. The nurses are each using different ethical approaches.
c. The first nurse is correct because autonomy demands that the woman decide for
herself.
d. There is no single accepted approach for resolving such disagreements.
ANS: A, B, D
One of the criticisms of using ethical principles is that they can conflict with one another in any given situation. No rule exists for
helping resolve such conflicts. Each nurse can apply different ethical principles to reach their own ethical decision. Because there is
no one rule to assist with solving an ethical conflict, and ultimately no one right answer, there is not a correct decision that can be
made.

Chapter 07: Culture of Populations in Communities
MULTIPLE CHOICE
1. Which of the following best describes most Americans’ attitude toward immigrants?
a. Ambivalence, because there are no clear solutions about how to address their
needs.
b. Strongly negative, because immigrants take jobs that native-born Americans
could have instead.
c. Strongly positive, because immigrants bring useful job skills and often join
previous family members already in the United States.
d. Strong opposition to further immigration, because of the increasing population in
the United States.
ANS: A
Most Americans are ambivalent about immigration, recognizing both the positive and negative aspects involved and realizing that
it is a complex issue that has no clear solutions. Because Americans are ambivalent, there is neither a strong negative nor a positive
attitude toward immigrants. However, many times immigrants do enter the United States because they have useful job skills or
family ties. They are more likely to be low-income workers who work in low-wage, blue-collar jobs and industries.
2. Earlier in the week, a nurse carefully taught a patient from a different culture exactly how much medication to take and emphasized
the importance of taking the correct amount. However, the patient is back in the hospital today with symptoms of an overdose
although the patient denies taking more than the label indicated. Which of the following is the most likely explanation?
a. The patient was taking more mediation in the hope of getting well faster.
b. The patient was also taking folk medicines that had many of the same effects and
perhaps some of the same ingredients as the prescribed medication.
c. The patient truly did not understand and thought the dose being taken was correct.
d. The patient had a unique response to the medication and should have a smaller
dose ordered.
ANS: B
For fear of disapproval, a person may not tell the nurse that he or she is using folk medicine as well as Western medication. The
two medicines may have cumulative effects that could be dangerous to the client. Nurses who lack cultural knowledge may develop
feelings of inadequacy and helplessness because they are often unable to effectively help their clients. It is unlikely that the patient
was taking too much medication, taking the incorrect dose, or having a unique reaction to the medication. Rather the nurse should
first interview the patient about use of folk medicine which may interact with the prescribed medication regimen.
3. A nurse wishes to develop cultural competence. Which of the following actions should the nurse take first?
a. Complete a survey of all the various ethnicities represented in the nurse’s
community.
b. Consider how the nurse’s own personal beliefs and decisions are reflective of his
or her culture.
c. Invite a family from another culture to join the nurse for an event.
d. Study the beliefs and traditions of persons living in other cultures.
ANS: B
Cultural awareness requires self-examination and an in-depth exploration of one’s own beliefs and values as they influence
behavior. Cultural awareness is the first element in the model of cultural competence. Following the development of cultural
awareness, the next step is cultural knowledge in which information about organizational elements of diverse cultures and ethnic
groups is collected. The next stage of the model, cultural skill, occurs with the effective integration of cultural awareness and
cultural knowledge to obtain relevant cultural data and meet the needs of culturally diverse clients. The fourth construct essential to
this model is cultural encounter, which is the process that permits nurses to seek opportunities to engage in cross-cultural
interactions with clients of diverse cultures to modify existing beliefs about a specific cultural group.
4. A nurse is caring for a client of another culture. Which of the following actions would be the most appropriate for the nurse to take?
a. Alter personal nonverbal behaviors to reflect the cultural norms of the client.
b. Keep all behaviors culturally neutral to avoid misinterpretation.
c. Rely on friendly gestures to communicate caring for the client.
d. Avoid any pretense of prejudice by treating the client in the same way as any
other client.
ANS: A
Cultural competence in nursing includes adoption of culturally congruent behaviors. Culturally skillful nurses use appropriate touch
during conversation, modify the physical distance between themselves and others, and use strategies to avoid cultural
misunderstandings while meeting mutually agreed-upon goals. Nurses who strive to be culturally competent are expected to respect
other cultures and value diversity. These behaviors tend to provide more responsive care. Nurses should be knowledgeable of other
cultures and communicate with the client based on cultural norms. Culturally skillful nurses understand the unique difference
among individuals within a given culture and work with those individuals to learn more about their culture and provide culturally
sensitive care.

5. A male nurse had a habit of sitting with the lower part of one leg resting over the knee of his opposite leg when collecting a client’s
history. He stopped doing this around specific clients after being told that they were offended when he exposed the sole of his foot
(shoe) to their face. Which of the following was exhibited by the nurse when he changed his behavior?
a. Cultural accommodation
b. Cultural imposition
c. Cultural re-patterning
d. Cultural skill
ANS: D
Cultural skill is the effective integration of cultural knowledge and awareness to meet client needs—in this case, the clients need to
not be offended by having the bottom of the nurse’s foot or shoe in view of the client’s face. The nurse using cultural skill makes
sure that nonverbal communication techniques take into consideration the client’s use of body language and space. Cultural
accommodation involves negotiation with clients to include aspects of their folk practices with the traditional health care system to
implement essential treatment plans. Cultural imposition is the process of imposing one’s values on others. Cultural re-patterning is
working with clients to make changes in their health practices if cultural behaviors are harmful or decrease their well-being.
6. The nurse practitioner (NP) discovered that an immigrant client is not taking the penicillin prescribed because his illness is “hot”
and he believes that penicillin, a “hot” medicine, will not provide balance. Which of the following terms best describes the action
taken by the NP when the client’s prescription is changed to a different yet equally effective antibiotic?
a. Cultural awareness
b. Cultural brokering
c. Cultural knowledge
d. Cultural skill
ANS: C
Cultural knowledge is information about organizational elements of diverse cultures and ethnic groups; emphasis is on learning
about the client’s worldview from an emic (native) perspective. Cultural skill involves the provision of care that is beneficial, safe,
and satisfying to the client. The medication change allows the client to retain his cultural beliefs and also satisfies the nurse
practitioner’s need to prescribe an effective antibiotic. Cultural awareness is the self-examination and in-depth exploration of one’s
own biases, stereotypes, and prejudices that influence behavior. Cultural brokering is advocating, mediating, negotiating, and
intervening between the client’s culture and the biomedical health care culture on behalf of clients.
7. An immigrant who takes metamizole (banned in the United States) for pain may experience life-threatening agranulocytosis. Which
of the following actions would be taken by a nurse who employs cultural re-patterning?
a. Complete a cultural assessment to identify any other dangerous medications that
the client may be taking.
b. Put this into perspective by considering that many drugs used in the United States
cause agranulocytosis.
c. Explain the harmful effects of metamizole and recommend an alternative
medication for pain.
d. Recognize that taking metamizole is common among persons living in Mexico
and accept this as a cultural tradition.
ANS: C
Cultural re-patterning means that the nurse works with clients to help them reorder, change, or modify their cultural practices when
the practice is harmful to them. Completing a cultural assessment involves learning more about the client’s culture but does not
address the need to consider changing or modifying cultural practices. In order to complete cultural re-patterning, the nurse has to
take an action to resolve this potential problem.
8. A health care worker tells a nurse, “It does no good to try to teach those Medicaid clients about nutrition because they will just eat
what they want to no matter how much we teach them.” Which of the following is being demonstrated by this statement?
a. Cultural imposition
b. Ethnocentrism
c. Racism
d. Stereotyping
ANS: D
Stereotyping occurs when someone attributes certain beliefs and behaviors about a group to an individual without giving adequate
attention to individual differences. In this instance, the health care worker makes the assumption that clients with low incomes are
not educable. The health care worker is guilty of making another assumption as well: noncompliance among other Medicaid clients
the worker has known may have been related to an inability to afford nutritious food. Cultural imposition is the belief in one’s own
superiority, or ethnocentrism, and is the act of imposing one’s values on others. Ethnocentrism is a type of cultural prejudice at the
population level which involves the belief that one’s own group determines the standards for behavior by which all other groups
should be judged. Racism refers to the belief that persons who are born into a particular group are inferior in intelligence, morals,
beauty, or self-worth.
9. An American nurse says, “I’m not going to change the way I practice nursing based on where the client is from because research
shows that Western health care technology and research is best.” Which of the following is being demonstrated by the nurse’s
statement?
a. Ethnocentrism
b. Prejudice
c. Racism
d. Stereotyping
ANS: A
Ethnocentrism, a type of cultural prejudice at the cultural population level, is the belief that one’s own group determines the
standards for behavior by which all other groups are to be judged. For example, some American nurses and providers may think,
“The way we do it is the only right way to provide this care.” Prejudice refers to having a deeply held reaction, often negative,
about another group or person. Racism refers to the belief that persons who are born into a particular group are inferior in
intelligence, morals, beauty, or self-worth. Stereotyping occurs when attributing certain beliefs and behaviors about a group to an
individual without giving adequate attention to individual differences.

10. A nurse states, “The best way to treat a client from another country is to care for them the same way we would want to be cared for.
After all, we are all humans with the same wants and needs.” What does this statement reflect in relation to culture?
a. Awareness
b. Blindness
c. Knowledge
d. Preservation
ANS: B
Cultural blindness is the tendency to ignore differences between cultures and to act as if they do not exist. People from different
cultures may have different expectations, wants, and needs. Cultural awareness is the self-examination and in-depth exploration of
one’s own biases, stereotypes, and prejudices that influence behavior. Cultural knowledge is information about organizational
elements of diverse cultures and ethnic groups; emphasis is on learning about the client’s worldview from an emic (native)
perspective. Cultural preservation means that the nurse supports and facilitates the use of scientifically supported cultural practices
from a person’s culture along with those from the biomedical health care system.
11. A Spanish-speaking family comes to the public health department. No one in the family speaks English, and nobody at the health
department speaks Spanish. Which of the following actions should be taken by the nurse?
a. Attempt communication using an English–Spanish phrase book.
b. Call the local hospital and arrange a referral.
c. Emphatically state, “No hablo Español” (I don’t speak Spanish).
d. Obtain an interpreter to translate.
ANS: D
Communication with the client or family is required for a careful assessment. When nurses do not speak or understand the client’s
language, they should obtain an interpreter. The nurse must use strategies that will allow effective communication with the client.
The client has the right to receive effective care, to judge whether the care was appropriate, and to follow up with appropriate
action if the expected care was not received. The nurse must contact an interpreter in order to provide the best care for the
client—attempting communication using a book, stating that he or she does not speak English, and arranging for a referral do not
address the priority action of finding an interpreter.
12. A nurse who is explaining to an immigrant client why it is important to take medication states, “The medication takes a couple of
weeks to be effective, but then you should feel better.” When the client is next seen, no medication has been purchased. Which of
the following is the most likely explanation?
a. The nurse emphasized that eventually the client would feel better, but the client
needed to feel better immediately so didn’t bother with the drug.
b. The medication required a trip to the pharmacy, and the client just hadn’t had
time to obtain the drug yet.
c. The medication was too expensive for the client’s family.
d. The client really hadn’t understood why the medication was important.
ANS: A
If we look closely at what the nurse stated, there may have been a cultural disconnect based on time perception. Many nurses are
future oriented, whereas many families may place greater value on quality of life and view present time as being more important.
When nurses discuss health promotion and disease prevention strategies with persons from a present orientation, they should focus
on the immediate benefits these clients would gain rather than emphasizing future outcomes. The cultural disconnect of time should
be the immediate concern of the nurse. It is possible that the client did not have the necessary resource or did not understand the
importance of the medication, but the nurse should first investigate the potential cultural disconnect.
13. A client is crying softly and saying, “What did I do to deserve this punishment, Lord?” Which of the following responses by the
nurse would be the most appropriate?
a. “God doesn’t punish people. You’re sick just because of bad luck.”
b. “I can call the hospital chaplain to help you talk about these feelings.”
c. “What can I do to be helpful to you right now?”
d. “Would you like to confess your sins and repent so this illness will go away?”
ANS: C
Some clients may view their illness as punishment for misdeeds and may have difficulty accepting care from nurses who do not
share their beliefs. Because the nurse may not be a member of the client’s religious faith group, an open-ended response showing
caring is the most appropriate statement. The most therapeutic response from the nurse is an open-ended question. This allows the
client to share information and not feel like his or her actions are being judged by the nurse. Also, this allows the nurse to not give
advice or offer false information to the client.
14. A patient who identifies as Buddhist enters the hospital for diagnostic testing just before lunch time. The nurse tells the aide to give
a meal tray to the new patient, because no tests will be done until later that evening. The aide gives the patient a meal of Salisbury
steak, bread, green beans, and potatoes with brown gravy. The patient eats nothing but a slice of bread and the green beans. Which
of the following considerations was omitted by the nurse?
a. The patient should not be served any food until a primary care provider’s order is
obtained.
b. The patient’s Buddhist faith probably requires a vegetarian diet.
c. The patient may be too frightened about the tests to want to eat very much.
d. The patient may have diabetes or be allergic to some foods.
ANS: B
Although it is always wise to check with a patient before sending in food, the meal given to this patient was offensive. Most
Buddhists are vegetarians and don’t eat meat. The nurse should be aware of the cultural considerations that should be made for
Buddhist patients. The nurse should ask the client about dietary restrictions before ordering a meal for the client so that these
considerations can be made. The nature of the test determines the fasting requirements; no order is needed. Whether the client is
diabetic or allergic to some foods should be determined upon admission.

15. At a local hospital, the postpartum care policy requires that nurses observe the mother during infant care to assess the mother’s
ability to care for the new baby and to promote bonding. A new mother expresses concern that in her country, all infant care is
provided by other family members so that the mother can rest and recover. Which of the following actions would be taken by a
culturally competent nurse?
a. Allow family members to provide the newborn’s care and assess the mother’s
knowledge of child care through discussion.
b. Reinforce the importance of bonding and that all good mothers gladly assume
these responsibilities.
c. Explain that the process of postpartum recovery does not require this much rest
and require that she provide infant care.
d. State that she must abide by hospital policy because documentation of the
mother’s ability to give the infant care is required for discharge.
ANS: A
Culturally competent nursing care focuses on the specific patient, reflects the patient’s individual beliefs and values, and is
provided with sensitivity. The nurse should accept the cultural norms and behaviors of this client and her family. Thus, the nurse
should provide culturally competent care and comply with the client’s desire. This should take priority over any judgments the
nurse could make about this client or hospital documentation related to infant care by the mother. This respect of culture makes the
other options incorrect.
16. For a bedridden Muslim patient, the nurse rearranges the room and moves the bed so that it faces toward Mecca for the patient’s
daily prayers. Which of the following is the nurse demonstrating through these actions?
a. Accommodation
b. Awareness
c. Brokering
d. Imposition
ANS: A
Cultural accommodation involves including aspects of the patient’s religious beliefs and/or folk practices in the traditional health
care system to implement essential treatment plans. For this patient, daily prayer in the tradition of Islam is important—from the
patient’s perspective, possibly more important than medical treatment. Cultural awareness is the self-examination and in-depth
exploration of one’s own biases, stereotypes, and prejudices that influence behavior. Cultural brokering is advocating, mediating,
negotiating, and intervening between the client’s culture and the biomedical health care culture on behalf of clients. Cultural
imposition is the belief in one’s own superiority, or ethnocentrism, and is the act of imposing one’s values on others.
17. A nurse gives detailed information on how to apply for Medicaid to a new mother who moved to the United States from Russia
about 10 years ago. The nurse’s next client is an African-American mother of newborn twins who worked until the children were
born. The nurse knows the woman is eligible to maintain her insurance after her employment was lost and does not discuss
insurance options at all. Which of the following errors is being made by the nurse?
a. Covert intentional prejudice
b. Covert unintentional prejudice
c. Overt intentional prejudice
d. Overt unintentional prejudice
ANS: C
The nurse may have assumed that the African-American mother knew the available resources and could negotiate for assistance on
her own and that the immigrant Russian woman had no experience negotiating government programs and thus needed the nurse to
advocate for her and inform her of the programs available to her. The nurse, not knowing the health-seeking behaviors of either
client, stereotyped both women and intentionally used her informational power to help one client while denying assistance to the
other client. Covert prejudice involves subtle or passive acts of prejudice. This can occur intentionally or unintentionally. In this
case, the actions of the nurse were intentional, which means it was an overt behavior. Overt prejudice includes any action that
intends to give unequal treatment to an individual or group. Given the scenario, it appears that the action of the nurse was
intentional, not unintentional.
18. A 40-year-old Bosnian, Muslim woman who does not speak English presents to a community health center in obvious pain. She
requests a female health care provider. Through physical gestures, the woman indicates that the pain is originating in either the
pelvic or genital region. Which of the following interpreters would be the most appropriate in this situation?
a. A Bosnian male who is certified as a medical interpreter
b. A female from the client’s community
c. A female who does not know the client
d. The client’s 20-year-old daughter
ANS: C
Although having experience in medical interpretation is important, in many cultures it is inappropriate to have a male interpreter
for females. This client has specifically requested a female provider; therefore, one might anticipate that the client will not be as
forthcoming with a male interpreter. Regardless of certification and ability, the interpreter cannot interpret information the client
may withhold because she feels it inappropriate to discuss private matters in front of a male. This client may also feel it
inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or if they involve
infidelity). Additionally, to avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community
as the client.

19. When teaching a nutrition class to a student group with a large Latino population, the school nurse incorporates foods such as salsa
and other healthy dishes familiar to students into the presentation. Which of the following best describes the action taken by the
nurse?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Both primary and secondary preventions
ANS: A
Primary prevention involves activities such as health teaching to prevent a problem from occurring. Secondary prevention occurs
when a nurse completes screenings. Tertiary prevention occurs after a problem has occurred and aims to restore the client to the
highest level of functioning as possible.
MULTIPLE RESPONSE
1. An undocumented immigrant comes to a primary care provider’s office to receive care. Which of the following services can the
client receive? (Select all that apply.)
a. Treatment for tuberculosis
b. Treatment for type 2 diabetes
c. Immunization for polio
d. Physical examination
e. Sutures for a laceration
ANS: A, C, E
Undocumented immigrants or illegal aliens are individuals who have crossed a border into the United States illegally or whose
legal permission to stay in the United States has expired. They are eligible only for emergency medical services, immunizations,
treatment for the symptoms of communicable diseases, and access to school lunches. Undocumented immigrants are not eligible to
receive treatment for chronic diseases such as type 2 diabetes or physical examinations.
2. A nurse recognizes that although a patient speaks English, the patient is from a culture with which the nurse is unfamiliar.
Therefore, a cultural assessment should be attempted. Which of the following questions should the nurse ask? (Select all that
apply.)
a. “Can you tell me where your family is from?”
b. “Do you practice a particular religious faith?”
c. “What other countries have you lived in?”
d. “Is there anything special we need to know about your food preferences?”
e. “What do you think is causing your health problem?”
ANS: A, B, D, E
In a general cultural assessment, nurses ask clients about their ethnic background, language, education, religious affiliation, dietary
practices, family relationships, hospital experiences, occupation and socioeconomic status, cultural beliefs, and language. Nurses
want to also ask about the client’s perception of the health issue and what caused it and how it should be treated as well as the
results they expect from the care they get. Such basic data help nurses understand the client from the client’s point of view and
recognize what is unique about the person, thus avoiding stereotyping. Knowing the other countries that the client has lived in may
be helpful; however, necessary information about the client’s culture should be able to be collected through broad questions about
the client’s culture.

Chapter 08: Environmental Health
MULTIPLE CHOICE
1. A nurse wants to have a better understanding of the physiological effects of selected chemicals. Which of the following individuals
would provide the most useful information to the nurse?
a. Chemist
b. Epidemiologist
c. Pharmacist
d. Toxicologist
ANS: D
Toxicology is the basic science that studies the health effects associated with chemical exposures. A chemist, epidemiologist, or
pharmacist would probably be able to provide some information, but the toxicologist would most likely provide information related
to physiological processes.
2. A nurse wants to find information about environmental threats that are present in the community. Which of the following would be
the best source of data for the nurse?
a. Cumulative Index of Nursing and Allied Health (CINAHL) database
b. National Library of Medicine
c. State health department
d. Closest local library
ANS: B
Technology helps us understand environmental threats. The National Library of Medicine (NLM) databases are user-friendly and
accessible on the Internet. The NLM website provides access to medical databases such as PubMed and GratefulMed, which can be
searched for possible environmental linkages to illnesses using key terms. The CINAHL database provides access to literature
related to nursing and allied health journals and would not be as comprehensive as the National Library of Medicine. It would be
difficult to access information easily through the health department. The information that is available at the local library would be
dependent on the community in which one lived.
3. A nurse is assessing potential environmental health risks in the community. Which of the following would be the first step that the
nurse should take?
a. Conduct health risk assessments of randomly selected individuals.
b. Perform a windshield survey.
c. Review facility permits and consumer confidence reports.
d. Survey community members.
ANS: B
Conducting a windshield survey is a useful first step to understanding potential environmental health risks. This provides firsthand
information about the community and areas of concern that must be investigated. Conducting health risk assessments of randomly
selected individuals or surveying community members does not give the nurse a good assessment of potential environmental health
risks of the entire community. Reviewing facility permits and consumer confidence reports would not provide enough information
to assess the environment of a community.
4. A community citizen reports to the public health nurse that the city water in one neighborhood has had an unusual taste for the past
few months. Which of the following actions should the nurse take first?
a. Check the most recent consumer confidence report.
b. Consult the Centers for Disease Control and Prevention.
c. Notify the Environmental Protection Agency (EPA).
d. Place a call to the poison control center.
ANS: A
The consumer confidence report (also known as the right-to-know report) reports the condition of drinking water. Because this is
only one citizen, whose sense of taste may be affected by many conditions, it would not be appropriate to overreact by calling in
governmental agencies or poison control first. Even so, in case one needed to contact an authority, it would be appropriate to start
with local governmental agencies such as the city water department rather than federal agencies.
5. A nurse who works at the local hospital asks a public health nurse what might be causing her hands to become very sore and
sensitive. Which of the following statements would be the most appropriate response by the public health nurse?
a. “Ask the staff in employee health if there have been any other complaints.”
b. “Call the local health department about any recent problems at the hospital.”
c. “Check the material safety data sheet on any chemicals you have used recently.”
d. “See the nurse’s health care provider for a complete work-up.”
ANS: C
Employees have the right to know about hazardous chemicals with which they work. Employers must maintain a list of all
hazardous chemicals used on the premises, along with a material safety data sheet that addresses health risks related to these
chemicals, as well as information about safe use and handling. After checking the material safety data sheets, the next steps would
be to connect with a health care provider which could include staff in employee health, a local health department, or one’s own
health care provider. The first step should be to determine what exposure occurred.

6. Which of the following statements about children and environmental hazards is correct?
a. The prevalence of autism is directly related to the increase in environmental
toxins.
b. Children are more susceptible to environmental toxins because of their smaller
size.
c. The incidence of asthma among children has been decreasing.
d. Children are more susceptible to cancer if they have a family history of the
disease.
ANS: B
Because of the smaller size of children, they are exposed to higher doses of pesticide residues in the foods they eat and drink.
Infants and young children drink more fluids per body weight than adults, and this increases the dose of contaminants in their
drinking water, milk (hormones and antibiotics), and juices (particularly pesticides). Only a small percentage of childhood cancers
are associated with heredity. However, exposure to ionizing radiation increases the risk of childhood leukemia and possibly other
cancers. All of the causes of autism spectrum disorder are not currently known. Environmental factors are thought to be a possible
cause, as are biologic and genetic factors. Asthma is common among children, and the strongest risk factors are genetic factors and
inhaled substances and particles that provoke an allergic reaction or irritate the airways. Indoor air quality is a grow ing concern
because of the alarming rise in the incidence of asthma in the United States, particularly among children.
7. Which of the following actions represents the use of secondary prevention to reduce environmental health risks?
a. Collecting blood specimens from preschool children to check for lead levels
b. Meeting with local government officials to request that the city clean up a
hazardous vacant lot
c. Referring a child with toxic lead levels to a neurologist
d. Teaching parents of a 2-year-old about the dangers of lead-based paint in older
homes
ANS: A
Secondary prevention refers to actions such as surveillance and screening, which are undertaken so that problems may be detected
at early stages. Meeting with local government officials to request that the city clean up a hazardous vacant lot and referring child
with toxic lead levels to a neurologist are examples of tertiary prevention as the problem already exists. Education to avoid
exposure is part of primary prevention which relates to teaching parents about the dangers of lead-based paint in older homes.
8. An occupational health nurse at a local factory is using primary prevention strategies to reduce the environmental health risks
among the employees. Which of the following activities would the nurse most likely implement?
a. Checking radiation detectors to monitor for unsafe levels of radiation exposure
b. Irrigating the eyes of an employee who has had a chemical splash to the face
c. Teaching new employees who will work outdoors about the signs and symptoms
of heat-related illness
d. Using spirometry to rule out obstructive or restrictive lung disease for workers
who will be wearing mask respirators
ANS: C
Education is a primary preventive strategy. When examining the sources of environmental health risks in communities and
planning intervention strategies, it is important to apply the basic principles of disease prevention. Checking radiation detectors and
using spirometry are both examples of screening for potential exposure which is part of secondary prevention. Irrigating the eyes of
an employee who had a chemical splash to the face addresses tertiary prevention as a problem has already occurred.
9. A nurse wants to help keep the community environment safe. Which of the following is the most appropriate action for the nurse to
take?
a. Conserve water by bathing less often.
b. Downsize to a smaller living space.
c. Reduce, reuse, and recycle.
d. Replace all his or her appliances with new energy-efficient ones.
ANS: C
All persons can engage in minimizing their impact on the environment by reducing, reusing, and recycling the individual products
they currently consume. Although it would be nice to replace all appliances for energy-efficient newer models, most people can’t
afford that—furthermore, it is an environmental issue to discard the used models. Similarly, downsizing to a smaller living space
could help the environment, because the nurse would use less energy, but again, not everyone can afford all the expenses involved
in moving.
10. Which of the following best describes the purpose of local health departments making unannounced inspections of local
restaurants?
a. To enforce local laws and regulations
b. To ensure compliance
c. To provide oversight to potential exposure
d. To monitor employee safety
ANS: B
Ensuring compliance refers to the process of making certain that permitting requirements are met. Although this activity may be
seen as a type of monitoring, the question asks for the purpose, which is to ensure compliance. Enforcement involves penalties such
as fines or facility closure.

11. A city has announced its plans to build a city dump near a community of poor and predominantly African-American citizens.
Which of the following principles would the nurse be using when vocalizing opposition for this plan?
a. Environmental justice
b. Environmental epidemiology
d. Risk communication
ANS: A
Environmental justice is the goal of campaigns seeking to improve the unequal burden of environmental risks borne by
impoverished and minority communities. The Environmental Justice Act would be used in support of the nurse’s position.
Environmental epidemiology is concerned with the discovery of environmental exposures that contribute or protect against disease
or illness which is not accomplished by the nurse vocalizing opposition to the plan. Vocalizing opposition to the plan would not be
a tertiary prevention strategy as the nurse is addressing a problem that does not yet exist. Risk communication includes general
principles of good communication (right information, to the right people, at the right time). In this scenario, the nurse is vocalizing
opposition, not communicating risks.
12. A nurse is completing a basic health assessment. Which of the following questions should be asked by an environmentally aware
nurse?
a. “Is anyone else in your family having these symptoms?”
b. “How many people live in your home?”
c. “What jobs have you held the longest?”
d. “Where did you live 10 years ago?”
ANS: C
An exposure history should identify current and past exposures, have a preliminary goal of reducing or eliminating current
exposures, and have a long-term goal of reducing adverse health effects. The “I PREPARE” mnemonic consigns the important
questions to categories that can be easily remembered. Asking about previous employment helps to answer the “P” of past work.
The other questions do not address the topics identified in the “I PREPARE” mnemonic (investigate potential exposures, present
work, residence, environmental concerns, past work, activities, referrals, and resources, and educate).
13. A high school student considering a job in the restaurant industry after graduation asks a nurse about workplace safety issues.
Which of the following acts would the nurse most likely discuss with the student?
a. Chemical Safety Information, Site Security, and Fuels Regulatory Act
b. Comprehensive Environmental Response, Compensation, and Liability Act
c. Food Quality Protection Act
d. Occupational Safety and Health Act
ANS: D
The Occupational Safety and Health Act (OSHA) was passed to ensure worker and workplace safety in all employment settings,
including restaurants. The Chemical Safety Information, Site Security, and Fuels Regulatory Act, Comprehensive Environmental
Response, Compensation, and Liability Act, and Food Quality Protection Act may contribute to safety but do not have the full
oversight of OSHA.
14. The nurse is examining blood lead levels in school-age children 1 year after a community-wide education intervention. Which of
the following phases of the nursing process is being implemented?
a. Assessment
b. Diagnosis
c. Intervention
d. Evaluation
ANS: D
In this instance, the nurse is evaluating the results of the intervention to determine whether goals were reached. Assessment would
have been done earlier in the process because this was needed to determine that a problem existed and that interventions were
needed. Diagnosis occurs when the disease and environmental factors are related to the diagnosis. When intervention is used, the
nurse coordinates medical, nursing, and public health actions to meet the client’s needs.
15. A nurse practitioner has established a mobile clinic to vaccinate adults against influenza. Which of the following phases of the
nursing process is being implemented?
a. Assessment
b. Planning
c. Intervention
d. Evaluation
ANS: C
Giving immunizations is an intervention that will increase the number of people who will be vaccinated. Intervention includes
coordinating medical, nursing, and public health actions to meet the client’s needs. Assessment would have been done earlier in the
process because this was needed to determine that a problem existed and that interventions were needed. Planning occurs when the
nurse looks at community policy and laws as methods to facilitate the care needs for the client. When criteria that includes the
immediate and long-term responses of the client as well as the recidivism of the problem for the client are examined, it is part of the
evaluation phase.

MULTIPLE RESPONSE
1. A public health nurse is assisting the community in dealing with the effects of lead paint poisoning. Which of the following
activities would the nurse most likely complete? (Select all that apply.)
a. Administering medications to those with signs of lead poisoning
b. Assessing community members for any health problems
c. Setting up a blood screening program with the local health department
d. Encouraging local landlords to improve the condition of their housing
e. Educating the public on the dangers of lead paint
ANS: C, D, E
The nurse’s role is to understand the roles of each respective agency and organization, know the public health laws, and work with
the community to coordinate services to address the community’s needs. Other needed interventions include organizing a
blood-lead screening program through the local health department, educating local health providers to encourage them to
systematically test children for lead poisoning, and working with local landlords to improve the condition of their housing stock.
Educating the community of the hazards of lead paint falls within the roles of the public health nurse. Administering medications to
those with signs of lead poisoning is not a typical role of the nurse when dealing with lead poisoning. Assessing community
members for any health problems is too broad of an intervention and does not address the specific need of the nurse working with
lead poisoning in the community.
2. Which of the following are the major sources of air pollution in the United States? (Select all that apply.)
a. Burning of fossil fuels
b. Waste incineration
c. Wood burning fireplaces
d. Motor vehicles
e. Coal-fired power plants
ANS: A, B, D, E
Motor vehicles are the greatest single source of air pollution in the United States. The burning of fossil fuels (diesel, industrial
boilers, and power plants) and waste incineration are two other major contributors. Wood burning fireplaces are not one of the
major sources of air pollution that has been identified.
3. A nurse wants to use the principles of risk and outrage to improve an environmental hazard in the community. To accomplish this,
which of the following actions would be taken by the nurse? (Select all that apply.)
a. Advertise in the media throughout the entire surrounding area.
b. Communicate the correct information in a timely fashion.
c. Share all the data found on the community assessment.
d. Talk to those affected or those worried about the situation.
e. Conduct a community-based survey to identify risks.
ANS: B, D
The correct information must be given in a language the audience—namely those at risk or worried about the risk—can understand.
Use the communication channels the neighborhood residents use and meet at a common meeting place of the community. A survive
is appropriate, but the question is focused on distribution of the found information. It is wasteful of resources to advertise in media
throughout a wider region or to meet at a central regional facility when only community residents will be interested or involved.
Sharing all the data would be overwhelming, and much of the data might not be relevant. Using epidemiological statistics would
not be meaningful to those without the education or experience to be able to draw an appropriate conclusion.
4. Which of the following strategies would a nurse expect to be implemented by a typical state environmental agency? (Select all that
apply.)
a. Acting, through unannounced inspections, to ensure compliance
b. Completing a community assessment
c. Monitoring hazardous substances to uphold established standards
d. Obtaining and analyzing samples to confirm compliance
e. Involvement in the permitting process established by the state
ANS: A, C, D, E
The organization and approach to environmental protection vary somewhat among states, but the common essential strategies of
prevention and control via the permitting process, establishment of environmental standards, and monitoring, as well as compliance
and enforcement, are found in every state. Completing a community assessment is not a strategy that is typically implemented by a
state environmental agency, rather that typically occurs at the local level.
5. Which of the following actions would a nurse take when serving as an advocate for the community? (Select all that apply.)
a. Asking questions related to health implications at policy meetings
b. Calling the local health department to report problems at the hospital
c. Serving as a source of information at public meetings
d. Volunteering to serve on health-related committees
e. Conducting a health-related screening at a day care center
ANS: A, C, D
Advocacy roles of the community-oriented nurse include attending policy meetings to obtain health-related information, holding
public meetings (or serving on panels at meetings) to provide health-related information, serving on health-related committees, and
informing local media about environmental hazards in the community. Calling the local health department to report problems at the
hospital and conducting a screening at a local day care center do not demonstrate the nurse advocating for the community as the
hospital and the day care do not represent the entire community.

Chapter 10: Epidemiological Applications
MULTIPLE CHOICE
1. A nurse is using analytic epidemiology when conducting a research project. Which of the following projects is the nurse most
likely completing?
a. Reviewing communicable disease statistics
b. Determining factors contributing to childhood obesity
c. Analyzing locations where family violence is increasing
d. Documenting population characteristics for healthy older citizens
ANS: B
Epidemiology refers not only to infectious epidemics but also to other health-related events. The goal of analytic epidemiology is to
discover the determinants of outcomes—the how and the why. Analytic epidemiology looks at the etiology (origins or causes) of
disease. It discusses the disease in terms of how and why. Descriptive epidemiology considers health outcomes in terms of what,
who, where, and when. It discusses a disease in terms of person, place, and time.
2. A nurse is employed as a nurse epidemiologist. Which of the following activities would most likely be completed by the nurse?
a. Eliciting the health history of a client presenting with an illness
b. Evaluating the number of clients presenting with similar diseases
c. Performing a physical examination of an ill client
d. Providing treatment and health education to a client with a disease
ANS: B
Epidemiology monitors the health of the population by examining measures of morbidity, especially incidence proportions,
incidence rates, and prevalence proportions and learning about the risk for disease, the rate of disease development, and the levels
of existing disease in a population, respectively. Epidemiology differs from clinical medicine, which focuses on the diagnosis and
treatment of disease in individuals.
3. Which of the following actions by Florence Nightingale demonstrates her role as an epidemiologist?
a. She convinced other women to join her in giving nursing care to all the soldiers.
b. She demonstrated that a safer environment resulted in decreased mortality rate.
c. She obtained safe water and better food supplies and fought the lice and rats.
d. She met with each soldier each evening to say goodnight, thereby giving
psychological support.
ANS: B
Nightingale examined the relationship between the environment and the recovery of the soldiers. Using simple epidemiological
measures, she was able to show that improving environmental conditions and adding nursing care decreased the mortality rates of
the soldiers. Nightingale used statistics to document decreased mortality rates when the environmental factors were improved.
Asking other women to assist with providing nursing care, obtaining safe water, and meeting with each soldier are not interventions
that demonstrate the use of epidemiology (the relationship between the health events and the determinants or factors that influence
those patterns).
4. Which of the following statements describes how nursing in the community is more challenging than nursing in an acute care
setting?
a. There is limited access to information useful to the nurse in giving care in the
community.
b. More paperwork and forms are required when giving care in the home.
c. It is more challenging to control the environment in the community.
d. Specialization isn’t possible in the community setting.
ANS: C
In the community, nurses often use epidemiology, since the factors that affect the individual, family, and population group cannot
be as easily controlled as in acute care settings. It is essentially impossible to control the environment in the community. Nurses
working in the community have multiple resources that can be used to access information about the community. There may be
additional paperwork and forms to complete in the home environment, but the lack of control of the environment is a larger
challenge than the completion of paperwork. Community health nursing is recognized as a specialty within nursing.
5. Several small communities have applied for grant funding from the state department of health to help decrease their teenage
pregnancy rate. Which of the following communities should the nurse suggest receive funding first?
a. Community A—with 23 single teenage pregnancies in a city of 500
b. Community B—with 45 single teenage pregnancies in a city of 1000
c. Community C—with 90 single teenage pregnancies in a city of 2000
d. Community D—with 90 single teenage pregnancies in a city of 1500
ANS: D
The pregnancy rates of A, B, and C are 45–46:1000, whereas the rate in Community D is 60:1000. Without doing any actual math,
it should be fairly obvious that 23:500, 45:1000, and 90:2000 are all about the same proportion but that 90:1500 is a larger
proportion.

6. Between 2010 and 2015, 1000 of 10,000 young women age 17 to 20 years at a university tested positive for a sexually transmitted
infection (STI). Of the 1000 diagnosed STIs, 300 were gonorrhea and 500 were chlamydia. Which of the following statements best
summarizes these findings?
a. The proportion of cases of gonorrhea to all STIs was 300:1300.
b. The proportion of cases of gonorrhea to chlamydia was 300:500.
c. The proportion of cases of gonorrhea to all STIs was 50%.
d. The proportion of STIs to the total population was 100:1000.
ANS: D
A proportion is a ratio in which the denominator includes the numerator. If the proportion is small, we can express the number per
1000. The answer of 100:1000 correctly summarizes that 1000 of 10,000 (or 100:1000) young women had the problem. The answer
of 300:1300 adds the total of the numerator to the denominator, which is unnecessary because the gonorrhea cases were already
included in the denominator. In the answer of 300:500, the ratio comparing gonorrhea to chlamydia does not meet the
epidemiological definition of proportion (i.e., the denominator must contain the numerator). Although proportions may be
expressed as percentages, in the answer of 50%, the percentage reflects the number of gonorrhea cases to all STIs, which doesn’t
summarize the total STI problem.
7. The nursing staff has attempted to screen the entire African-American population in the community for diabetes. Which of the
following would provide immediate verification of the success of the nursing staff’s efforts?
a. An epidemic of diabetes will be recognized.
b. The incidence of diabetes will increase in the community.
c. The prevalence of diabetes will decrease in the community.
d. The risk for diabetes in the community will increase.
ANS: B
If the screening has been successful, more diabetes will be diagnosed and, hopefully, treated. Thus, the incidence of new cases will
increase. Overall, prevalence will also increase, but that is not one of the answer options. An epidemic occurs when the rate of
disease, injury, or other conditions exceeds the usual level of that condition. The prevalence (measure of existing disease in a
population at a particular time) of diabetes would also increase. The risk for diabetes would not increase rather it would be more
likely that the disease would be detected.
8. In a particular community, several high school students were diagnosed with diabetes mellitus type 2 during the annual high school
health fair. Over the next few years, the nursing staff developed and implemented educational programs about the risk factors for
diabetes mellitus type 2 and proper nutrition. Which of the following would be the most useful for the nurses to use to determine if
they are having any impact?
a. The epidemic of diabetes in the high school is gradually ending.
b. The incidence of diabetes is slowly decreasing during screening events.
c. The prevalence of diabetes is slowly decreasing during screening events.
d. The risk for diabetes is slowly increasing over time.
ANS: B
Incidence rates and incidence proportions are the measure of choice to study etiology because incidence is affected only by factors
related to the risk of developing disease and not to survival or cure. If the educational programs are having the desired impact, the
incidence of diabetes being diagnosed will decrease in future screenings. Prevalence is a fairly stable number over time, but
incidence reacts more quickly to changes in risk factors or intervention programs. In order for an epidemic to have occurred, the
rate of the illness would have had to exceed the usual level of that condition. There is no evidence in this question to support that
the disease was at an epidemic level in this population. If the educational programs are effective, the risk for diabetes should be
slowly decreasing over time.
9. This year 600 of 8000 young women age 17 to 20 years at a university health center tested positive for a sexually transmitted
infection (STI). Which of the following terms best describes this data?
a. An epidemic
b. Incidence
c. Prevalence
d. Risk
ANS: C
Prevalence is the measure of existing disease in a population at a particular time. Because we do not have baseline data, we have no
way to conclude that this is an epidemic with higher-than-normal results from the screening. Incidence refers to new cases, whereas
prevalence means all cases. We don’t know whether the finding represents the first time a woman was told she had an STI or
whether she had previously been diagnosed with the problem. Therefore, we can’t say whether these are new cases (incidence), but
the results do represent all cases (prevalence). Risk is the probability of developing an STI, but no risk factors are discussed.
10. A nursing staff has successfully screened for diabetes in the community. Which of the following might best persuade the health
board to increase funding for diabetic clinics in this community?
a. An epidemic of diabetes is now recognized and must be addressed.
b. The incidence of diabetes is now higher than previously recognized in the
community.
c. The prevalence of diabetes is now higher than previously recognized in the
community.
d. The risk for diabetes in the community could decrease if funding is received.
ANS: C
Prevalence is a fairly stable number. Prevalence proportions reflect duration in addition to the risk for getting the disease.
Prevalence is useful in planning health care services because it is an indication of the level of disease existing in the population and
therefore the size of the population in need of services. An epidemic occurs when the rate of disease, injury, or other conditions
exceeds the usual level of that condition. Incidence is affected only by factors related to the risk for developing the disease and not
survival or cure. The nurse is proposing to increase funding for diabetic clinics, and having more diabetic clinics would assist those
who already have the disease, so it would have limited impact on decreasing the risk of developing the disease among members of
the community.

11. A public health nurse found that out of the 70 people who ate the potato salad at a school picnic, 63 developed symptoms of food
poisoning. Which of the following best describes the attack rate?
a. 63%
b. 70%
c. 90%
d. 100%
ANS: C
The attack rate is the proportion of persons exposed to an agent who develop the disease. Because 63 of the 70 persons became ill,
the attack rate is 63:70, or 90%. Sixty-three (63) is the number of clients who developed symptoms of food poisoning. Seventy (70)
is the total number of people who ate the potato salad at the school picnic. These numbers need to be used as part of the formula to
calculate the attack rate. One hundred (100) does not represent any part of the formula that would be used to calculate the attack
rate.
12. A man is diagnosed with prostate cancer. Which of the following data should the nurse know to answer the man when he asks,
“What are the chances I’ll survive this thing?”
a. Attack rate
b. Case fatality rate
c. Cause-specific morbidity rate
d. Crude mortality rate
ANS: B
The case fatality rate (CFR) is the proportion of persons diagnosed with a particular disorder (i.e., cases) who die within a specified
period. The CFR is considered an estimate of the risk for death within that period for a person newly diagnosed with the disease.
Persons diagnosed with a particular disease often want to know the probability of surviving. The CFR provides that information.
The attack rate is the proportion of persons exposed to an agent who develop the disease. The cause-specific mortality rate is an
estimate of the risk for death from some specific disease in a population. The crude mortality rate is an estimate of the risk for death
for a person in a given population.
13. Which of the following statistics is used by countries to compare the success of their health care systems?
a. Attack rate
b. Infant mortality rate
c. Proportionate mortality ratio
d. Cause-specific mortality rate
ANS: B
Infant mortality is used around the world as an indicator of overall health and availability of health care services. The attack rate is
the proportion of persons exposed to an agent who develop the disease. The cause-specific mortality rate is an estimate of the risk
for death from some specific diseases in a population. The proportionate mortality ratio is the proportion of all deaths resulting
from a specific cause.
14. A nurse is examining all of the various factors which can lead to disease. Which of the following models would the nurse most
likely use?
a. Epidemiologic triangle
b. Health promotion
c. Levels of prevention
d. Natural history of disease
ANS: A
The epidemiologic triangle categorizes factors as agent, host, or environment. The model encourages the health care provider to
examine all the influences that lead to increased risk. Levels of prevention are actions taken to improve health outcomes. Health
promotion addresses health improvement, not the risk for disease.
15. A nurse is examining the various factors that lead to disease and suggesting several areas where nurses could intervene to reduce
future incidence of disease. Which of the following models would the nurse most likely use?
a. Epidemiologic triangle
b. Health promotion
c. Levels of prevention
d. Web of causality
ANS: D
The web of causality model recognizes the complex interrelationships of many factors interacting to increase or decrease the risk
for disease. Causal relationships (one thing or event causing another) are often more complex than the epidemiologic triangle
conveys. Levels of prevention are actions taken to improve health outcomes. Health promotion addresses health improvement not
identification of where nurses could intervene to reduce future incidence of disease.

16. Which of the following actions would a nurse take to reduce the high incidence of coronary artery disease (CAD) in a community?
a. Introduction of a heart-healthy curriculum beginning in the first grade,
presentations on diet and exercise for the community at large, and special
education sessions for high-risk populations
b. Provision of online activities related to prevention of cardiac disease, smoking
reduction programs, and blood pressure screenings
c. Distribution of handouts, including age-appropriate games, self-assessments, and
education on heart-healthy lifestyles; availability of community screenings for
hyperlipidemia in persons age 35 and older; and walking programs for those
affected with CAD
d. Enrollment of clients with CAD into cardiac rehabilitation programs, routine
evaluation of effectiveness of CAD treatment regimens, and participation in
clinical trials that evaluate interventions for those diagnosed with CAD
ANS: C
Distributing handouts includes all three levels of prevention to target all members of the population. Targeting all members of the
population and implementing all levels of prevention increase the likelihood of positive outcomes for the community as a whole.
Education in schools, the community, and high-risk populations focuses only on primary prevention activities. Online activities
focus only on primary and secondary preventions. Efforts focused only on those who already have CAD are not primary
prevention.
17. A school nurse wants to decrease the incidence of obesity in elementary school children. Which of the following describes a
secondary prevention intervention that the nurse could implement?
a. Giving a presentation on the importance of exercise and physical fitness
b. Designing a game in which students select healthy food choices
c. Weighing students to identify those who are overweight
d. Putting students on a diet if they weigh greater than 20% of their ideal weight
ANS: C
Secondary prevention refers to interventions that increase the probability that a person with a condition will have the condition
diagnosed early. Health screenings are the mainstay of secondary prevention. Weighing students and assessing whether the weight
is higher than recommended will allow for early intervention so that obesity may be avoided. Giving a presentation and designing a
game are both examples of primary prevention. Placing overweight students on a diet is an example of tertiary prevention.
18. A nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of
prevention is being used by the nurse?
d. Treatment, but not prevention
ANS: C
Interventions that prevent worsening of a condition are tertiary prevention activities. In this instance, the client alr eady has a health
problem (osteoporosis). By advising adequate dairy intake, the nurse aims to ensure that enough calcium is available to limit
worsening of the osteoporosis. Primary prevention would focus on interventions that reduce the risk of one getting the disease.
Secondary prevention addresses screening tests to detect the disease at the earliest stage possible. Treatment is not a level of
prevention.
19. A nurse has only a regular blood pressure cuff when conducting a health screening for all of the residents of a community. Which
of the following may be lacking when obtaining blood pressure readings?
a. Reliability
b. Sensitivity
c. Specificity
d. Validity
ANS: D
Validity is the accuracy of a test or measurement, or how closely it measures what it claims to measure. With only one regular BP
cuff, the nurse cannot obtain accurate measurements on those who are extremely obese or extremely thin. A thigh cuff and a
pediatric cuff would allow the nurse to obtain accurate—that is, valid—measurements. Reliability refers to the consistency or
repeatability of the measure. If the wrong size blood pressure cuff is used, it is likely that the same wrong blood pressure would be
repeatedly obtained. Sensitivity and specificity are the two ways that validity can be described. Sensitivity quantifies how
accurately the test identifies those with the condition or trait. Specificity indicates how accurately the test identifi es those without
the condition or trait. With the wrong size blood pressure cuff, the sensitivity and specificity of the screening would be in question.
20. A nurse is administering a tuberculosis (TB) skin test to a client who has acquired immune deficiency syndrome (AIDS). Which of
the following results should the nurse anticipate when using this screening test?
a. Decreased positive predictive value
b. Decreased reliability
c. Decreased sensitivity
d. Decreased specificity
ANS: C
Persons with immune deficiencies may have a negative tuberculosis skin test even though they are infected. Sensitivity is the extent
to which a test identifies those individuals who have the condition being examined. AIDS is an acquired immune deficiency; thus,
clients with AIDS may have a false-negative response to TB skin tests; that is, they have the disease but the test is not sensitive
enough to detect infection in these individuals. Therefore, there is decreased sensitivity with those clients. A positive predictive
value is the proportion of persons with a positive test who actually have the disease, interpreted as the probability that an individual
with a positive test has the disease. In this case, it is likely that if the individual has the disease, it will not be detected. Reliability
relates to the consistency or repeatability of the measure. Because of the client’s altered immune status, it is likely that the same
results would be obtained if the test was to be repeated. Specificity indicates how accurately the test identifies those without the
condition or trait. In this case, it is likely that a false-negative reading would be obtained, so the specificity may not be accurate.

21. Persons in an auditorium may have been exposed to a disease. If they are infected, it is crucial that they receive immediate
treatment and not take the disease home to their families. Which of the following characteristics would be most important to
consider when selecting the screening test to be used?
a. The negative predictive value
b. The positive predictive value
c. The sensitivity of the test
d. The specificity of the test
ANS: C
Because it is most important to identify every case, the sensitivity of the test is crucial. High sensitivity is needed when early
treatment is important and when the identification of every case is important. A negative predictive value is the proportion of
persons with a negative test who are actually disease free. A positive predictive value is the proportion of persons with a positive
test who actually have the disease, interpreted as the probability that an individual with a positive test has the disea se. Specificity
indicates how accurately the test identifies those without the condition or trait.
22. A woman is sitting in a corner of the clinical waiting room, crying audibly. The nurse asks, “What’s wrong? Can I help?” The
woman responds, “They just told me I have a positive mammogram and I need to see my doctor for follow-up tests. I know I’m
going to die of cancer. How can I tell my family?” Which of the following information does the nurse need to know in order to help
the woman cope with this finding?
a. The negative predictive value of mammography
b. The positive predictive value of mammography
c. The reliability of mammography
d. The validity of mammography
ANS: B
The positive predictive value is the proportion of persons with a positive test who actually have the disease, interpreted as the
probability that an individual with a positive test has the disease. A negative predictive value is the proportion of persons with a
negative test who are actually disease free. Reliability relates to the consistency or repeatability of the measure. Validity in a
screening test is typically measured by sensitivity (how accurately it identifies those with the condition) and specificity (how
accurately the test identifies those without the condition).
23. The administration at a local medical center examines the trends in health problems when developing long-range plans for staffing
and space allocation. Which of the following sources of information would be most helpful?
a. Local data drawn from a professional survey in the city
b. The National Health Interview Survey
c. The National Hospital Discharge Survey
d. The state’s vital statistics
ANS: A
For many studies, however, the only way to obtain the needed information is to collect the required data in a study specifically
designed to investigate a particular question. Both the National Health Interview Survey and the National Hospital Discharge
Survey provide information on the health status and behaviors of the national population. A state’s vital statistics are the birth and
death certificates within the state which would not give the administration the information that they are looking for in this
community.
24. Statistics clearly demonstrate that there are significantly more cases of a disease in one particular neighborhood than in all the rest
of the city. Assuming all else is the same, which of the following is the most likely explanation for a single neighborhood having
such a different pattern of illness?
a. A cultural or ethnic concentration in the neighborhood
b. The geographic location of the neighborhood within the city
c. A statistical fluke without meaning
d. The time of year the different statistics were collected throughout the city
ANS: A
The most probable reason is that there is a cultural or ethnic concentration in that particular neighborhood that has a different
lifestyle pattern, resulting in different health outcomes. The assumption is made that all things in the city are the same, thus the
geographical location would not be a likely explanation for the difference. However, location may play a role at times with
increased incidence of disease depending on exposure to certain environmental factors which could place the population at risk. A
statistical fluke does not provide a likely explanation for the difference. There are times when there are cyclical patterns of disease.
However, the question states that the assumption should be made that all else is the same, so one can assume that the data were
collected within the city at the same time.
25. Two women seem to agree on almost everything from favorite music to favorite media stars to the best way to prepare a meal.
Which of the following best explains this similarity in the two women?
a. They are both members of the same birth cohort.
b. They are close friends.
c. They attended the same school.
d. They both go to the same church.
ANS: A
Being born at about the same time would mean both women have lived through similar social events and media occurrences and
therefore would have much in common. Being close friends is probably the result of the similarity rather than the cause. Going to
the same school or the same church, depending on the size of the institutions, might not result in any personal interaction
whatsoever.

26. A nurse reports that in comparison to all the children in a particular school, the children who are members of the Cub Scouts have
0.3 risk for obesity before entering the sixth grade. Which of the following recommendations would the nurse make to the new
parents of two boys who had just moved into this school’s neighborhood?
a. Discourage the parents from enrolling their sons in Cub Scouts because of the
risk.
b. Don’t say anything about Cub Scouts, because it isn’t relevant to nursing care.
c. Encourage the parents to enroll their sons in Cub Scouts.
d. Share the finding and let the parents draw whatever conclusions they feel
appropriate.
ANS: C
Relative risk is an estimation of the risk of acquiring a problem for those who are exposed compared with those who are
unexposed. As the risk for obesity is less for those that are members of Cub Scouts, joining the group is protective and reduces the
incidence among members. Parents should be encouraged to enroll their sons in Cub Scouts as joining the group is protective and
reduces the risk for becoming obese. The finding should be interpreted for the parents, and the protective aspect of joining the
group should be explained.
27. A principal comments to the school nurse that it seems there are a lot more problems with asthma among the students than there
were before the school was remodeled a couple of years ago. The nurse investigates the principal’s observation by reviewing all the
school records to determine visits to the health office because of asthma by week and month for the past 5 years. Which of the
following best describes the type of study the nurse is conducting?
a. Descriptive epidemiological study
b. Ecological study
c. Prospective cohort study
d. Retrospective cohort study
ANS: D
Retrospective cohort studies rely on existing records to define a cohort that is classified as having been exposed or unexposed at
some time in the past. In this case, the issue is whether there is some health risk in the new building addition that is increasing
frequency of visits to the school nurse because of asthma. In a descriptive epidemiological study, the disease is investigated in
terms of person, place, and time. An ecological study is a bridge between descriptive and analytic epidemiology, looking at
variations in disease rates by person, place, or time and trying to determine if there is a relation of disease rates to variations in rates
for possible risk factors. A prospective cohort study, or subjects who do not have the outcome under investigation, are classified on
the basis of the exposure of interest at the beginning of the follow-up period.
28. Which of the following types of study should the nurse researcher choose if the goal is to identify the long-term benefits and risks
of a particular nursing intervention for senior citizens living in the community?
a. Cross-sectional study
b. Ecological study
c. Clinical trial
d. Retrospective analysis
ANS: C
The goal of a clinical trial is to evaluate the effectiveness of an intervention. Clinical trials are generally the best way to show
causality. A cross-sectional study provides a snapshot of a population or group. An ecological study is a bridge between descriptive
and analytic epidemiology, looking at variations in disease rates by person, place, or time and trying to determine if there is a
relation of disease rates to variations in rates for possible risk factors. A retrospective analysis relies on existing records to define a
cohort that has been exposed or unexposed at some point in the past.
29. A teacher recommends that surveys to obtain data on drug use be given to high school students when they meet for various school
organizations. Which of the following best describes why the nurse would reject this suggestion?
a. This method of data collection would result in classification bias.
b. This method of data collection would result in confounding bias.
c. This method of data collection would result in personal bias.
d. This method of data collection would result in selection bias.
ANS: D
Any study is subject to bias resulting from selective choice. There may be a difference between students who choose to belong to
an organization and students who choose not to join an organization. Selection bias occurs when selection procedures are not
representative of the population as a whole. In this instance, the goal is to determine drug use of all students at the school. If only
students who join school organizations are selected, those who do not join organizations will not be represented. Classification bias
occurs once subjects are enrolled in the study and relates to how information is collected. Confounding bias results from the
relationship between the outcome and the study factor and some third factor that was not accounted for. Personal bias deals with
personal opinions and attitudes of the researcher which may interfere with the proper selection of the participants.
30. A nurse is investigating a bacterial illness that has caused a health problem in the community. Only some of the people exposed to
the bacteria have become ill. Which of the following factors best explains why this would have happened?
a. Chemical agent factors
b. Environmental factors
c. Host factors
d. Physical agent factors
ANS: C
The epidemiologic triangle includes the agent, host, and environment. Only differences in host factors can explain why some
became ill and some were able to fight off the bacterial infestation. The epidemiologic triangle includes the agent, host, and
environment. The bacteria were the agent, so chemical and physical agents are not relevant. The environment was apparently the
same for everyone, since all were exposed to the bacteria.

MULTIPLE RESPONSE
1. Which of the following explains why contagious infections are becoming a central focus of public health? (Select all that apply.)
a. Americans are fearful of terrorists using biological agents.
b. Awareness of human susceptibility to animal diseases has been publicized.
c. Drug-resistant strains of old diseases have evolved.
d. Media coverage exaggerates the dangers of exposure to crowds.
e. The American population has become more health conscious in the last 20 years.
ANS: A, C
New infectious diseases and new forms of old diseases, such as drug-resistant strains of TB, have emphasized the dangers of
infectious diseases. Potential threats from terrorist use of infectious agents have also emphasized infectious diseases. There has not
been any increased awareness of human susceptibility to animal diseases that has caused contagious infections to become a central
focus of public health. Also, media coverage has not exaggerated the danger of exposure to crowds when it comes to contagious
infections. While health and wellness is a higher priority for many Americans, the interest is not a factor in focus on contagious
infections.
2. A nurse is concerned about the high incidence of sexually transmitted infection (STIs) in the community college population and
sets up a special STI screening. Which of the following groups of students would be encouraged to attend? (Select all that apply.)
a. Sexually active students currently receiving treatment for an STI
b. Sexually active students who had been screened the previous year
c. Students who are not sexually active and do not plan to become sexually active
d. Students who are sexually active but never “go all the way”
e. Students who are freshmen or new transfers
ANS: B, D
Those who are at risk to develop the problem should be encouraged to attend the screening. This should be anyone who is or plans
to be sexually active to any degree. Those already diagnosed with the problem are not at risk, because they already have the
condition and are no longer at risk for developing it. Thus, it would not be beneficial for this population to attend the screening as
they have already been diagnosed. Students who are not sexually active do not need to attend the screening as they are not at risk
for contracting an STI because they are not having sex.
3. A nurse is planning to host a health screening at a large urban mall. Which of the following variables will help the nurse determine
which screenings should be included? (Select all that apply.)
a. Adequate space for persons to lie down after testing until side effects are reduced
b. Health problems for which the specific population is at risk
c. Whether adequate privacy can be obtained for the invasive or embarrassing
procedures
d. Whether health care providers are available to follow up on any positive
screening results
e. Ability to provide the individual health screenings free to the public
ANS: B, D
The screening tests should be reliable, valid, fast, and inexpensive. Results should be known immediately. Ethically, nurses should
not screen for any problem unless they can refer those with positive results to a source for follow-up testing and treatment. The
screening tests should have few side effects, be minimally invasive, and be capable of detecting enough new cases to warrant the
effort and expense. No tests should be used that have negative side effects, are invasive, or cause embarrassment.
4. A nurse believes a new mouth care procedure (MCP) is exacerbating a client oral tissue problems. Which of the following must be
present for the nurse to go to administration with confidence that the MCP is causing problems? (Select all that apply.)
a. A plausible explanation of how the new MCP could cause harm
b. A strong feeling that the MCP is the cause
c. Consistently seeing mouth inflammation in many of the patients who have
received the MCP
d. Documentation from patient records that mouth inflammation in clients did not
occur until after the new procedure was implemented
e. A less expensive option for appropriate oral care
ANS: A, C, D
Strength of association is suggested by the fact that patients who did not receive the MCP and patients seen on the floor before the
new MCP did not have problems, whereas patients who received the new MCP are having problems. Seeing the problems in many
of the patients suggests a consistency. The fact that those who had the procedure more often have worse problems suggests a
dose–response relationship. A plausible explanation of how the new procedure could cause harm enhances the biological risk.
Although one would hope that previous testing would have been done before the product was released to market, the product could
be safe for healthy persons but a risky process for those with compromised immunity or those who are under stress. Feelings alone
are not convincing. A study should be set up to confirm or dispute the nurse’s hypothesis. Cost of the initial procedure is not a
relevant factor.

Chapter 11: Infectious Disease Prevention and Control
MULTIPLE CHOICE
1. Which of the following is the number one cause of death worldwide?

a. Chronic diseases (heart disease, cancer, stroke)
b. Infectious diseases
c. Injuries (accidental or purposeful)
d. Terrorism
ANS: B
Infectious diseases, however, are still the number one cause of death worldwide. In countries with higher standards of living, where
people live longer, chronic diseases—heart disease, cancer, and stroke—are the leading causes of death. Injuries and terrorism are
not the number one cause of death worldwide.
2. Which of the following places best describes where the incidence of Vancomycin-resistant Staphylococcus aureus (VRSA) and
methicillin-resistant S. aureus (MRSA) is currently rising?
a. Areas where people share dressing or bathing facilities
b. Daycare centers and schools
c. Long-term care facilities
d. Senior citizen centers
ANS: A
Vancomycin-resistant Staphylococcus aureus (VRSA) and methicillin-resistant S. aureus (MRSA) remain problems for people who
acquire the bacteria in the hospital, but there is a growing incidence of community-acquired MRSA in places where people closely
share facilities such as locker rooms, prisons, and other close bathing areas. Daycare centers, schools, long-term care facilities, and
senior citizen centers are not places where the incidence of VRSA and MRSA is rising. These are not places where people are
closely sharing dressing and bathing facilities.
3. During an outbreak of hepatitis A, nurses are giving injections of hepatitis A immunoglobulin to selected susceptible persons.
Which of the following best describes the type of immunity that will follow the administration of these injections?
a. Active immunity
b. Acquired immunity
c. Natural immunity
d. Passive immunity
ANS: D
Passive immunity refers to immunization through the transfer of a specific antibody from an immunized individual to a
non-immunized individual, such as the transfer of antibody by the administration of an antibody-containing preparation (immune
globulin or antiserum). Passive immunity from immune globulin is almost immediate but short-lived. It often is induced as a
stopgap measure until active immunity has had time to develop after vaccination. Active immunity occurs as antibodies develop
due to exposure to the antigen. Acquired immunity is the resistance acquired by a host as a result of previous natural exposure to an
infectious agent. Natural immunity refers to a species-determined, innate resistance to an infectious agent.
4. A man loudly protests his increased property tax bill right after the public health department has made a plea for more funds.
“Why,” he asks, “should my tax dollars be used to pay for their children to be immunized?” Which of the following would be the
best response by the nurse?
a. “Immunizations are required by law, and if their parents can’t afford it, you and I
will have to pay for it.”
b. “It’s just the right thing to do.”
c. “Only by making sure most kids are immunized can we stop epidemics that might
hurt all of us.”
d. “We’re a religious God-fearing community, and we take care of each other.”
ANS: C
Herd immunity is the resistance of a group of people to invasion and spread of an infectious agent because a high proportion of
individual members of a group are resistant to the infection. Higher immunization coverage will lead to greater herd immunity,
which in turn will block the further spread of the disease. The purpose of immunization laws is to promote herd immunity.
Receiving immunizations helps to block the further spread of the disease as more members of the community become resistant to
the infection.
5. Which of the following components of the epidemiologic triangle contributes most to a female client developing a vaginal infection
caused by fungi after successful treatment of her strep throat with antibiotics?
a. Agent
b. Environment
c. Host
d. Agent and host
ANS: B
The antibiotic therapy eliminates a specific pathological agent, but it also may alter the balance of normally occurring organisms in
the woman’s body, which causes a change in the vaginal environment and allows normally present fungi to proliferate, resulting in
a yeast infection. The agent is the factor that is causing the disease or illness. The host is the human or animal that becomes
infected.

6. Which of the following best represents an example of infectious disease spreading via a vector?
a. Being bitten by an infected mosquito
b. Disease spreading from infected mother to infant via the placenta
c. A group of partygoers hugging and shaking hands
d. Two persons, one of whom is infected, sharing a glass of soda
ANS: A
Vectors include mosquitoes, which can transmit the infectious agent by biting the host. Vertical transmission is the passing of
infection from parent to offspring via placenta. Horizontal transmission is the person-to-person spread of infection through (among
other ways) contact. Common vehicle refers to transportation of the infectious agent from an infected host to a susceptible host via
food, water, milk, or other substance.
7. Which statement made by the nurse best describes the effect vaccines have had on tuberculosis (TB)?
a. Tuberculosis is no longer a threat in most of the world.
b. Tuberculosis has developed resistance to the all antibiotics.
c. The treatment has helped greatly reduce the incidence of TB in the United States.
d. The incidence of TB has remained constant since the 20th century.
ANS: C
In 1900, communicable diseases were the leading causes of death in the United States. Since that time, improved sanitation and
nutrition, the discovery of antibiotics, and the development of vaccines has ended some epidemics such as diphtheria and typhoid
fever and greatly reduced the incidence of others such as tuberculosis (TB).
8. Which population is best protected against pertussis by the DTaP vaccine?

a. Young children
b. The pre-teen
c. The teen
d. Adult
ANS: A
More than 200,000 children previously got pertussis each year. Two vaccines protect again this disease: DTaP protects young
children from diphtheria, tetanus, and pertussis; and Tdap protects preteens, teens, and adults.
9. Which of the following data would most likely be collected in a syndromic surveillance system?
a. Incidence of bioterrorism attacks
b. Number of air travelers
c. Incidence of school absenteeism
d. Number of influenza vaccines administered
ANS: C
Syndromic surveillance systems use existing health data in real time to provide immediate analysis and feedback to those charged
with investigation and follow-up of potential outbreaks. These systems incorporate factors such as the previously mentioned
temporal and geographic clustering and unusual age distributions with groups of disease symptoms or syndromes (e.g., flaccid
paralysis, respiratory signs, skin rashes, gastrointestinal symptoms) with the goal of detecting early signs of diseases that could
result from a bioterrorism-related attack. Syndromic surveillance systems may include tracking emergency department visits sorted
by syndrome symptoms as well as other indicators of illness including school absenteeism and sales of selected over-the-counter
medications. In recent years, the tracking of cold medicines used to make crystal methamphetamine has received considerable
attention. Syndromic surveillance systems use existing health data—the number of air travelers is not existing health data. It is the
intention of syndromic surveillance systems to detect early signs of diseases that could result from a bioterrorism-related attack;
thus, the system is not measuring the incidence of bioterrorism attacks. Administration of influenza vaccines should decrease the
prevalence of this disease. Therefore it is unlikely that the administration of vaccines would be data that is collected; the incidence
of the influenza would be more likely to be examined.
10. The nurse is trying to determine if a disease occurrence needs to be reported to the state health department. Which of the following
resources should the nurse use to answer this question?
a. Centers for Disease Control and Prevention Weekly Report
b. Communicable Diseases Weekly Report
c. Nationally notifiable infectious diseases on the CDC website
d. State health department website
ANS: D
Requirements for disease reporting in the United States are mandated by state rather than federal law. The list of reportable diseases
varies by state. State health departments, on a voluntary basis, report cases of selected diseases to the Centers for Disease Control
and Prevention (CDC) in Atlanta, Georgia. The CDC updates these conditions annually, and the list can be found under the heading
of Nationally notifiable infectious diseases on the CDC website. The weekly reports may provide information about the current
incidence or prevalence of certain diseases, but it will not provide the nurse with information about what is required to be reported.
11. There is great concern in the nurse’s community over three local cases of West Nile virus. Which of the following actions should
the nurse take to get the community involved in addressing this problem?
a. Ask the state department of health for assistance.
b. Demand that everyone over age 65 become immunized immediately.
c. Encourage immunization of all children under 12.
d. Have an educational campaign to remove any containers of standing water.
ANS: D
Periodic outbreaks of West Nile virus appear to result from a complex interaction of multiple factors, including
weather—especially hot, dry summers followed by rain, which influences mosquito breeding sites and population growth.
Removing standing water will remove mosquito breeding sites. Currently, there is not a vaccine available for humans; an equine
vaccine does exist, and work is under way to develop a vaccine for both birds and humans. The state health department would most
likely not become involved in this local health problem, rather this may be the role of a local health department.

12. Which of the following is the most probable cause of the increase in new emerging infectious diseases?
a. Activities or behavior of humans, including changes in the environment
b. Increasing urbanization and growth in new housing materials
c. New infectious agents are evolving throughout the world
d. Overpopulation in many areas, creating a need to reduce global population
ANS: A
Most of the emergence factors are consequences of activities and behavior of the human hosts and of environmental changes such
as deforestation, urbanization, and industrialization. For example, the rise in households with two working parents has increased
the number of children in daycare, and with this shift has come an increase in diarrheal diseases such as shigellosis. Urbanization is
not a problem, but increasing development into formerly unaffected areas such as rainforests is. The environmental changes around
the world are causing new infectious agents to emerge, not evolve. The environmental changes that occur because of overcrowding
is the issue, not the population itself.
13. Which of the following best describes the current goal in relation to communicable diseases?
a. To control political borders so diseases cannot spread further
b. To exterminate specific infectious agents one by one
c. To expand health care facilities to improve infectious disease treatment
d. To achieve worldwide immunization to control new cases
ANS: B
The goal of prevention and control programs is to reduce the prevalence of a disease to a level at which it no longer poses a major
public health problem. In some cases, diseases may even be eliminated or eradicated. The goal of elimination is to remove a disease
from a large geographical area (e.g., a country or region of the world), such as has been done with polio in the Americas.
Eradication is the irreversible termination of all transmission of infection by extermination of the infectious agents worldwide, as
has been done with smallpox. Because of the large amount of international travel, it is impossible to prevent the spread of diseases
from occurring worldwide. The expansion of health care facilities would not improve the treatment of infectious diseases, rather
improved sanitation could assist in this. The goal for the spread of communicable diseases is eradication, not control of new cases.
14. Which of the following biological warfare agents poses the greatest bioterrorism threat to a community?
a. Anthrax
b. Botulism
c. Smallpox
d. Tularemia
ANS: A
Because of factors such as the ability to become an aerosol, the resistance to environmental degradation, and a high fatality rate,
inhalational anthrax is considered to have an extremely high potential for being the single greatest biological warfare threat.
Botulism, smallpox, and tularemia do not have the ability to be transmitted through a resistant aerosol that is highly fatal.
15. Which of the following public health actions has been particularly instrumental in reducing childhood infectious diseases in the
United States?
a. Answering parents’ questions about the safety and importance of vaccines today
b. Educational campaigns to all health care providers about the importance of
immunizations whenever a child is seen
c. “No shots, no school” legislation, which legally requires children be immunized
before school
d. Offering all immunizations to all children free of any charge
ANS: C
Vaccines are one of the most effective methods of preventing and controlling communicable diseases. One of the most effective
programs has been the “no shots, no school” legislation, which has resulted in the immunization of most children by the time they
enter school. Hopefully, all nurses answer questions, remind colleagues to think about immunizations whenever a child is seen, and
encourage continuing free or low-cost immunization clinics. These interventions have not been particularly instrumental in
reducing childhood infections.
16. A student comes to the college health clinic with typical cold symptoms of fever, sneezing, and coughing, but the nurse also notes
small white spots on the inside of the student’s cheeks. Which of the following actions should be taken by the college health nurse?
a. Inform all students, staff, and faculty of a possible rubella epidemic.
b. Inform all students, staff, and faculty of a possible measles epidemic.
c. Reassure the student that it is just a bad cold and will soon pass.
d. Tell the student to take two acetaminophen and drink lots of fluids.
ANS: B
Measles is an acute, highly contagious disease that, although considered a childhood illness, is often seen in the United States in
adolescents and young adults. Symptoms include fever, sneezing, coughing, conjunctivitis, small white spots on the inside of the
cheek (Koplik spots), and a red, blotchy rash beginning several days after the respiratory signs. Measles is serious. Around 10% of
measles cases require hospital admission. It can lead to pneumonia and encephalitis, and it can kill. Persons who may have been
exposed should be informed that anyone under 18 who has not received both immunization doses should receive measles vaccine.
The student is displaying symptoms of measles, not rubella. Symptoms of rubella include a low-grade fever, runny nose, headache,
and a rash that starts on the face and spreads to the rest of the body. The white spots (Koplik spots) should make the nurse suspect
that the client has measles, not just a bad cold in which case the nurse would recommend the acetominophen and fluids.

17. An instructor is reviewing Salmonella infections with her class. Which of the following comments indicates that the student needs
further review on how Salmonella is spread?
a. “Certain pets and farm animals may be Salmonella carriers.”
b. “It is possible to transmit Salmonella by person-to-person contact.”
c. “Salmonella may be spread by spores that form once contaminated blood is
exposed to the air.”
d. “Salmonella outbreaks are usually due to contaminated meat, poultry, and eggs.”
ANS: C
Anthrax (not Salmonella) forms spores when infected blood is exposed to air. Meat, poultry, and eggs are the foods most often
associated with salmonellosis outbreaks. Animals are the common reservoir for the various Salmonella serotypes, although infected
humans may also fill this role. Animals are more likely to be chronic carriers. Reptiles such as iguanas have been implicated as
Salmonella carriers, along with pet turtles, poultry, cattle, swine, rodents, dogs, and cats. Person-to-person transmission is an
important consideration in daycare and institutional settings.
18. Which of the following is the most common vector-borne disease in the United States?
a. Babesiosis
b. Ehrlichiosis
c. Lyme disease
d. Rocky Mountain spotted fever
ANS: C
Lyme disease became a nationally notifiable disease in 1991 and is now the most common vector-borne disease in the United
States. Babesiosis, Ehrlichiosis, and Rocky Mountain spotted fever are all diseases borne by ticks as the vectors. These are not the
most common vector-borne diseases.
19. A student reports to the college health nurse that her academic work has been going downhill because of lack of sleep. “My
3-year-old probably misses her babysitter since she has started going to the big daycare center. She hasn’t been sleeping well and
keeps scratching her bottom. Hopefully, she’ll adapt to daycare soon.” Which of the following information should the nurse
provide to the student?
a. “Dry skin in winter weather can cause itchiness; try to put on lotion before
bedtime.”
b. “Your daughter may have pinworms; let me teach you how to check for this.”
c. “Perhaps your child is not developmentally ready for group play.”
d. “Try to arrange more one-on-one time with your 3-year-old.”
ANS: B
Enterobiasis (pinworm infection) is the most common helminthic infection in the United States with about 42 million cases a year.
This infection is seen most often among children in institutional settings. Pinworms cause itching, especially around the anus,
which can result in a lack of sleep for both child and caregiver. The nurse should suspect that the underlying problem is pinworms,
not dry skin. These symptoms do not demonstrate a developmental delay or the need for additional one-on-one time.
20. Which of the following is the most common vector-borne disease is a result of travelers introducing the disease to the United
States?
a. Dengue
b. Malaria
c. Onchocerciasis (river blindness)
d. Yellow fever
ANS: B
Globally, malaria is the most prevalent vector-borne disease, with over 2.4 billion people at risk and more than 275 million cases
reported each year. About 2000 cases of malaria are diagnosed in the United States each year. The vast majority of cases in the
United States are in travelers and immigrants returning from countries where malaria transmission occurs, many from sub-Saharan
Africa and South Asia. Dengue is rarely transmitted in the United States. Onchocerciasis and Yellow fever are not reported as
common vector-borne diseases.
21. At a town meeting with public health officials to discuss a communicable disease outbreak, a nurse is asked to explain what is
meant by the phrase “a virulent organism.” The nurse explains that this means the organism causing the disease is able to do which
of the following?
a. Bypass normal immunological response mechanisms
b. Invade major organ systems
c. Produce toxins and poisons that weaken the body
d. Produce very severe physical reactions
ANS: D
Virulence is the ability to produce a severe pathological reaction. Bypassing the normal immunological response mechanisms,
invading major organ systems, and producing toxins and poisons that weaken the body are not correct definitions of virulence.
22. A client is using a primary prevention strategy to prevent infectious disease. Which of the following actions is the client most likely
taking?
a. A client receives a tetanus booster every 10 years.
b. A client receives a tetanus booster after stepping on a nail.
c. A client receives tetanus immunoglobulin after stepping on a nail.
d. A client with tetanus is given antibiotics and is placed on seizure precautions.
ANS: A
Tetanus boosters given before exposure are a measure of primary prevention because exposure has not yet occurred. If given after
exposure (i.e., the client may be infected but disease has not developed), they are considered secondary prevention (similar to the
textbook examples of immunoglobulin and rabies immunizations given after exposure). Immunoglobulin would be given if the
client had not been previously immunized; however, this again is after exposure, so it is secondary prevention. Because the client
has the condition, treatment is aimed at prevention of further injury.

23. Which of the following infectious disease interventions best represents the use of secondary prevention?
a. Clients with HIV infection are encouraged to use condoms to protect sexual
partners.
b. Clients with HIV infection are given medications to improve immunological
response.
c. Health care workers are encouraged to receive annual vaccinations for influenza.
d. Health care workers are required to have a tuberculosis skin test or chest X-ray.
ANS: D
Tuberculosis screening for health care workers is an example of secondary prevention. TB skin tests and chest X-rays are methods
of tuberculosis screening. Encouraging clients with HIV to use condoms is an example of primary prevention, because the goal is to
prevent exposure to the partner. Encouraging annual influenza vaccinations is also an example of primary prevention. Giving
clients with HIV medications is an example of tertiary prevention, because the goal is to reduce complications in those already
having the infection.
MULTIPLE RESPONSE
1. Five students order meals at a local restaurant. Which of the following students are at highest risk for illness? (Select all that
apply.)
a. The first student asks for a salad with chicken strips and dressing on the side.
b. The second student asks for a hamburger, very rare.
c. The third student orders a tuna salad sandwich with extra mayonnaise.
d. The fourth student orders a breakfast meal with two very soft-poached eggs and
toast.
e. The fifth student asks for a vegetable platter and a side of hummus.
ANS: B, D, E
Escherichia coli O157:H7 can produce a strong cytotoxin that can cause a potentially fatal hemorrhagic colitis. Hamburger is often
involved in outbreaks, since the grinding process exposes pathogens on the surface of the whole meat to the interior of the ground
meat, effectively mixing the once-exterior bacteria thoroughly throughout the hamburger so that searing the surface no longer
suffices to kill all bacteria. Also, hamburger is often made of meat ground from several sources. The best protection against
foodborne pathogens is to thoroughly cook food before eating it. Salmonella is also transmitted by undercooked foods such as eggs,
poultry, dairy products, vegetables and seafood. Consequently, students eating very rare hamburger and undercooked eggs are at
high risk. The food items requested by the first (salad with chicken strips and dressing) and third (tuna salad sandwich with extra
mayonnaise) students are at the lowest risk for illness. These foods have been thoroughly cooked which helps to assure that
potential bacteria have been destroyed.
2. Which of the following symptoms suggests smallpox as opposed to the more common and much less dangerous chickenpox?
a. Child appears only mildly ill until late stages in smallpox.
b. Lesions appear in various stages in the same area of the body rather than all at
once.
c. Rash lesions are most abundant on the face and extremities, not on the trunk.
d. Rash occurs 2 to 4 days after sudden onset of fever rather than with the fever.
e. Vesicles do not collapse when punctured.
ANS: C, D, E
Symptoms of smallpox include rash lesions on face and extremities (“centripetal”), rash that occurs 2 to 4 days after onset of fever,
and vesicles that are deep seated and do not collapse on puncture. Symptoms of chickenpox include a sudden onset with slight
fever and mild constitutional symptoms, rash that is present at onset, rash progression is maclopapular for a few hours, vesicular for
3 to 4 days, followed by granular scabs, rash is “centifugal” with lesions most abundant on the trunk or areas of the body usually
covered by clothing, lesions appear in “crops” and can be at various stages in the same area of the body, and vesicles are superficial
and collapse on puncture.
3. The advanced practice nurse explains that the client has an upper respiratory infection (URI) and suggests several measures that
might make the client more comfortable. Which of the following best describes why the nurse doesn’t just prescribe antibiotics as
the client repeatedly requests? (Select all that apply.)
a. Antibiotics are expensive, whereas the support measures would be almost free of
cost.
b. Viral diseases are not affected by antibiotics.
c. Clinics cannot afford to continually give antibiotics to anyone who asks for them.
d. The more antibiotics are prescribed, the more infectious agents develop resistance
to such drugs.
e. Antibiotics are not particularly effective against coughs and nasal congestion.
ANS: B, D
Antibiotics are not effective against viral diseases, a fact found unacceptable to many clients looking for relief from the misery of a
cold or flu. The inappropriate prescribing of antibiotics contributes to the growing problem of infectious agents that have developed
resistance to once-powerful antibiotics. There are many broad-spectrum antibiotics that are inexpensive. Typically, insurance
providers or clients are paying for the cost of prescription antibiotics, not the clinic. So, although the health care system is impacted
by these increased costs it is most likely not impacting the clinic itself.

Chapter 12: Communicable and Infection Disease Risks
MULTIPLE CHOICE
1. Which of the following sexually transmitted diseases can be prevented through immunization?
a. Chlamydia
b. Gonorrhea
c. Hepatitis B
d. Genital Herpes Simplex
ANS: C
Hepatitis B infection can be prevented by immunization; vaccines for the remaining options are not yet available. There are not yet
vaccines for chlamydia, gonorrhea, or genital herpes simplex.
2. Which of the following provides the best explanation as to why people do not immediately seek medical treatment when they first
become ill with HIV?
a. They are afraid to get tested for fear that the results will be positive.
b. They avoid the problem (maybe it will go away).
c. They don’t recognize their symptoms as possibly being due to HIV.
d. It is too expensive to get an HIV test.
ANS: C
When HIV enters the body, it can cause a flu-like syndrome referred to as a primary infection or acute retroviral syndrome. This
may go unrecognized. The symptoms are similar to flu or a bad cold including sore throat, lethargy, rash, fever, and muscle pain.
An antibody test at this stage is usually negative. So the person or a medical provider may not recognize the illness as HIV. Thus, it
is not worthwhile to be tested during this stage of the illness. This information supports the incorrectness of the other options.
3. A client was clearly very relieved when an HIV test came back negative. “Thank goodness. I’ve had sex several times without a
condom, and when one of my friends said he was sick, I think I panicked.” Which of the following would be most important to
emphasize to the client immediately?
a. Abstinence is the only way to be certain you are HIV free.
b. Sex should be restricted to one partner.
c. The test could be wrong and the client might still have an HIV infection.
d. The test would not cover any recent infection, so if the client has had recent
unprotected sex, the test should be repeated in 3 months.
ANS: D
The client needs to understand that the test cannot identify infections that may have been acquired within the previous 3 months
before the test. Appearance of the HIV antibody can take up to 12 weeks; thus, this test could be negative now, but positive in 3
months. All persons who have an STD test should be counseled about risk reduction activities before and after the test is done. This
information supports the incorrectness of the other options.
4. A student asks the nurse at the student health clinic how AIDS is diagnosed. Which of the following statements would be the best
response by the nurse?
a. “A diagnosis of AIDS is made when a screening test called an enzyme-linked
immunosorbent assay (ELISA) is confirmed by the Western blot test.”
b. “A diagnosis of AIDS is made when antibodies to HIV are detected about 6
weeks to 3 months following possible exposure.”
c. “A diagnosis of AIDS is made when antibodies to HIV reach peak levels of
1000/ml of blood.”
d. “A diagnosis of AIDS is made when CD4 T-lymphocytes drop to less than 22
cells/mm.”
ANS: D
AIDS is defined as a disabling or life-threatening illness caused by HIV; it is diagnosed in a person with a CD4 T-lymphocyte
count of less than 22 cells/ml with or without documented HIV infection. The HIV antibody test (usually the EIA) is the most
commonly used screening test for determining whether the antibody to HIV is present but does not confirm AIDS. Positive results
with the EIA are tested further with the Western blot test. However, false-negative results are frequent between 6 weeks and 3
months following exposure.
5. The correctional health nurse is doing a quick assessment on a newly admitted inmate who is HIV positive. Which of the following
diseases should the inmate receive screening for immediately?
a. Herpes zoster
b. Hepatitis B
c. Hepatitis C
d. Tuberculosis
ANS: D
HIV-infected persons, who live near one another, such as in correctional facilities, must be carefully screened and deemed
noninfectious before admission to such settings. A person with HIV is more susceptible to opportunistic infections, the most
common of which is TB. Hepatitis B and hepatitis C are both transmitted through blood and body fluids which are not as highly
contagious as tuberculosis which is transmitted through airborne droplets. Herpes zoster (shingles) is spread by direct contact with
fluid from the rash blisters. None of the other options are as directly related to HIV as an opportunistic disease.

6. A school nurse asks a class about the ways HIV can be transmitted. Which of the following comments by a student indicates a need
for additional teaching?
a. “I wouldn’t sit next to someone with HIV.”
b. “Having unprotected sex with someone who is infected spreads HIV.”
c. “Sharing needles when shooting up drugs spreads HIV.”
d. “Transfusions of blood products that are contaminated can spread HIV.”
ANS: A
HIV is not transmitted through casual contact such as touching or hugging someone who has HIV infection. It is not transmitted by
insects, coughing, sneezing, office equipment, or sitting next to or eating with someone who has HIV infection. HIV can be
transmitted through exposure to blood, semen, vaginal secretions, and breast milk and by sharing needles, syringes, and other
equipment used to prepare injectable drugs. It can also be spread by perinatal transmission from mother to child through delivery or
breastfeeding and by transfusions of contaminated blood. Worldwide, the largest number of HIV infections result from
heterosexual transmission.
7. In the United States, which group is most affected by a new HIV diagnosis?
a. Women having heterosexual relationships
b. White IV drug abusers
c. Young Black gay and bisexual men
d. Men who have sex with other men
ANS: C
Although new HIV diagnosis in general has declined, young Black gay and bisexual men are the most affected, with an 94%
increase in diagnosis. The largest number of new infections in 2018 was in men who had sex with other men, and this was followed
by heterosexual transmission. HIV infections in women are primarily due to heterosexual contact or IV drug use. This information
supports the incorrectness of the other options.
8. Which of the following best explains why some health clinics allow clients to be tested for HIV anonymously with no record of the
client’s name, address, or contact information?
a. Client doesn’t actually ever have to be told the results of the test.
b. Client may be engaged in illegal activities (drug use).
c. Client plans on not paying for the test, and collection agencies will not be able to
harass them.
d. Client wants to be sure care providers don’t share results with their family.
ANS: B
An advantage of anonymous testing may be that it increases the number of people who are willing to be tested, because many of
those at risk are engaged in illegal activities. The anonymity eliminates their concern about the possibility of arrest or
discrimination. If testing is anonymous, the client is given an identification code number that is attached to all records of the test
results and is not linked to the person’s name and address. Demographic data such as the person’s sex, age, and race may be
collected, but there is no record of the client’s name and associated identifying information. Thus, the client is able to know the
results of the test while staying anonymous. It would be a violation of HIPAA for the providers to share the results of this test or
any other medical information with family members. The follow-up related to payment is not a main concern for the population
who is requesting anonymous testing.
9. A nurse is providing education to a client about the use of PrEP. Which of the following statements would the nurse include as part
of this teaching?
a. “Side effects of PrEP include extreme lethargy and joint pain.”
b. “PrEP has been shown to be effective in preventing transmission of the disease
from sharing needles.”
c. “The effectiveness of PrEP will depend on your adherence to the medication
regimen.”
d. “PrEP will prevent you from contracting HIV and hepatitis B.”
ANS: C
Pre-exposure prophylaxis, or PrEP, is a new HIV prevention method for people who do not have the infection but would like to
reduce their risk of becoming infected. PrEP requires taking a pill to prevent the HIV virus from getting into the body. This
prevention method requires strict adherence to taking the medication and having regular HIV testing; it is also used in combination
with other HIV prevention methods rather than in isolation (CDC: PrEP, 2012b). It has been shown to be effective for people at
very high risk for HIV infection through sex; the results about its effectiveness with injection drug users are not yet available.
Extreme lethargy and joint pain are not common side effects of PrEP. PrEp provides protection against HIV, not against hepatitis
B.
10. A male client visits the clinic office reporting a yellow-green discharge from his penis. Which of the following STIs has the client
most likely contracted?
a. Gonorrhea
b. Syphilis
c. Herpes simplex virus 2
d. Human papillomavirus
ANS: A
The symptoms for gonorrhea in a male include a burning sensation when urinating, or a white, yellow-green discharge from the
penis. Some men may get swollen or painful testicles. In men, gonorrhea can cause epididymitis, a painful condition of the testicles
that if untreated can lead to infertility. Symptoms of syphilis may not appear for several years after contracting the disease. The first
stage of syphilis is called primary syphilis when a chancre, a firm, round, small and painless lesion, develops. Signs and symptoms
of HSV-2 infection range from no symptoms to painful lesions or blisters around the genitals, rectum, or mouth. Most people with
HPV are asymptomatic.

11. A client is being treated for secondary syphilis. Which of the following signs and symptoms would the nurse anticipate the client
would exhibit?
a. Chancre at the site of entry
b. Jaundice
c. Difficulty coordinating muscle movements
d. Skin rash without itching
ANS: D
Secondary syphilis occurs when the organism enters the lymph system and spreads throughout the body. Signs include skin rash on
one or more areas of the body and do not cause itching. Other symptoms may include fever, swollen lymph glands, sore throat,
patchy hair loss, headaches, weight loss, muscle aches, and fatigue. A chancre at the site of entry is a symptom of primary syphilis.
Difficulty coordinating movements is a sign of tertiary syphilis. Jaundice is a sign of congenital syphilis.
12. Which of the following best explains why chlamydia is a major focus of public health efforts?
a. It has more serious long-term outcomes than other STDs.
b. It can cause problems in infants born to infected mothers.
c. It is not frequently seen in the United States.
d. It is so difficult and expensive to treat.
ANS: B
Like gonorrhea and other STDs, chlamydia can cause neonatal complications in infants born to infected mothers. It is treated rather
easily with antibiotics. Chlamydia does have serious long-term outcomes for the client, but so do syphilis and other STDs.
However, unlike syphilis, which in its later stages is rare in the United States, chlamydia is the most common reportable infectious
disease in the United States and hence is a major focus of public health.
13. Which of the following statements best explains why HSV-2 infection is more challenging for a client than gonorrhea infection?
a. HSV-2 is a viral infection that is both chronic and incurable.
b. HSV-2 is extremely expensive to treat.
c. HSV-2, like HIV, is almost impossible to diagnosis in the early stages.
d. Once a person has been treated for HSV-2, the person is immune to further
outbreaks.
ANS: A
Unlike gonorrhea, there is no cure for HSV-2 infection; it is considered a chronic disease. Recurrence with HSV-2 is common. The
treatment for HSV-2 may be episodic or suppressive for frequent recurrence, which is not expensive to treat. HSV-2 may be
asymptomatic but does appear as vesicles, painful ulceration of penis, vagina, labia, perineum, and anus with lesions lasting 5 to 6
weeks.
14. When a nurse discovers that a woman has been treated for cervical cancer, the nurse asks the woman whether she has ever been
tested for HIV or other STDs. The woman is offended and asks why the nurse would ask her such a thing. Which of the following
statements would be the best response from the nurse?
a. “Cervical cancer treatments may decrease immunity, so that it is easier to acquire
STDs.”
b. “Cervical cancer usually is caused by HPV, and often the presence of one STD is
accompanied by other STDs.”
c. “The presence of an STD in women with cervical cancer may lead to congenital
defects in offspring.”
d. “The presence of an STD in a woman with a history of cervical cancer has been
associated with a relapse of the cancer after treatment.”
ANS: B
The link between HPV infection and cervical cancer has been established and is associated with specific types of the virus. In 80%
to 90% of cases of cervical cancer, evidence of HPV has been found in the tumor. Additionally, HSV-2 infection is linked with the
development of cervical cancer. Because the presence of an STD increases the risk for the presence of other STDs, it is essential to
screen for this information. There is no evidence that the presence of an STD in women with cervical cancer will lead to congenital
defects in offspring. The presence of an STD increases the risk for another STD. There is no evidence of relapse of cervical cancer
when there is presence of an STD.
15. Which of the following best describes the characteristic appearance of lesions of human papillomavirus (HPV)?
a. Solitary growth with elevated borders and a central depression
b. Elevated growths with a “cauliflower” appearance
c. Thin-walled pustules that rupture to form honey-colored crusts
d. Vesicles that ulcerate and crust within 1 to 4 days
ANS: B
HPV causes genital warts that appear as textured surface lesions, with what is sometimes described as a cauliflower appearance.
The warts are usually multiple and vary between 1 and 5 mm in diameter. The other descriptions are not characteristic of lesions of
the human papillomavirus (HPV).
16. A client who is very upset says to the nurse, “But we always used a condom! How could I have genital warts?” Which of the
following would be the best response by the nurse?
a. “Are you positive you always used a condom?”
b. “Condoms don’t always work.”
c. “The condom might have had a tear in the latex.”
d. “Contact may have occurred outside the area that the condom covers.”
ANS: D
Warts may grow where barriers, such as condoms, do not cover, and skin-to-skin contact may occur. The challenge of HPV
prevention is that condoms do not necessarily prevent infection. Thus, even with correct usage and the use of undamaged condoms,
transmission may still occur.

17. Which of the following statements best explains why many health care providers are more afraid of getting hepatitis B (HBV) than
HIV?
a. Everyone would assume the person infected with hepatitis B is a drug user.
b. Having HBV would mean no further employment in health care.
c. The fatality rate is higher and occurs sooner with HBV.
d. There is no treatment for HBV, which can be a very serious illness.
ANS: D
Unlike HIV, there is no treatment for hepatitis B, and although some persons never have symptoms and others fight off the disease,
many suffer from chronic hepatitis B, a very serious illness. Others may become chronic carriers of the disease. There are multiple
populations that have a high prevalence of HBV including injection drug users, persons with STDs or multiple sex partners,
immigrants, and refugees and their descendants who came from areas where there is a high endemic rate of HBV, health care
workers, clients on hemodialysis, and inmates of long-term correctional institutions. Those who are infected with HBV are still able
to work in health care. There is no evidence that the fatality rate is higher or sooner with HBV than with HIV.
18. A nurse explained to a new mother that because she had tested positive for the hepatitis B virus, her newborn son would need the
hepatitis B vaccine immediately and then also an immune globulin injection. “Wait,” said the new mother. “Why is my son getting
two shots?” Which of the following statements would be the best response by the nurse?
a. “One injection protects your son, while the other encourages his body to build up
immunity.”
b. “One shot keeps your son from getting sick, while the other is a typical vaccine to
prevent you from accidentally infecting him.”
c. “Since you’ve already been infected with the virus, your son needs twice as much
protection.”
d. “The second shot is just to make sure the first one works.”
ANS: A
Because infected persons may not have any symptoms, all pregnant women should be tested for HBsAg. If the mother tests
positive, her newborn needs hepatitis B immune globulin to provide passive immunity and thus prevent infection. In addition, the
newborn is given the hepatitis B vaccine at birth, with two follow-up injections, to build active immunity to the infection. One of
the shots provides passive immunity and the other provides active immunity. The active immunity continues to be built up by
receiving two follow-up injections weeks later.
19. A client diagnosed with tuberculosis (TB) asks why the nurse is required to watch the client swallow the medication each day.
Which of the following statements is the best response by the nurse?
a. “Clients with TB are often noncompliant, so if I directly observe, you will be sure
to take the drugs that have been ordered.”
b. “This therapy is recommended to make sure that you receive the treatment you
need and the infection doesn’t become resistant to the drugs.”
c. “This is to make sure you take your medication if your condition becomes so
advanced that you do not have enough cerebral oxygenation to remember.”
d. “Tuberculosis medications are very expensive so this method ensures that
government money doesn’t get wasted on those who will not take the drugs.”
ANS: B
It is important to be respectful to clients and to consider their perspective and psychological health while also responding truthfully.
Directly observed therapy (DOT) programs for TB medication involve the nurse observing and documenting individual clients
taking their TB drugs. When clients prematurely stop taking TB medications, there is a risk that the TB will become resistant to the
medications. This can affect an entire community of people who are susceptible to this airborne disease. DOT ensures that
TB-infected clients receive adequate medication. Thus, DOT programs are aimed at the population level to prevent antibiotic
resistance in the community and to ensure effective treatment at the individual level. Many health departments have DOT home
health programs to ensure adequate treatment. The risk to client and the community if the client does not follow the treatment
regimen is that the TB will become resistant to these medications. It does not have to do with the possibility of noncompliance by
the patient, that the patient will not remember, or related to the cost of the medications.
20. A nurse is concerned about the prevalence of tuberculosis among migrant farm workers. Which of the following activities would be
best to use when implementing tertiary prevention?
a. Administer purified protein derivative (PPD) to contacts of those with
tuberculosis.
b. Initiate directly observed therapy (DOT) for tuberculosis treatment.
c. Provide education about the prevention of tuberculosis to members of the migrant
community.
d. Use skin tests to screen migrant health workers for tuberculosis infection.
ANS: B
Tertiary prevention is carried out among persons already infected with the disease. In this instance, DOT ensures compliance with
treatment to cure the disease and to prevent worsening or the development of secondary problems. Administering purified protein
derivative (PPD) to contacts of those with tuberculosis is secondary prevention as this is an at-risk population. Providing education
about the prevention of tuberculosis to members of the migrant community is a primary prevention strategy as it is aiming to
prevent the disease from occurring. Using skin tests to screen migrant health workers for tuberculosis infection is secondary
prevention as it is a screening aimed at early detection of the disease.

21. A mother felt very guilty that her baby was born HIV positive. When the nurse suggested the usual DPT and MMR immunizations,
the mother was extremely upset. “Don’t you know HIV children are immunosuppressed?” she exclaimed. Which of the following
would be the nurse’s best response?
a. “All children have to have these immunizations before they can attend school.”
b. “Being HIV positive, your child is more likely to catch an infection and be very
ill if not immunized.”
c. “I’m so sorry; I forgot for a moment your child was HIV positive.”
d. “The American Pediatric Association requires all health care providers to offer
these immunizations to all parents; it is your choice whether or not to accept
them.”
ANS: B
Because of impaired immunity, children with HIV infection are more likely to get childhood diseases and suffer serious
consequences of the diseases. Therefore, DPT, IPV, and MMR vaccines should be given at regularly scheduled times for children
infected with HIV. Other immunizations may also be recommended after medical evaluation. Although this child is HIV positive,
there is no medical reason why the child should not be immunized. Many states do have a “no shots, no school” law, but exceptions
can be made. The APA does recommend immunizations for most children, but this is not the best answer.
22. A nurse was reading PPD tests 24 hours after another nurse had administered them. Which of the following findings would cause
the nurse to interpret the test as positive?
a. 15 mm of erythema in a client with HIV infection
b. 5 mm of induration in an immigrant from a country where TB is endemic
c. A 5-mm ruptured pustule with purulent drainage in a homeless client
d. 10 mm of swelling and increased firmness in a client recently released from a
correctional facility
ANS: D
For a PPD test to be positive, induration (swelling with increased firmness) must be present. A diameter of 10-mm induration
would be a positive finding in an immigrant from a region with high TB infection. Erythema alone does not indicate a positive
finding. A 5-mm induration is not large enough to indicate a positive finding. A small pustule in a homeless client undoubtedly is
an infection but may not be due to the PPD test.
23. A high school student is planning to volunteer at the hospital after school, so he or she needs to have a Mantoux test before
beginning. Which of the following information should the nurse provide to the new volunteer?
a. “I will be using tiny tines to administer the TB antigen to the skin on your arm.”
b. “Notify the clinic immediately if you experience any redness or itching at the test
site.”
c. “The areas should be kept dry until you return; cover it with plastic wrap when
bathing.”
d. “You will need to return in 2 to 3 days to have any reaction interpreted.”
ANS: D
The Mantoux test is a TB skin test that involves a 0.1-ml injection containing 5 tuberculin units of PPD tuberculin (not tines as in
the TB tine test). The site should be examined for a reaction 48 to 72 hours (2 to 3 days) after injection. Only induration should be
measured, and the results should be recorded in millimeters. The Mantoux test involves a 0.1-ml injection not tines as in the TB
tine test. Slight redness or itching at the test site may occur, but that should resolve on its own and does not require the client to
notify the clinic. The client can engage in normal activities; the site does not need to be kept dry.
MULTIPLE RESPONSE
1. A woman and man who have come to the health clinic begin to argue loudly. “You gave me an STI!” the man yells. The woman
screams back, “Not me. I don’t have an STI!” Which of the following statements would be most appropriate for the nurse to say to
them? (Select all that apply.)
a. “Actually, you’re very fortunate to have been tested, so you and your partner can
begin treatment before more serious damage is done.”
b. “Some STIs may not have any symptoms, so you need to be tested for other
conditions and treated if necessary.”
c. “Sometimes the test is inaccurate, so before getting too upset, you should ask to
be tested again.”
d. “You may be able to get treatment from your pharmacist so you won’t have to be
embarrassed like this again.”
e. “Some STIs are spread in ways that are non-sexual in nature.”
ANS: A, B, C
Often cases of gonorrhea and chlamydia are asymptomatic, so treatment may not be sought and these infections are spread to others
through sexual activity. Similarly, during latency, syphilis has no symptoms. It should be noted, however, that STI test results can
sometimes be incorrect and the coexistence of other medical conditions may cause a false-positive test result. Having a partner
retested, if the results were negative, would also suggest retesting the first person. The pharmacist must receive an order from the
primary care provider in order to dispense a prescription.

2. The public health nurse comes to the hospital to see a client just diagnosed with hepatitis A. The nurse says, “I’m sorry to bother
you when you’re not feeling well, but I need to ask you a few questions.” Which of the following questions would be most
appropriate for the nurse to ask the client? (Select all that apply.)
a. “Do you know how you got this infection?”
b. “Who lives with you?”
c. “Where are you employed?”
d. “Where do you usually eat?”
e. “Are you sexually active?”
ANS: B, C, E
The nurse should ask about sexual contacts and ask who (if anyone) lives with the client because the named individuals will need to
have immune globulin administered to hopefully prevent the spread of hepatitis A and a community epidemic. The nurse should
also ask about the client’s place of employment because certain settings warrant special considerations. For example, in restaurants,
hospitals, daycare centers, or other institutions, the lack of careful hand-washing by an infected worker can result in contamination
of many others. Hepatitis A can be spread through food contaminated by an infected food-handler, contaminated produce, or
contaminated water. However, this mode of transmission is not very common in the United States.
3. In which of the following cases would the school nurse be correct to advise the parents of an HIV-infected child to keep the child
home from school? (Select all that apply.)
a. The child develops allergies with sneezing.
b. The child is unable to control body secretions.
c. The nurse is not comfortable with being responsible for the child.
d. There is an outbreak of chickenpox in the school.
e. The child persists in biting behavior.
ANS: B, D, E
Not attending school may be advisable if cases of childhood infections, such as chickenpox or measles, occur in the school, because
the immunosuppressed child is at greater risk for suffering complications. Alternative arrangements, such as homebound
instruction, might be instituted if a child is unable to control body secretions or displays biting behavior. HIV-positive children are
encouraged to obtain routine immunizations, because their immune systems are compromised and they are more susceptible to such
infections. To date, no cases of HIV infections being transmitted in a school setting have occurred in the United States. Thus, the
nurse should not be fearful of providing care to this child.

Chapter 13: Community Assessment and Evaluation
MULTIPLE CHOICE
1. Which of the following is the best brief definition of community?

a. A geographic area or political division under common leadership
b. A group sharing a common bond such as a profession or occupation
c. A group working together to confront a common problem
d. A social group with common goals within a geographic area
ANS: D
According to WHO, a community is “A group of people, often living in a defined geographical area, who may share a common
culture, values and norms, and are arranged in a social structure according to relationships which the community has developed
over a period of time. Members of a community gain their personal and social identity by sharing common beliefs, values and
norms which have been developed by the community in the past and may be modified in the future.” The correct answer includes
aspects of people, place, and function or aims. In addition to sharing geographic boundaries and leadership, a community also has
common values and interests. In addition to sharing a common bond, members within a community have to interact with one
another. A group working together to confront a common problem only addresses the aspect of function; it does not address people
or place.
2. A nurse is practicing in the community but also has the community as the target of practice. Which of the following best describes
the activities of this nurse?
a. Providing care to an active caseload of 50 families in the neighborhood
b. Inviting all the parents of asthmatic children in the school to meet together for
mutual support
c. Sharing assessment findings and health goals with every community group that
will listen
d. Writing articles for the local newspaper highlighting the various programs and
services of the local health department
ANS: C
Meeting with all interested community groups is the only way to keep the focus on the community rather than on individuals.
Although it is not possible to know the nurse’s goals from the nurse’s behavior, giving care to select groups does not represent the
whole community. Publicizing services increases knowledge but doesn’t necessarily help eligible clients access care.
3. Persons often point out that smokers choose to light their cigarettes; alcoholics lift the glass to their mouth, and drug addicts inject
or ingest their drugs. Which of the following statements best describes why nurses don’t simply focus on helping persons who
engage in poor health behaviors to behave appropriately?
a. Addicts don’t have the willpower to change their behavior.
b. It is too rewarding to continue the behavior for a person to be able to change.
c. Laws and policies must reward good healthy behaviors and punish unhealthy
behaviors to help individuals recognize the importance of change.
d. Society must offer healthy choices, offer support, and practice helpful policies.
ANS: D
Change for the benefit of the community client often must occur at several levels, ranging from the individual to society as a whole.
Lifestyle-induced health problems cannot be solved simply by asking or encouraging individuals to choose health-promoting
habits. Society also must provide healthy choices. Most individuals cannot change their habits alone; they require the support of
family members, friends, community health care systems, and relevant social policies. Change in society is helpful for addicts to
change their behavior. Many times, certain aspects of society limit an individual’s ability to make change on their own. Laws and
policies within society must support individuals to make healthy lifestyle choices.
4. A nurse is focusing on the process dimension of a community’s health. Which of the following interventions will the nurse most
likely implement?
a. Assessing the health care services available in a community
b. Establishing screening programs to diagnose diseases as early as possible so that
the treatment can begin
c. Implementing health promotion activities such as education programs
d. Planning for new programs to be developed based on identified needs
ANS: C
When the emphasis is on the process dimension—usually the level of intervention of the nurse in community health—the best
strategy is usually health promotion, such as various primary prevention strategies. The other responses represent the structure
dimension of the community. Structure is defined as the services and resources within the community. This includes service use
patterns, treatment data from various health agencies, and provider-to-client ratios.

5. A nurse has invited community members to participate as full partners in creating changes to improve the health of the community.
Which of the following may be an unexpected consequence of this action?
a. A change in the distribution or redistribution of power and influence
b. An increase in awareness of the importance of health
c. Continued ongoing interest in community health activities
d. Improved family functioning and involvement in health activities
ANS: A
Collaborative practice models involving the community and nurses in joint decision-making and specific nursing roles are required.
Nurses must remember that collaboration means shared roles and a cooperative effort in which participants want to work together.
These participants must see themselves as part of a group effort and share in the process, beginning with planning and including
decision-making. This means sharing not only the power but also the responsibility for the outcomes of the intervention. By having
the community members involved in creating the health change, it is likely they will have an increased awareness of the importance
of health, an ongoing interest in the health of the community. These things should occur because the community is more educated
about its health because of its involvement. Being involved will not necessarily result in improved family functioning, so this
consequence will most likely not occur.
6. During the assessment phase, the nurse compiles and interprets available data and draws conclusions as to the community’s
strengths and concerns. Which of the following best describes why the nurse would also conduct interviews with key informants?
a. To ensure that others agree with the nurse’s plans for interventions
b. To confirm the nurse’s initial findings and conclusions
c. To encourage community partners to feel they “own” the data
d. To generate non-statistical data such as values, beliefs, and perceived needs
ANS: D
Data generation is the process of developing data that do not already exist, through interaction with community members,
individuals, families, or groups. Such information might include the community’s knowledge and beliefs, values and sentiments,
and goals and perceived needs. Such data are collected by interviews and observation. Interviews with key informants provide data;
the purpose is not to ensure agreement with the nurse’s plan or confirm findings. The key informants are formal or informal leaders
within the community, and although they may have information to share about the community, it may not be important that they
feel that they “own” the data.
7. A nurse just accepted a position in community health and has been assigned to a neighborhood very close to where she lives.
Which of the following best describes the rationale for this assignment?
a. To allow participant observation by the nurse
b. To ensure that the nurse would care about her intervention outcomes
c. To maximize convenience and minimize commuting time for the nurse
d. To save gasoline in these difficult economic times
ANS: A
Such an assignment allows for participant observation or the deliberate sharing in the life of a community. If the nurse lives in the
community, activities such as participating in clinical organizations and church life and reading the newspaper give the nurse
“observations” of the community’s life. The nurse should care about the interventions that are performed regardless of where the
nurse lives. The priority is that the nurse is knowledgeable of and can observe the community, the assignment does not have to do
with the convenience of the nurse.
8. A community health nurse drives through an assigned community before visiting the community groups scheduled for the day. The
nurse then drives through the community again that evening before going home. Which of the following best describes the nurse’s
reason for driving through the community twice in the same day?
a. On the second trip, the nurse can carefully confirm the results of the first
assessment.
b. Repeating the experience ensures that the nurse absorbed all the relevant details.
c. Driving through twice allows the nurse to see the community when many
residents are at work or at school and then again when most are at home.
d. When leaving in the evening, the nurse has more time to write down the results of
the earlier assessment.
ANS: C
When doing a windshield survey as part of community assessment, the nurse should observe two times: one during the day when
people are at work and children are at school and a second time in the evening after work is done and school is out. It is likely that
different things are occurring in the community when the nurse drives through the community at different times. Therefore, it is
likely that the nurse will learn more about the community by doing this and not necessarily confirm previous findings. If the nurse
was interested in writing down the results of the findings, the nurse could use public transportation or ride in a car with another
nurse driving for more efficient documentation of her findings; this would not necessarily occur by the nurse driving through the
community in the evening.
9. Before beginning to survey the community to assess its health needs and strengths, the nurse reviews various documents, including
local statistical data and the minutes of the previous meeting of the health care agency. Which of the following best explains why
the nurse would start with this activity?
a. To avoid confronting the community until the nurse is thoroughly oriented
b. To become familiar with previous goals and priorities of the agency
c. To help get a better understanding of the assigned community
d. To save time and effort and perhaps have new insights
ANS: D
The nurse uses previously gathered data because it saves time and effort. Many sources of data are readily available and useful for
secondary analysis. Being familiar with the community before the assessment is important; however, being thoroughly oriented is
not necessary. The nurse should become familiar with the community, not the goals and priorities of the agency. It is helpful for the
nurse to better understand the community, but the main reason is to save time and avoid duplication of data that may already exist.

10. A new nurse is overwhelmed with the needs of the community. Which of the following should be the first priority of the nurse?
a. A problem that affects the most disadvantaged residents in the community
b. A problem that is very easy and inexpensive to address
c. A problem that is of high concern to the community
d. A problem in an area in which the nurse has a great deal of expertise
ANS: C
Choice of priority must depend on the community’s awareness of the problem—and their motivation to improve it. Other bases for
choosing include determining which individuals would be most affected, what benefits to the community would result, what might
happen if the problem is not resolved, how much it might cost to address the problem, and how much support for or opposition to
the problem seem likely based on community values and priorities. Rather than examining the issues from the perspective of the
most disadvantaged residents, the nurse should look at the problem which affects most individuals in the community who may or
may not be disadvantaged. The cost of the problem will need to be addressed, but if the problem is not a priority to the community,
the agency may be wasting money addressing a problem that the community does not care to solve. If the nurse is unfamiliar with
interventions to solve the problem, the nurse should collaborate with others to solve the problem. The priority should be the needs
of the community, not the needs of the nurse.
11. Which of the following objectives is most appropriate for the development of a community-oriented nursing care plan?
a. All monitored patients will receive abortive therapy for lethal dysrhythmias
within 3 minutes of dysrhythmia recognition.
b. Of mothers receiving nutrition counseling, 80% will identify five sources of
calcium by the end of class.
c. 95% of children will be immunized by 1 year of age.
d. There will be a 25% reduction in health disparities by 2015.
ANS: B
Objectives must be precise, behaviorally stated, and measurable. The response that describes mothers receiving nutrition
counseling represents a specific, measureable behavior as an objective. Treatment in an acute care setting is not part of a
community-oriented care plan. The objective that 95% of children will be immunized by 1 year does not precisely state which
children (in a county? in the country?) and does not state which immunizations. (Some are not appropriate to give to children who
are only 1-year-old.) A 25% reduction by 2015 is a goal, not an objective.
12. During which of the following activities is the nurse in community health acting as a partner in change?
a. Administering vaccinations to preschoolers
b. Analyzing community problems to determine the best interventions
c. Establishing an elder-care center for older adults living with family members who
work
d. Teaching anger management skills to a group of teens in a halfway house
ANS: D
Content-focused roles often are considered change agent roles, whereas process roles are called change partner roles. Change
partner roles include those of enabler-catalyst, teacher of problem-solving skills, and activist agent. Teaching anger management
skills to a group of teens in a halfway house demonstrates the use of a change partner role of teacher of problem-solving skills.
Change agent roles stress gathering and analyzing facts and implementing programs. The nurse establishing an elder-care center is
acting as a change agent. The nurses administering vaccinations and analyzing community problems are carrying out other nursing
roles.
13. A nurse is assessing a community’s openness to change. Which of the following variables indicate that the community is ready?
a. Commitment to current processes and policies
b. High socioeconomic status in the community as a whole
c. Long history of dependence on the community health agency and its staff
d. Minimal level of social participation by community members
ANS: B
The ability to change is often directly related to higher socioeconomic status; a perceived need for change; the presence of liberal,
scientific, and democratic values; and a high level of social participation by community residents. Not all communities are open to
change. Ability to change is often related to the extent to which a community focuses on traditional norms. The more traditional the
community, the less likely it is to change. A community that is open to change is likely to be open to changing current processes
rather than focusing on tradition. Communities that are open to change typically have a high level of social participation by its
residents.
14. A nurse is working toward an objective to “increase to at least 90% the proportion of all pregnant women who receive first
trimester prenatal care.” During which of the following phases of the nursing process would determination of the objective occur?
a. Assessment phase
b. Planning phase
c. Implementation phase
d. Evaluation phase
ANS: B
Evaluation begins in the planning phase, when goals and measurable objectives are established, and goal-attaining activities are
identified. Assessment involves getting to know and understand the community as the client. Implementation involves the work and
activities aimed at achieving the goals and objectives. Evaluation is the appraisal of the goals and objectives that have been created.

15. A nurse is assessing the status of a community’s health. Which of the following will the nurse examine?
a. Community awareness
b. Health facilities
c. Health care manpower
d. Vital statistics
ANS: D
The status of community health involving biological indicators is often measured by traditional morbidity and mortality rates,
life-expectancy indices, and risk-factor profiles. Vital statistics are measures of community health status. Health care manpower
(e.g., nurses, physicians) and health facilities (e.g., hospitals, clinics) are measures of community health structure. Community
awareness is a measure of the process.
16. A nurse is assessing the structure of a community’s health. Which of the following data will the nurse examine?
a. The community’s commitment to health
b. Health-risk profiles of selected aggregates
c. Statistics of morbidity and mortality in comparison with similar communities
d. Treatment and service use patterns from local health agencies and care providers
ANS: D
Community health, when viewed from the structure of the community, is usually defined in terms of community characteristics, as
well as services and resources. Indicators used to measure community health services and resources include service use patterns,
treatment data from various health agencies, and provider/client ratios. The community’s commitment to health is part of the
process dimension of the community. Health risk profiles and vital statistics are part of the status dimension of the community.
MULTIPLE RESPONSE
1. A community health nurse encourages members of the community to partner and assist in creating health programs. Which of the
following best describes the rationale for this action? (Select all that apply.)
a. Partnering results in increased effectiveness
b. Involving community members results in contributions of time and money into
the program
c. Having many partners results in increased publicity for the program
d. Participating in planning results in having a vested interest in the outcome
e. Involving community partners ensures increased support by the populace
ANS: A, D
The primary reason community partnership is crucial is that community members and professionals who are active participants in a
collaborative decision-making process have a vested interest in the success of efforts to improve the health of their community. The
significance and effectiveness of partnership in improving community health are supported by a growing body of literature.
Community partners do contribute time and money into programs and most likely will increase the publicity for the program;
however, this should not be the primary reason for including them in the partnership. Increased populace support is not necessarily
assured by community partnerships. Through the partnership, it is likely that the program will have increased success and better
outcomes, which should be the primary objective of the nurse.
2. A community health nurse is beginning to work with a newly assigned community. Which of the following would be appropriate
actions for the nurse to take to help ensure acceptance? (Select all that apply.)
a. Asking those with whom the nurse interacts in the course of daily living their
perception of the community (e.g., clerks in grocery stores or pharmacies)
b. Attending community events such as festivals or fairs and interacting with
participants
c. Becoming involved in and contributing to volunteer community organizations
d. Completing a comprehensive physical assessment on nearby neighbors
e. Arranging to meet with the community’s governing body
ANS: A, B, E
Gaining entry or acceptance into the community is perhaps the biggest challenge in assessment. The nurse is usually an outsider
and often represents an established health care system that is neither known nor trusted by community members, who may therefore
react with indifference or even active hostility. Entry into the community is critical. Often the nurse can gain entry by taking part in
community events, visiting people in formal leadership positions, and clarifying community members’ perceptions of health needs.
While an activity such as volunteering is a positive action, it is not the most efficient way to become involved in the wider
community. Completing physical assessments on individuals is an individual-based, not community-based intervention and would
not be anticipated to be performed by the community health nurse.
3. A nurse is deciding which alternative interventions should be implemented. Which of the following factors must be considered by
the nurse when making this decision? (Select all that apply.)
a. The expected effect or outcome of each possible intervention
b. How interested others are in helping in any particular intervention
c. The nurse’s own interest in implementing each intervention
d. The likelihood that the intervention will resolve the problem
e. Change process required to achieve stated objective
ANS: A, B, D, E
The nurse can list each possible intervention and then consider the resources or barriers to that particular interventio n, the expected
effect of each choice, the likelihood that the activity will help meet the objective and resolve the problem, whether others can be
educated to implement the intervention, and the change process necessary to complete the objective. The primary interest should be
the concern of the community, not the nurse’s personal interests.

4. A nurse wants to determine whether health problems have been improved and interventions have been appropriate and successful
over a period of time. Which of the following data should the nurse examine? (Select all that apply.)
a. Changes in staffing patterns in the health agency
b. Demographic data
c. Education and school statistics
d. Environmental factors
e. Utilization of health services
ANS: B, D, E
To see the outcomes of chosen interventions, the nurse would examine changes in demographics, socioeconomic factors,
environmental factors, health status, and/or use of health services. Changing in staffing patterns and education and school statistics
would not be impacted by a change in the health problems in the community. Epidemiologic data and trends would be the best
sources to examine to evaluate the change.
5. Which of the following activities are considered to be part of the core competencies for public health professionals? (Select all that
apply.)
a. Defining variables relevant to current public health problems
b. Obtaining and interpreting information regarding risks and benefits to the
community
c. Implementing nursing care and subsequent evaluation outcomes
d. Maintaining public health departments throughout the United States
e. Focusing on health concerns of the individuals residing within the community
ANS: A, B
Eleven core competencies for the nurse and other health providers working in the community have been defined by the Council on
Linkages Between Academia and Public Health Practice. Defining variables relevant to current public health problems and
obtaining and interpreting information regarding risks and benefits to the community are two of the eleven core competencies.
Implementing nursing care focuses on care for individuals and not the community; it is not one of the core competencies. Public
health nurses have various roles within the community, they may or may not work for a public health department. It is not within
the scope of public health nurses to be responsible to maintain these departments.
6. A community health nurse has been recently hired to work in an unfamiliar community. Which of the following persons would be
the effective key informants for the nurse? (Select all that apply.)
a. Community’s immigrant group activist
b. Federal senators and representatives
c. Health board members
d. The town mayor
e. Local Clergy
ANS: A, D, E
Informant interviews, which consist of directed talks with selected members of a community about community members or groups
and events, are basic to effective data collection. Talking to key informants is a critical part of the community assessment. Key
informants are not always those who have a formal title or position. Key informants often have an informal role within the
community. Examples of informal key informants would include a member of a minority group who is listened to by other
members of the group, a church leader, and a parent who is active and vocal about the school health curriculum. Key informants
should be formal or informal leaders within the community. Based on the information provided, it is not known if the federal
senators, representatives, and health board members fulfill these roles within the community.

Chapter 14: Health Education in the Community
MULTIPLE CHOICE
1. A member of a community weight-loss group has maintained a healthy weight for 2 years through healthy eating and daily
exercise. Which of the following steps of the affective domain is this participant demonstrating?
a. Analysis
b. Application
c. Evaluation
d. Knowledge
ANS: C
Steps in the affective domain have the learner doing the following in this sequence: knowledge, comprehension, application,
analysis, synthesis, and evaluation. During evaluation, the learner adopts behaviors consistent with the new values. In this example,
the individual has adopted the behavior, and this has resulted in the ability to maintain the value of a healthy weight. Steps in the
affective domain have the learner doing the following in this sequence: (1) knowledge: receives the information; (2)
comprehension: responds to what is being taught; (3) application: values the information; (4) analysis: makes sense of the
information; (5) synthesis: organizes the information; (6) evaluation. None of the other options are considered in the sequence.
2. A nurse just finished teaching breast self-examination to a large group of women at a professional conference. During the session,
the nurse distributed literature and used culturally appropriate visual aids. However, the session was not as effective as it could
have been. Which of the following was the most important thing omitted by the nurse?
a. Time for audience members to ask questions and clarify the information
b. Explanation of why culturally appropriate images are more acceptable
c. Opportunity for the women to practice what they learned
d. Use of simple language instead of printed material
ANS: C
The learner must have opportunities to practice the new skills being learned. Provide practice sessions during the program because
many people may not have the time, facilities, motivation, and/or support to practice at home what they have learned. Because
breast self-examination is a psychomotor skill, the emphasis should be placed on the learner having the ability to perform the skill
after the conference. The most important aspect should be the time for practice in this situation, and not on the time for questions.
The nurse would not need to explain to the audience why culturally appropriate images are acceptable, rather these should have
been incorporated into the session. Having printed materials is important so that the learner has a reference after leaving the
conference.
3. A nurse is providing an educational program about testicular self-examination (TSE). Which of the following would be the best
learning objective for this program?
a. Each participant will state why TSE is important and explain how to do it.
b. Each participant will describe how to do TSE and discuss the dangers of testicular
cancer.
c. 90% of the men will correctly demonstrate testicular self-examination.
d. 100% of the men will do a testicular examination correctly on a model.
ANS: C
If the goal is to learn TSE, the best goal is for the person to be able to do TSE correctly. Being able to state why it is important is a
helpful first step, as is practice on a model, but to be sure the person can really do the procedure, you need to allow practice time
and feedback until the person can demonstrate the procedure properly.
4. A nurse planned a presentation about the latest trends in disaster planning for the senior nursing students at the local college.
However, when the nurse began to share the information, the students were talking to one another and essentially ignoring the
nurse. Which of the following actions should be taken by the nurse?
a. Ask the students why they are being so rude.
b. Explain why the information is crucial to their current clinical practice.
c. Nothing; let the instructor of the course handle the problem.
d. Tell a joke to get the students’ attention.
ANS: B
Before learning can take place, you need to gain the learner’s attention. One way to do this is by convincing the learner that the
information about to be presented is important and beneficial to them personally. Asking the students why they are being so rude
would not be a professional response by the nurse. The nurse should take responsibility for gaining the attention of the audience
and not expect the instructor to do so. Gaining the students can best be accomplished by telling the students why it is important
rather than telling a joke.
5. Which of the following statements by the client indicates the client is experiencing a learner-related barrier to new information
about type 2 diabetes management?
a. “I know about diabetes; my sister has it.”
b. “I Don’t like to read’ just tell me what I need to know.”
c. “It won’t change my life; it’s type 2 diabetes.”
d. “It can’t be that hard to learn; I don’t have to take shots.”
ANS: B
One of the most important learner-related barriers is low literacy. Nurses often deal with individuals and populations who are
illiterate or who have low literacy levels. These individuals may be embarrassed to admit their reading deficit to health care
providers, and educators and may try to appear to understand when they really do not. Denying the impact or the importance of
learning about a new diagnosis is problematic but not considered a primary barrier.

6. A nurse uses lecturing as the primary method of educating clients. Which part of the education process is missing?
a. Evaluation
b. Experience
c. Participation
d. Understanding
ANS: C
Educators should include participation. Lack of participation is a barrier to learning. Merely sitting and listening to someone lecture
are not as effective as discussion, even when the presentation is stimulating, interesting, and dynamic. Evaluation occurs at the end
of the education; evaluation is not necessarily missing when an educator uses lecture as the primary method of education. The nurse
may be able to include experiences as part of the lecture when educating clients. It may be difficult to assess understanding if
lecture is the primary method of education; however, the nurse should be able to use nonverbal clues to assess understanding. Also,
the use of lecture does not mean that understanding is missing from the process.
7. The nurse gives a very informative and engaging presentation and then gives everyone in the audience a handout that outlines the
presentation. Later, the nurse discovers that many of the handouts were thrown away before the audience left the building. Which
of the following educational principles has the nurse forgotten?
a. Audiences expect PowerPoint or video presentations, not lectures.
b. Many Americans do not have a high reading level.
c. People want photographs and images, not wordy outlines.
d. The nurse gave them too much information too fast for them to want to cope with
it all.
ANS: B
Most health information is printed at a tenth-grade reading level, which is too difficult for almost half of the adult readers in the
United States. If people cannot read or understand the material, they discard it. Although visual images are certainly helpful, it does
not explain why the handouts were discarded. Audience’s expectations of the use of PowerPoint or video presentations or receiving
too much information too fast do not explain why the handouts were thrown away. If the nurse covered information too fast, it is
likely that the participants may have been more inclined to keep the handout.
8. Which of the following statements regarding the Health Belief Model is accurate?
a. Cues to action are an important component of the model.
b. Multiple methods of education should be used when implementing this model.
c. The first stage experienced in this model is the pre-contemplation stage.
d. To successfully implement this model, ongoing maintenance of the behavior must
be considered.
ANS: A
The Health Belief Model includes six components that attempt to answer the question of what motivates an individual to do
something. These components are perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to
action, and self-efficacy. The Health Belief Model does not indicate the number of methods of education that should be used. The
pre-contemplation stage is part of the Transtheoretical Model. Maintenance is part of the Precaution Adoption Process Model.
9. A nurse is planning an educational program about cardiovascular disease. Which of the following would be the optimal time for the
nurse to elicit feedback from program participants?
a. At the beginning of the program
b. At the program midpoint
c. Immediately following program completion
d. Throughout the program
ANS: D
Not only should learners receive feedback but the educator should also elicit feedback from learners throughout the educational
process. On the basis of the feedback that the educator receives from learners, the implementation and presentation of the
educational program can be modified. Obtaining feedback only at one point in time during the program does not give the nurse
enough feedback as to what is happening throughout the presentation. In order for the educator to modify the teaching process and
better meet the learner’s needs, evaluation data should be obtained at multiple points in time.
10. When evaluating an educational program, the nurse discovers that only 25% of community members met the learning objectives.
Which of the following parts of the program should be improved?
a. Educator
b. Content
c. Learners
d. Objectives
ANS: A
Ultimately, the educator is responsible for the success or failure of the educational process and the development of learner
knowledge, skills, and abilities. If evaluation reveals that the learning objectives are not being met, the nurse must determine why
the instruction is not effective. The educator is responsible for presenting the material creatively and meaningfully in new ways to
increase learner retention and ability to apply the new knowledge. The educator determines how content can be tailored to the
learner. The educator determines the objectives.

11. A man says, “I just can’t get myself to leave the house and go for a 30-minute walk each day. I wish I could think of some way to
motivate myself.” Which of the following would be the best action for the nurse to take?
a. Establish a written contract between him and his employer that states walking is
required each day.
b. Recognize the reasons why 30 minutes of walking each day is one of the best
health promotion activities he can choose.
c. Join a group that walks early each morning.
d. Set up rewards, such as a nice snack after he gets back from walking.
ANS: C
Health behavior is influenced by the groups to which people belong. Having someone else to walk with is an effective way to
maintain the behavior. Group support often helps people make needed changes for health that they are unable to accomplish on
their own or with the help of just one individual. The role of the employer is not to dictate employee health behaviors, so having a
written contract would be inappropriate. The man may already recognize that walking is one of the best health promotion activities
he can choose; however, he has expressed that he is lacking motivation. Setting up rewards for himself may be helpful; however, it
may not be enough to get him motivated to take action. Group support may help him to get motivated.
12. A nurse is meeting to discuss problems and solutions with a group of teenagers who have been newly diagnosed with diabetes. One
teenager states, “My mom found this particular brand of popcorn that has only 15 carbohydrates in the whole giant bag.” Which of
the following best describes the group purpose that is being served by the teenager’s statement?
a. Maintenance function of encouraging everyone to continue the discussion
b. Maintenance function of helping everyone feel comfortable talking about food
c. Task function of resolving problems about what to nibble during movies
d. Task function of sharing information and resources
ANS: D
A task function is anything a member does that deliberately contributes to the group’s purpose. Members with task-directed
abilities are attractive to the group. These traits include strong problem-solving skills, access to material resources, and skills in
directing. The teenager’s statement shared information about a good resource for the group. Maintenance functions help members
affirm, accept, and support one another, resolve conflicts, and create social and environmental comfort. The teenagers’ comment
does not support a maintenance function of the group, rather it focuses on a task function by contributing to the group’s purpose.
13. A nurse invited all the teenagers who were newly diagnosed with diabetes to a group meeting to discuss issues they all had in
common. One teenager replied, “I don’t know if I want to share all the problems I’m having with strangers.” Which of the
following is the best nurse response?
a. “Don’t share anything with anyone until you’re comfortable doing so.”
b. “I can understand what you are saying.”
c. “No one will require you to do anything you don’t want to do.”
d. “The purpose of the group is to have a safe place to share problems with others
who may be having similar problems.”
ANS: D
During the first phase, potential participants do not know whether they can trust one another. The primary task of the leader at this
point is to clarify the purpose. The response explaining that “the purpose is to have a safe place” both recognizes what was said and
clarifies the purpose of the group. The statements of “Don’t share anything until you’re comfortable” and “No one will require you
to do anything…” are supportive, but they do not recognize the phase of development of the group. The statement “I understand…”
offers the client empathy but does not reinforce the purpose of the group.
14. The leader of an Alzheimer’s support group surveys the members of the group to determine the best time for the group to meet.
Which of the following norms is being supported through this action?
a. Group norms
b. Task norms
c. Maintenance norms
d. Reality norms
ANS: C
Maintenance norms create group pressure to affirm members and maintain their comfort. Maintenance behaviors include
identifying the social and psychological tensions of members and taking steps to support those members at high-stress times.
Maintenance norms often refer to things such as scheduling meetings at convenient times and in an accessible and comfortable
space. Group norms set the standards for the group members’ behaviors, attitudes, and perceptions. Task norms are the
commitment to return to the central goals of the group. Reality norms occur when members reinforce or challenge and correct their
ideas of what is real.
15. A nurse established an ongoing group meeting of teenagers with diabetes. In the early stages, the nurse was very directive in
arranging location, providing low-carbohydrate drinks and snacks, steering the discussion, and trying to meet all the teenagers’
needs. After the group had been meeting for about 3 months, the nurse noticed that the group members no longer simply accepted
everything the nurse suggested. Instead, the teenagers began making decisions themselves, and eventually, the nurse no longer
controlled the group. Which of the following most likely happened to cause this shift?
a. The group became cohesive enough to share leadership tasks.
b. Teenagers don’t like feeling dependent on adults with power.
c. Teenagers often rebel against adult authority.
d. The nurse was overwhelmed and lost control of task process.
ANS: A
In the beginning, the nurse used an authoritarian style because the nurse was responsible for the group direction. After a group is
well established, nurses may best facilitate leadership by relinquishing central control and encouraging group members themselves
to determine the norms for their group. As the group matured, continuing an authoritarian style would have resulted in low morale
and lack of cohesion, not necessarily a rebellion against adult authority. The group naturally progressed to leading itself based on
normal group development. This did not occur because of the teenagers’ attitudes, behaviors, or because of the feelings of the
nurse.

16. A group of teenagers with diabetes become upset and angry because they cannot agree on whether or not to have meetings during
summer vacation. Which of the following should the nurse do to be effective in helping the teenagers resolve the conflict?
a. Admit that it is difficult for everyone to agree on everything; then ask whether the
group can try to decide how to agree on the issue.
b. Assume adult authority and announce that meetings will be suspended until fall.
c. Recognize that most of the teenagers want to have the meetings, but two are being
stubborn; ask the two deviant members to leave the group.
d. Suggest that the group avoid discussing it further but rather think about it over the
next week and try to discuss the situation more rationally next week.
ANS: A
Open communication and recognition that conflict is inevitable may allow the group to focus on a procedure for fairly resolving the
conflict. If the nurse were to respond to conflict by avoiding (suggesting that they avoid further discussion), forcing with power
(assuming adult authority), capitulating, or excluding some members (asking the deviant members to leave), the behavior would
fail to satisfy the concerns of those involved.
MULTIPLE RESPONSE
1. The nurse is scheduled to teach carbohydrate counting to middle-aged adults newly diagnosed with diabetes. Which of the
following actions will the nurse need to take when teaching this population? (Select all that apply.)
a. Appeal to the need for autonomy and choice.
b. Emphasize that anyone with diabetes must know this information.
c. Explain how to cope with being a guest at a dinner.
d. Recognize that this audience will depend on the instructor to set goals for
learning.
e. Reinforce learning with handouts.
ANS: A, C
Because the nurse is working with middle-aged adults, the assumption can be made that they are members of Generation X. This
generation tends to be self-directed, likes to work with teams, and may need to develop skills because they are not as likely to be as
tech savvy. Members of this group can tolerate delayed gratification; they want clear information with practical value; and they are
able to have fun and engage in games and activities when appropriate. Because of this, the best approach will be to use adult
experiences and practical problems as learning motivators—for instance, appealing to adults’ sense of autonomy and choice, basing
examples on practical adult situations such as cooking meals or eating in restaurants, and discussing how clients can cope with
possibly awkward situations such as being a guest at dinner but having diet restrictions. This generation tends to be self-directed so
they most likely will not depend on the instructor to set goals for learning or need the instructor to emphasize how important it is to
know this information. Reinforcement with handouts are generally helpful. Members of this generation are likely to have the
intrinsic motivation to accomplish these things on their own.
2. Which of the following characteristics must a learner possess to successfully master psychomotor learning? (Select all that apply.)
a. The necessary ability to perform the skill
b. An open mind to learn the new skill
c. A sensory image of how to perform the skill
d. Opportunities to practice the skill
e. Desire to learn the skill
ANS: A, C, D
Psychomotor learning is dependent on the learners meeting the following three conditions: having the necessary ability including
both cognitive and psychomotor abilities, having a sensory image of how to carry out the skill, having opportunities to practice the
new skill. Having an open mind to learn a new skill and wanting to learn the skill are important. However, it is not necessary in
order to master psychomotor learning.
3. Which of the following strategies should be used when providing educational programs for children? (Select all that apply.)
a. Emphasize how to build learning from previous experiences.
b. Use simple words to enhance understanding.
c. Use objects to help increase their attention.
d. Emphasize the importance of the long-term consequences.
e. Use concrete examples to reinforce learning
ANS: B, C, E
When providing educational programs for children, the nurse should use more concrete examples and word choices; use objects or
devices to increase attention; incorporate repetitive behaviors into games to help with knowledge retention and acquiring new
skills. When working with adults, emphasis should be placed on previous experience. This is not as important when working with
children as they have had more limited experiences. Children are not concerned with long-term consequences, rather they focus on
consequences and activities that will occur in the near future (short-term).
4. A client tells a nurse, “I know all about this already. I read about it on the Internet” and then begins to summarizes what he has
learned. Because some of this information seems incorrect, what questions would be effective for the nurse to ask? (Select all that
apply.)
a. Were you able to find what you wanted easily on the website?
b. Did the website say when the information was updated?
c. Did the website state who was responsible for the information?
d. Did you enjoy reading the material on the website?
e. Did the information sound correct to you?
ANS: A, B, C
To assess the quality of information, the nurse should attempt to find information about the authors, the purpose of the site (to share
information or sell a product?), any available editorial reviews, the date of the material, the design of the site (easy to navigate?
well organized?), etc. Assessing if the material was enjoyable to read or sounded correct does not help the nurse to assess the
quality of information that was read by the client.

Chapter 15: Case Management
MULTIPLE CHOICE
1. Which of the following best describes case management?

a. A tool of health maintenance organizations
b. Targeted toward a specific segment of the population
c. Implemented with individual clients
d. Used to monitor the health status, resources, and outcomes for an aggregate
ANS: C
Case management, in contrast to the definition of care management, involves activities implemented with individual clients in the
system. Managed care is a tool of health maintenance organizations. Care management is an enduring process in which a
population manager establishes systems and monitors the health status, resources, and outcomes for an aggregate—a targeted
segment of the population or a group.
2. Which of the following best describes why planning care for an individual is so challenging in today’s health care system?
a. Because today’s clients have high expectations of the health care system
b. Because multiple providers, payers, and settings have to be coordinated
c. Because of the new high technology constantly being created and used for client
treatment
d. Because so many different health care providers are in the acute care setting today
ANS: B
Case management practice is complex because of the coordinating activities of multiple providers, payers, and settings throughout
a client’s continuum of care. Planning care is so challenging because of the complexities of the system, not the high expectations of
the population, new technology, or different providers. Coordination of all of these aspects of care, not just one of them, is what
makes planning so difficult.
3. Which of the following best describes the primary problem that can result from health care today being given by many different
care providers?
a. Clients are not sure which provider to see first.
b. Health care providers have to make referrals to other providers.
c. Clients sometimes are not sure who their primary provider is.
d. Overuse, underuse, or gaps in care may result.
ANS: D
A particularly challenging problem is the fragmenting of services, which can result in overuse, underuse, gaps in care, and
miscommunication. Clients who have a primary care provider typically know who that provider is and recognize that this is the
provider that should be seen first. The referral system is not a primary problem with health care being given by various providers. It
is the fragmentation of services that causes the problems within the system.
4. Which of the following public health nurse applicants is the least qualified for a position of case manager in a rural county?
a. A 24-year-old who has a master’s degree in public health
b. A 34-year-old who will be moving from a large city
c. A 44-year-old who was born and raised in the community
d. A 54-year-old who, until recently, was a member of the community’s school
board
ANS: B
Case management competency requires the following knowledge and skills: knowledge of community resources and financing
methods; written and oral communication and documentation skills; negotiation and conflict resolution skills; critical thinking
processes to identify and prioritize problems from the provider and client views; and identification of best resources for the desired
outcomes. Because communities are unique, someone new to the area will lack knowledge of community resources and financing
methods. There is nothing in the descriptions of the other public health nurses that indicates a lack of current knowledge or skills.
5. Which of the following best explains why every client doesn’t receive care from a case manager?
a. Case management time is demanding; thus it is restricted to complex cases.
b. Many health agencies do not employ case managers.
c. Most clients would not benefit from case management.
d. Most nurses do not know how to function as case managers.
ANS: A
Case management can be labor intensive, time consuming, and costly. Because of the increasing number of clients with complex
problems in nurses’ caseloads, the intensity and duration of activities required to support the case management function may soon
exceed the demands that the direct caregiver can meet. Health agencies continue to employ more case managers as the cost spent
for the care saves the agency money in the long term. Because case management is labor intensive and costly, it is unrealistic for all
clients to have a case manager although additional clients could benefit from case management. Nurses fulfill the roles of advocate,
care coordinator, and referral agent which are necessary to function as case managers.

6. The nurse suggests use of telehealth to assess how a client is progressing. Which of the following resources must be available for
continuing care to be implemented?
a. A primary care provider who is willing to use wireless prescriptions and plans of
care
b. Family permission for the nurse to make home visits
c. Long-distance telephone service or a computer with Internet access
d. Willingness of the caregiver to drive the client to the nearest clinic
ANS: C
Telehealth is an organized health care delivery approach to triage and to provide advice, counseling, and referral for a client’s
health problem using phones or computers with cameras. The client is usually in the home, and the nurse is at an office, health care
facility, or phone bank location. Wireless prescriptions and plans of care are not necessary for a client who is receiving telehealth
services. Home visits may not be necessary for a telehealth client. Through the use of telehealth, the need to visit clinics is
decreased.
7. A nurse is using a case management plan to maximize patient care outcomes. Which of the following describes an important
consideration that should be made by the nurse?
a. Case management plans should be used only by nurses to manage care.
b. Case management plans should be individualized for each client.
c. Case management plans provide additional expense to the client and family.
d. Case management plans focus on the natural progression of the disease.
ANS: B
Adaptation of the case management care plan to each client’s characteristics is a crucial skill for standardizing the process and
outcome of care. It links multiple provider interventions to client responses and offers reasonable predictions to clients about health
outcomes. Institutions report that sharing case management plans with clients empowers the clients to assume responsibility for
monitoring and adhering to the plan of care. Case management plans should link the care that is provided together and involve
multiple providers. Case management is part of the standard of care that is provided and does not provide an additional expense to
the client, although it may cause an additional expense to the agency. Disease management, not case management, focuses on the
natural progression of the disease.
8. A client spends a great deal of time on the Internet or reading articles related to diabetes and its long-term effects. One day, the
client asks why the nurse has not suggested a life care plan. Which of the following would be the best response by the nurse?
a. “Life care plans are only for young persons who are newly diagnosed.”
b. “Life care plans are primarily used to determine long-term financial needs for
legal reasons.”
c. “You are receiving appropriate care for your diabetes without serious side effects,
so a life care plan isn’t currently appropriate.”
d. “I was waiting for you to express interest in having a life care plan.”
ANS: C
Life care plans are typically used for clients experiencing catastrophic illness or adverse events resulting from professional
malpractice. Others who benefit from life care planning are those who have sustained injury when younger and whose care
requirements have changed as a result of aging. Life care plans are typically used for clients experiencing catastrophic illness or
adverse events resulting from professional malpractice, not young persons with a newly diagnosed illness. The life care plan is a
customized, medical-based document that provides assessment of all present and future needs (i.e., medical, financial,
psychological, vocational, spiritual, physical, and social), including services, equipment, supplies, and living arrangements for a
client. These plans may be used by either a plaintiff or a defense lawyer to analyze damages. They are also used to set financial
rewards, which can be used to pay for care in the future and create a lifetime care plan.
9. Which of the following Medicaid clients would most likely receive case management?
a. An elderly person
b. A person receiving rehabilitation following an injury
c. A person who has a high-cost chronic disease
d. A person with acute illness
ANS: C
Some states, through their Medicaid programs, are developing disease management programs for high-cost chronic diseases among
their populations, such as asthma and diabetes. An elderly person is most likely to receive Medicare services, not Medicaid
services. Additionally, there is not any information that states that the elderly person has a high-cost chronic disease. A person who
is receiving rehabilitation following an injury or who has an acute illness does not have a diagnosis that warrants case management,
as case management is reserved for those with high-cost chronic diseases.
10. Which of the following best describes the goal or priority of the nurse advocate?
a. To gain organizational and governmental support for the promotion of nursing
objectives
b. To improve community service needs identified by research findings
c. To integrate evidence-based practice guidelines in the provision of community
nursing service
d. To promote the client’s rights and self-determination
ANS: D
In today’s practice, the nurse advocate makes the client’s rights the priority. Thus, the goal of advocacy is to promote
self-determination in a constituency or client group. Integrating evidence-based practice is part of the role of the nurse as a
researcher. Gaining organizational and government support and improving community service needs identified by research are not
roles of the nurse as an advocate. In the advocate role, the nurse promotes the self-determination of the group.

11. A case manager advocates for a client by helping an insurer understand the client’s needs and desires and by helping the client
understand programs and benefits offered by the insurer. What role is the nurse?
a. Arbitrator
b. Systems allocator
c. Mediator
d. Negotiator
ANS: D
Negotiating is a strategic process used to move conflicting parties toward an outcome. Parties must see the possibility of achieving
an agreement and the costs of not achieving an agreement. As a systems allocator, the nurse distributes limited health care
resources according to a plan or rationale. Mediating is the process of assisting parties to understand each other’s concerns and to
determine their conclusion of the issues. The mediator has no authority to decide, whereas an arbitrator is legally allowed to
suggest an appropriate outcome.
12. A nurse reviews with the client what can be expected during the next 3 days, as well as how the client should expect to feel each of
those days. The client laughs and says, “You’ve got my care all mapped out.” Which of the following tools is the nurse using to
determine what will happen when?
a. Care planning
b. Critical pathway
c. Demand management
d. Use management
ANS: B
Critical paths are tools that name activities to be used in a timely sequence to achieve desired outcomes for care with measureable
outcomes. Care planning involves developing a plan of care for an individual. Use management attempts to redirect care and
monitors the appropriate use of provider care and treatment services. Demand management seeks to control use by providing
clients with correct information to empower themselves to make healthy choices, to use healthy and health-seeking behaviors to
improve their health status, and to make fewer demands on the health care system.
13. A nurse, client, family, and other care providers meet to discuss what will be the best approach to use to continue care. Which of
the following best describes why the nurse suggests changing the goal from obtaining appropriate long-term care placement to
ensuring that the client’s recovery is beneficial and safe?
a. To consider all possible consequences of long-term care placement
b. To encourage the group to review the client outcomes in the different settings
c. To expand the goal so that different solutions can be generated and considered
d. To help the group focus on the critical aspects the client’s family considered most
important
ANS: C
One problem with seeking solutions is stating the problem in such a narrow fashion that only one possible outcome is acceptable.
To avoid this, the nurse may restate the problem. By expanding the goal, different solutions can be generated. Clients and
advocates may feel limited in their options if they generate solutions before completely analyzing the problems, needs, desires, and
consequences. Changing the goal allows other possibilities, which may or may not include long-term care, to be considered. The
client outcomes in different settings are not being addressed at this time. Examining the aspects that the family feels is most
important can better be considered by broadening the goal.
14. The case manager explains to two disagreeing parties that coming to an agreement will save personnel costs for both of them.
Which of the following terms best describes this action?
a. Assertiveness
b. Collaboration
c. Cooperation
d. Compromising
ANS: B
In collaborating, an individual attempts to work with others toward solutions that satisfy the needs of both parties. Assertiveness is
the ability to present one’s own needs. Cooperation is the ability to understand and meet the needs of others. When compromising,
an individual attempts to find a mutually acceptable solution that partially satisfies both parties.
15. A nurse is using the problem identification phase of the case management process. To which of the following phases of the nursing
process does this correspond?
a. Assessment phase
b. Diagnosis phase
c. Planning phase
d. Implementation phase
ANS: B
The diagnosis phase of the nursing process is analogous to the identification of the problem in the case management process. It is
during this phase that the case manager determines conclusions based on the assessment. During the assessment phase, the nurse
develops networks with the target population and disseminates written materials. In the planning phase, the nurse validates and
prioritizes problems with all participants. When working through the implementation phase, the nurse contacts providers and
negotiates contracts and services.

16. A nurse is completing a case management advocacy activity which corresponds to the implementation phase of the nursing process.
Which of the following activities would the nurse most likely use?
a. Asking the client what is most important
b. Seeking appropriate referrals for the client
c. Assuring the client that his wishes will be supported
d. Determining the order in which actions will occur
ANS: C
Assuring the client is a component of the advocacy process that corresponds to the implementation phase. Asking the client what is
most important is a way to illuminate values, which occurs in the assessment phase. Seeking appropriate referrals for the client
occurs in the assessment phase. Determining the order in which actions will occur is a prioritization of action, which occurs in the
planning phase.
17. A case manager implements a primary prevention activity. Which of the following actions would the nurse most likely complete?
a. Advocating for the client whose values conflict with those of the medical service
provider
b. Collaborating between nursing and occupational health personnel
c. Educating a group regarding community services that are available if ever needed
d. Resolving conflict between a primary care clinic and a tertiary health care facility
ANS: C
Primary prevention involves the use of the information exchange process to increase the client’s understanding of how to use the
health care system. Primary prevention occurs at a point before illness or problem exists. In the remaining options, the client has a
problem for which interventions have been employed.
MULTIPLE RESPONSE
1. Which of the following are the primary goals of case management? (Select all that apply.)
a. To ensure that care coordination occurs across the continuum
b. To emphasize evidence-based clinical decision-making
c. To manage resource use and control expenses
d. To stress the advantages and benefits of community-based care
e. To reduce institutional care as a means of achieving wellness
ANS: A, B, C, E
The goals in case management are to reduce institutional care while maintaining quality processes and satisfactory outcomes;
manage resource use through protocols, evidence-based decision-making, guideline use, and disease management programs; and
control expenses by managing care processes and outcomes. Case management involves more aspects of care than only care that
occurs in the community. Thus, stressing the advantages and benefits of community-based care is not part of the primary goals of
case management.
2. A case manager is concerned about exposure to possible lawsuits. Which of the following are appropriate actions to take to
minimize this risk? (Select all that apply.)
a. Assure clients they can appeal any decision.
b. Carefully document client involvement and reasons for decisions.
c. Share client information with the other involved providers and agencies.
d. Confirm credentials and capabilities of providers or agencies to give care.
e. Being mindful to maintain effective lines of communication with all clients.
ANS: A, B, D, E
Elements that reduce risk exposure include clear documentation of the extent of participation in decision-making and reasons for
decisions; records demonstrating accurate and complete information on interactions and outcomes; use of reasonable care in
selecting referral sources, which may include confirming credentials and capabilities of providers and agencies; maintaining good
communication with clients; and informing clients of their rights of appeal. In compliance with the Health Insurance Portability and
Accountability Act (HIPAA), no nurse is allowed to share information with others without written consent of the client.

Chapter 17: Public Health Surveillance and Outbreak Investigation
MULTIPLE CHOICE
1. A nurse considered copying last month’s surveillance report and changing the date because the number of occurrences per month
had not noticeably changed. Which of the following best explains why the nurse should continue to spend time collecting and
reporting data that is always nearly the same?
a. Because such data are legally required
b. Because it is still part of the nurse’s responsibilities, even if on minimal value
c. To determine a local baseline rate and immediately notice any change
d. To determine differences among communities in need for state assistance
ANS: C
Disease surveillance generates knowledge of a disease or event outbreak patterns. Surveillance systems help nurses and other
professionals monitor emerging infections and bioterrorist outbreaks. Surveillance provides a means for nurses to monitor disease
trends to reduce morbidity and mortality and improve health. Disease surveillance is not part of a legal requirement. There are
many useful purposes for surveillance including monitoring for emerging infections and disease trends. The purpose of the monthly
surveillance report is not for comparison among communities, rather it is a description of what is happening within the local
community.
2. A nurse attends a conference to learn more about public health surveillance. Why is it so important that the nurse be knowledgeable
about this topic?
a. Because nurses are employed in public health agencies
b. Because nurses are often the first to recognize and respond to a problem
c. Because nurses are responsible for ensuring that action is taken when necessary
d. Because nurses are typically the ones to interact with the public and the media
ANS: B
Nurses are often in the forefront of responses to be made in the surveillance process whether working in a small rural agency or a
large urban agency; within the health department, school, or urgent care center; or on the telephone performing triage services
during a disaster. It is the nurse who sees the event first. Nurses may work in a variety of community agencies, including public
health agencies. Nurses will collaborate with others to take action as necessary; it would not be the sole responsibility of the nurse.
A wide variety of public health professionals interact with the public and the media, not only nurses.
3. A rural public health nurse is spending time reviewing death certificates. Which of the following best explains the purpose of this
activity?
a. To ensure that local causes of death are consistent with national causes of death
b. To confirm that no local health problems are beginning
c. To evaluate effectiveness of health promotion programs
d. To obtain mortality data for the local area
ANS: D
Mortality data are often the only source of health-related data available for small geographic areas. Vital statistics reports, such as
death certificates, are reviewed. Useful information also comes from administrative data such as discharge reports and billing
records. It is not necessary that the local causes of death are consistent with national causes, rather it is important that the nurse be
aware of the major causes of mortality in the community so that the needs of the community can be addressed. Mortality data can
occasionally be used to evaluate the effectiveness of health promotion programs, but this would not be the primary purpose of
reviewing death certificates. Other data can be used to detect the start of local health problems. Analyzing death certificates as the
only means of examining local health problems would provide the nurse with data that is not current.
4. Which of the following types of surveillance systems is being used when case reports are routinely sent to local health departments
by health care providers and laboratories, where the data are then summarized and forwarded to those responsible for monitoring
such reports?
a. Active
b. Passive
c. Sentinel
d. Special
ANS: B
In the passive surveillance system, case reports are sent to local health departments by health care providers or laboratories. The
case reports are summarized and forwarded to the state health department, national government, or organizations responsible for
monitoring the problem, such as the CDC. In active surveillance, the health department nurse may begin a search for cases through
contacts to determine the magnitude of the problem. Sentinel surveillance involves looking for trends. Special surveillance is
developed when a particular type of data is sought.

5. In which of the following situations would the nurse most likely use an active surveillance system?
a. A newspaper wants to know the incidence of asthma in the community.
b. A real-time ongoing communication channel is established to monitor a particular
symptom.
c. Several children become ill with gastrointestinal (GI) upset at one local school.
d. The nurse is asked to report the incidence of a specific nonreportable common
problem in the community.
ANS: C
In active surveillance, the nurse may begin a search for cases to determine the magnitude of the problem (how widespread it is). An
example would be when several school children become ill after eating lunch in the cafeteria or at the local hot dog stand, in which
case, active surveillance would be used to investigate the possibility of food poisoning. In the passive surveillance system, case
reports are sent to local health departments by health care providers or laboratories. The case reports are summarized and
forwarded to the state health department, national government, or organizations responsible for monitoring the problem, such as the
CDC. Special surveillance is developed when a particular type of data is sought.
6. Several children were hospitalized for severe vomiting and diarrhea. Which of the following best explains why the nurse would
continue to pursue the cause of the illness even after the children have been discharged from the hospital?
a. So that the children’s families know the public health department cared about
them
b. So that action could be taken to avoid any such future episodes
c. Because the children’s parents need to know whom to sue for their medical
expenses
d. To confirm that the symptoms were due to an infectious disease
ANS: B
The objectives of an investigation are to control and prevent disease or death by identifying factors that contribute to the occurrence
and implementing measures to prevent occurrences. In this case, the nurse wanted to make sure children did not become ill again
when it could be avoided. The further investigation of the illness is not to demonstrate caring on the part of the public health
department, rather it assists with learning about what factors contributed to the occurrence. It is unlikely that the parents would sue
for a hospitalization for severe vomiting and diarrhea. Also, there is no indication that there would be an individual or agency to
sue for the symptoms that the child is experiencing. There is no indication as to what caused these symptoms, thus, the nurse would
need to do further investigation to determine if they were related to infectious disease or some other contributing factor.
7. A child came to school coughing almost constantly. The next day, six other children in the same school room were coughing.
Which of the following types of outbreak would the nurse suspect?
a. Common source
b. Mixed
c. Propagated
d. Intermittent
ANS: A
A common source outbreak refers to a group exposed to a common noxious influence, in this case, the ill child who was attending
school. A mixed outbreak is a common source outbreak followed by secondary exposures related to person-to-person contact.
Intermittent source cases may be exposed over a period of days or weeks. A propagated outbreak does not have a common source
but spreads gradually from person to person over more than a single incubation period.
8. A nurse noted that of 18 children in a daycare center room, 5 became ill. Which of the following best describes a host factor that
may be associated with this illness and who became ill?
a. Some of the children were from very low socioeconomic families.
b. Some of the children inhaled car exhaust while playing outside.
c. The bacterial cause of the illness was easily removed by handwashing.
d. The daycare center room was much warmer on three sides in comparison to the
side with the floor to ceiling windows.
ANS: A
Factors that must be considered as causes of outbreak are categorized as agents, hosts, and environmental factors. Host factors may
be age, sex, race, socioeconomic status, genetics, and lifestyle choices. The cause of the illness and exposure to pollutants are
considered agent factors, and the difference in temperature in the room is an environmental factor.
9. In January, a nurse is listening to colleagues talk about the increase in depressed patients asking for help from their primary care
providers recently. The incidence of reports of depression was higher in the last month than in the previous 3 months. Based on this
data, which of the following would be the next step for the nurse to take?
a. No further action is necessary because depression is known to worsen during the
shorter darker days of winter.
b. No further action is necessary because this short-term increase may just be a
statistical error or even just a mistaken impression by the involved nurses.
c. Action should be taken because there must be some cause for this noted increase.
d. Action should be taken because this increase may be the beginning of an epidemic
and should be investigated.
ANS: A
Typically, any unusual increase in incidence should be investigated. But in the majority of cases, the increased incidence occurs
naturally and/or is predictable when compared with the consistent patterns of previous outbreaks. Many illnesses are seasonal.
Seasonal affective disorder (depression) often worsens during the shorter periods of daylight in the winter. The nurse should
recognize that depression can be seasonal and not attribute this problem to an error in the data that has been collected. Because this
is being recognized as a seasonal problem, there is no need for the nurse to take action. However, the nurse should continue to
monitor the data to make sure that this trend does not continue as the weather begins to warm and more hours of daylight occur.

10. Which aspect of a biological agent is probably the most frightening to those exposed?
a. Infectivity
b. Invasiveness
c. Pathogenicity
d. Virulence
ANS: D
Virulence refers to the proportion of people with clinical disease who become severely ill or die. It is assumed people could cope
with illness but possible death is truly frightening for most. Infectivity refers to the capacity of an agent to enter a susceptible host
and produce infection or disease. Invasiveness is the ability of an agent to get into a susceptible host. Pathogenicity measures the
proportion of infected people who develop the disease.
MULTIPLE RESPONSE
1. Which of the following describes the purpose of surveillance systems today? (Select all that apply.)
a. To obtain data used to fight for increased budgets from taxpayers
b. To evaluate the effectiveness of public health programs
c. To monitor the incidence of chronic diseases among the local population
d. To note and help prevent occupational exposure and diseases
e. To help formulate interventions to reduce the incidence of chronic diseases
ANS: B, C, D, E
Although surveillance was initially devoted to monitoring and reducing the spread of infectious diseases, it is now used to monitor
and reduce chronic diseases and injuries, as well as environmental and occupational exposures. With tight budgets, public health
workers must know which programs should be developed and continued based on the most commonly occurring public health
problems. Evaluation of the effectiveness of programs requires valid and reliable data. With limited budgets, surveillance systems
are important. The taxpayer money should be used in the most effective and efficient ways possible. This involves monitoring the
effectiveness of health programming, not asking for increased budgets from taxpayers.
2. A public health department becomes aware of an impending health problem before any problem is reported to the agency. Which of
the following has most likely occurred within the community? (Select all that apply.)
a. Doctors are feeling rushed as they interact with each patient.
b. Emergency departments are notably busier than usual.
c. Nurses are calling in ill to the local hospital.
d. Pharmacists are discussing the increase in medication purchases.
e. Orders for diagnostic tests have increased over last year at this time.
ANS: B, D, E
Syndromic surveillance systems were developed to monitor illness syndromes or events, as seen in such indirect measures as
increased numbers of medication purchases, trips to primary care facilities or emergency departments, orders for cultures or x-rays,
and rising levels of school or work absenteeism. These may indicate that an epidemic is developing. Doctors feeling rushed and
nurses calling in ill are not unusual events.
3. The outpatient health care data show a notable increase in asthma over the numbers treated the previous year. Which of the
following actions should the public health nurse take first? (Select all that apply.)
a. Analyze educational health programs offered to the public last year.
b. Congratulate the public health staff on the success of their asthma awareness
program.
c. Determine whether there are any other data sources that might confirm the
apparent increase in asthma.
d. Review data with the outpatient clinic staff such as confirming repeat visits versus
newly diagnosed cases.
e. Determine whether there are any other data sources that might dispute the
apparent increase in asthma.
ANS: C, D, E
Before drawing any conclusions, further data should be sought, including confirmation of the current data and their meaning. Data
can be inaccurate or collected differently than in the past. What might have led to an increase? Are there other valid sources that
might have relevant data? Should surveillance specific to asthma be established? Confirming the data by comparing it to other
sources would be the priority. After this has been completed, the next steps would be for the nurse to look at the health
programming and community awareness education that has taken place. It would be premature to look at the programming if the
initial data obtained is not accurate.

Chapter 18: Program Management
MULTIPLE CHOICE
1. Which of the following best describes the steps in program management?

a. Assess, plan, implement, evaluate
b. Identify, initiate, implement
c. Organize, operationalize, mobilize, subsidize
d. Substantiate, negotiate, evaluate
ANS: A
The program management process is similar to the nursing process. Program management consists of assessing, planning,
implementing, and evaluating a program. The other steps mentioned in other options are not part of program management. The
process of program management, such as the nursing process, consists of a rational decision-making system to help nurses
determine the complete process of program development, implementation, and evaluation.
2. Which of the following best describes the ultimate goal of program planning?
a. Avoid unanticipated conflicts in the program development phase.
b. Provide adequate funding to meet the program’s resource requirements.
c. Ensure that health care services are acceptable, equal, effective, and efficient.
d. Prevent unnecessary duplication of services.
ANS: C
The comprehensive goal of program planning is to ensure that health care services are acceptable, equal, efficient, and effective.
The other options are aspects of program planning, but they address only limited concerns.
3. Which of the following best describes the purpose of strategic planning?

a. To anticipate client needs now and in the future
b. To match client needs, provider strengths, and agency resources
c. To maximize effective use of agency resources
d. To utilize provider strengths and competencies
ANS: B
Strategic planning involves the successful matching of client needs, with specific provider strengths and competencies and agency
resources. Everyone involved can anticipate what will be needed to implement the program, what will occur during
implementation, and what the outcomes will be. Strategic planning addresses the client, agency, and provider. The other responses
address only one of these factors not all three of them which all need to be considered during the strategic planning process.
4. Which would be an appropriate descriptor that meets all criteria for defining a client to be served by a program?
a. All women ages 40 to 50 who have not had a menstrual period for three
consecutive months
b. Immigrants residing in Central County for less than 5 years who have difficulty
understanding care instructions because of limited English proficiency
c. Pregnant women who have received nutritional counseling but whose nutritional
status did not improve
d. Children ages 18 months to 5 years who have been treated for nutritional
deficiencies at the Central County Clinic
ANS: B
The client should be defined by biological and psychosocial characteristics, by geographic location, and by the problems to be
addressed. For example, in a community with a large number of preschool children who require immunizations to enter school, the
client population may be described as all children between 4 and 6 years of age residing in Central County who have not had
up-to-date immunizations. This example tells the reader who the client is, what the need is, how large the population is, and where
they are located. In order to meet all criteria for defining a client that is to be served by the program, information about the
biological and psychosocial characteristics, geographical location, and the problems addressed needs to be included. The incorrect
responses do not contain all of this necessary information.
5. After completing a needs assessment, the nurse presents ideas at a community interest meeting that focuses on community needs.
Unfortunately, attendees show essentially no interest in being involved. Knowing that the health problem must be addressed, the
nurse proceeds with implementation as planned. Which of the following is the most likely outcome of the program?
a. Community members will become increasingly positive about the new program.
b. Others will recognize the importance of the program and become involved.
c. The public health agency will both publicize and expand the program.
d. The program will fail because of the community’s lack of interest.
ANS: D
Perspectives on the program, or what people think about the need for a program, might differ among health providers, agency
administrators, policymakers, and potential clients. These groups are considered the stakeholders in the program. Collecting data on
the opinions and attitudes of all persons, whether directly or indirectly involved with the program, is necessary to determine if the
program is feasible, if there is a need to redefine the problems, or if a new program should be developed or an existing program
expanded or modified. If a new or changed program is to be successful, it must not only be available, but also be accessible and
acceptable to the people who will use it. If community members do not accept the programming, it is unlikely that they will
become increasingly positive about it or invite others to become involved. The public health agency could attempt to publicize and
expand the program, but without the acceptance of the community, it will most likely fail.

Chapter 23: Health Equity and Care of Vulnerable Populations
MULTIPLE CHOICE
1. Which of the following is the primary cause of vulnerability to health problems?

a. Breakdown of family structures
b. Poverty
c. Prejudice
d. Social isolation
ANS: B
People with lower incomes and less education tend to be at higher risk for health problems. Poverty is a primary cause of
vulnerability. Breakdown of family structures, prejudice, and social isolation may all influence vulnerability to health problems but
have not been identified as a primary cause.
2. Which of the following terms is used to describe aggregates who are at high risk for having poor health outcomes because of
limited resources?
a. Disadvantaged families
b. Multi-problem families
c. Resilient populations
d. Vulnerable populations
ANS: D
Vulnerable populations are groups (aggregates) with an increased risk to develop adverse health outcomes. Families are a subgroup
of populations and do not appropriately fit the definition of “aggregates.” Resilience refers to the ability to resist poor health
outcomes, not to succumb to them.
3. A community health nurse would like to implement an intervention to increase lasting resilience among new immigrants. Which of
the following actions should be taken by the nurse?
a. Direct clients to English-as-second-language courses.
b. Give immigrant clients money to help them get settled.
c. Identify areas in the city where housing is less expensive.
d. Solicit donations for food, clothing, and other needs.
ANS: A
Vulnerability can be reversed by obtaining resources to increase resilience. Learning the basic language of the country of residence
will give immigrants the ability to communicate and navigate through systems and thus remove barriers that promote
disenfranchisement and disadvantaged status. Although money, food, and clothing meet needs for the short term, they do not help
the immigrant develop the power and control to improve health risks over the long term or contribute to lasting resilience.
4. Which of the following factors predisposes many migrant farm workers to disenfranchisement?
a. Being a minority group member
b. Inability to attend religious services because of work requirements
c. Previous experiences of physical abuse
d. Short length of time in the community
ANS: D
Disenfranchisement refers to a feeling of separation from mainstream society. The person does not seem to have an emotional
connection with any group in particular or the larger society. For migrant workers who are frequently moving, the short length of
time they stay in the community does not allow for the development of social ties. Being a minority group member would not by
itself cause disenfranchisement if the minority group member lived in a community with persons from similar ethnic and cultural
backgrounds. A person’s inability to attend religious services or to have had experienced previous physical abuse are not
specifically related to disenfranchisement of the population of migrant farmworkers.
5. A large financial grant was being offered to whichever health facility wanted to accept the responsibility for giving care to local
vulnerable populations. Which of the following actions would most likely be taken by the local medical centers?
a. Agree to collaboratively apply for the funds in a cooperative proposal.
b. Individually compete eagerly for the additional funds now available.
c. Reach out enthusiastically to this previously underserved population group.
d. Strongly consider not applying, because this population will be expensive to treat.
ANS: D
Many agencies do not wish to provide services to vulnerable populations. Vulnerable populations are more expensive to treat
because they have multiple, cumulative risks and require special service delivery considerations (e.g., to help overcome
transportation problems or provide culturally competent care). Because of the major costs associated with providing care to this
population and risks related to reimbursement, it would not be in the best interest of the agency to want to eagerly apply to provide
care to this group.

6. Which individual has the greatest risk for becoming a member of the vulnerable population of the local community?
a. A male diagnosed with a cardiac issue who recently moved in with his adult child
b. A single mother who is studying for a law degree at the local university
c. A 50-year-old married female who has worked as a server in local restaurants for
her entire adult life
d. A single male who has a history that includes a learning disability and a parent
diagnosed with type 2 diabetes
ANS: D
The WHO, consistent with Healthy People 2030, describes three overall determinants of health to be (1) the social and economic
environment, (2) the physical environment, and (3) the person’s individual characteristics and behaviors. The WHO also notes that
individuals are unlikely to be able to directly control many of the determinants of health, and this is directly related to vulnerability.
The seven WHO factors are as follows (WHO, 2015, pp. 1-2):
1. Income and social status: Higher income and social status are associated with better health.
2. Education: Low education is linked with poor health, more stress, and lower self-confidence.
3. Physical environment: Safe water and clean air; healthy workplaces; safer homes, communities, and roads; and good
employment and working conditions, especially when the person has more control, all contribute to good health.
4. Social support networks: Family, friends, and community as well as culture, customs, traditions, and beliefs affect health.
5. Genetics, as well as personal behavior and coping skills, affect health.
6. Health services: Access and use of services affect health.
7. Gender: Men and women suffer from different types of diseases at different ages
The single male with a history of learning disabilities and a family history of type 2 diabetes has several potential risk factors
including those related to his social support network (being single); learning disabilities (effecting education and possible low
self-esteem); and a first degree family history of a chronic disease (type 2 diabetes). While the life stories in the remaining options
present the individual with risks, none have multiple risks like the male depicted in the correct option.
7. A homeless family brought their father to the public health clinic after he reported bleeding when he went to the bathroom. Which
of the following nursing actions would be most appropriate?
a. Begin tests to determine the cause of the bleeding while asking about other family
concerns from nutrition to shelter for the night.
b. Refer the man to a urologist to address the urinary bleeding.
c. Suggest that the family take him to an urgent care center immediately.
d. Treat the urinary infection and give the man medication to take to prevent the
recurrence of infection.
ANS: A
It is important to provide comprehensive, family-centered, “one-stop” services. Providing multiple services during a single clinic
visit is an example of one-stop services. If social assistance and economic assistance are provided and included in interdisciplinary
treatment plans, services can be more responsive to the combined effects of social and economic stressors on the health of special
population groups. If the family is referred to a different provider or agency, it is likely that this follow-up will never occur. Only
addressing the urinary infection, and not the homeless status of this family, does not provide the comprehensive services that are
expected from a public health clinic.
8. Nursing students have been assigned to set up a health fair for the homeless population in a large urban setting. Without any funds
to pay for space, where should the health fair be located, assuming that all of the following sites are available at no cost?
a. At the city’s homeless shelter, which is, by policy, vacant during the day
b. At a large medical center, where the students could get permission to use an
empty clinic in the evening
c. At the largest inner city police station, where there was a large empty space
available
d. At the local community college, where there are plenty of tables and chairs
ANS: A
The most convenient place for the clients would be the homeless shelter, where transportation and lack of comfort in an unfamiliar
place would not be issues. It is helpful to provide comprehensive services in locations where people live and work, including
schools, churches, neighborhoods, and workplaces. Thus, for the homeless population, the homeless shelter would be an
appropriate location. Homeless persons would probably avoid the police station, and many may not wish to go to the medical
center—also, there would be transportation issues. Depending on the location of the community college, there may also be
transportation issues.
9. Which of the following bills would the nurse lobbyist, who believes strongly in social justice, encourage legislators to support?
a. A bill that establishes policies requiring all persons to pay the same cost for
services regardless of income
b. A bill that promotes universal health insurance coverage
c. A bill that requires all health care providers to give care to uninsured persons
without charge
d. A bill that requires health care workers to report undocumented immigrants who
present for treatment
ANS: B
Social justice refers to providing humane care and social support to the most disadvantaged members of society. Nurses can be
advocates for policy changes to improve social, economic, and environmental factors that predispose vulnerable populations to
poor health. Many people do not have health insurance, particularly those who work in jobs where insurance is not offered, or costs
are too high. Promoting universal health insurance for all would be a step toward providing humane care for those who might not
otherwise be able to receive care. Requiring health care professionals to give care to uninsured persons without charge would
quickly bankrupt hospitals, and health professionals could not afford to continue in those roles. Such a law is unfeasible. A bill
requiring all persons to pay the same cost for services regardless of income is not feasible. Multiple factors, including the benefits
provided by individual health insurance, influence the amount of money individuals pay to receive health care services. A bill for
universal health insurance could potentially influence this inequality. Health care providers are obligated to provide c are to
individuals in an emergency regardless of citizenship in the United States; thus, this bill would not be feasible given current
standards. These options would also not support the philosophy of social justice.

10. A nurse who is providing diabetes screening at a community clinic discovers that a new client has type 2 diabetes mellitus. The
nurse provides counseling, refers the client to an endocrinologist for initial assessment and treatment, arranges for the client to see
someone regarding financial assistance, contacts the mobile van to arrange transportation, and sets up a follow-up appointment.
Which of the following types of service does these actions represent?
a. Case management
b. Client advocacy
c. Holistic care
d. Wrap-around services
ANS: A
Nurses often function as case managers for vulnerable clients, making referrals and linking them with community services. Case
management services are especially important for vulnerable persons because they often do not have the ability or resources to
make their own arrangements. Linking clients with health services is accomplished by making appropriate referrals and by
following up with clients to ensure that the desired outcomes from the referral were achieved. Client advocacy refers to actions
taken on behalf of another. Because of the variety of actions being taken by the nurse, the nurse is functioning in a larger role than
simply advocating for the client. Holistic care addresses providing care for physical as well as emotional and spiritual needs. The
nurse is not addressing all of these aspects of care through this coordination. Wrap-around services refer to when comprehensive
health services are available and social and economic services are “wrapped around” these services. These services are not being
necessarily all being provided by the same clinic.
11. A nurse offers homeless clients yearly tuberculosis (TB) screening and free treatment for those who test positive for TB. Which of
the following levels of prevention is being used?
d. Secondary and tertiary prevention
ANS: B
Screening homeless adults and providing medications to those who test positive for TB are examples of secondary prevention. The
TB screening identifies infection in early stages. Medications work to prevent infection from developing into disease. Primary
prevention refers to actions taken to prevent the disease from occurring. Tertiary prevention refers to actions taken after the disease
has already occurred. A screening test cannot be both secondary and tertiary preventions.
12. A community health nurse is implementing a tertiary prevention activity related to tuberculosis. Which of the following
interventions is the nurse most likely completing?
a. Administration of skin tests to identify persons who have been infected with
tubercle bacilli
b. Assessing for signs and symptoms of active tuberculosis
c. Directly observing clients with active tuberculosis as they take their
antitubercular medications
d. Interpretation of tuberculosis skin test findings
ANS: C
Tertiary prevention is exemplified when nurses provide directly observed medication therapy for people with active TB.
Administering skin tests, assessing for signs and symptoms, and interpreting tuberculosis skin test findings are all examples of
secondary prevention as these interventions are all focused on screening or the follow-up on a screening test.
13. A staff member is orienting a new nurse to a health clinic that serves primarily vulnerable populations. Which of the following
statements indicates a need for additional staff education?
a. “If a client who does not speak English comes in, you must obtain an interpreter
right away.”
b. “We try to take care of as many problems as possible in one visit, so when you
interview the client, ask about additional concerns.”
c. “You will like working with Hispanic immigrants because they all have close-knit
family structures.”
d. “You will need to assist the client by scheduling any referral or follow-up
appointments around their work schedules.”
ANS: C
Assumptions are not helpful. Each person and family should be assessed individually. No two people or groups are alike. Any
stereotype, positive or negative, can be problematic. Even though Hispanic groups, as a whole, do have close-knit family structures,
by assuming that all Hispanics are this way, staff members are less likely to be open to the possibility of issues such as family
violence. It is important for the staff member to obtain an interpreter after learning that a client does not speak English, so this
statement does not indicate the need for additional education. Addressing multiple concerns within one visit is also appropriate and
does not indicate the need for additional staff education. Also, it is important for the staff member to recognize the importance of
working around work schedules; thus, this action is appropriate and does not indicate the need for additional staff education.

14. Nurses at a homeless clinic are concerned that homeless clients rarely return to have the nurses assess the findings of their
tuberculosis (TB) skin tests. Which of the following is the most appropriate policy for the clinic to have regarding the screening test
findings?
a. Call all homeless clients 48 hours after TB skin testing to remind them to return
to the clinic for test interpretation.
b. Have homeless individuals read their TB skin test, if necessary, and mail in
results on a postage-paid card coded to protect privacy.
c. Readminister the TB skin test if the client returns later than scheduled for test
interpretation.
d. Routinely refer all homeless clients for chest X-rays.
ANS: B
Nurses should develop a way for homeless individuals to read their TB skin test, if necessary, and give them a self-addressed,
stamped card they can return by mail with the results. Homeless people often do not have a way to receive telephone calls.
Additionally, they usually face numerous barriers to return to the clinic. These issues often require deviation from strict policies,
especially strict policies that are not working.
15. A nurse is working as a case manager with a vulnerable population. Which of the following actions should the nurse do when
providing care?
a. Be willing to enter into a long-term relationship with families.
b. Direct and control the client’s care because the nurse knows what is most needed.
c. Encourage families to become self-sufficient and less dependent on nursing
personnel for advice and referrals.
d. Rotate assignments periodically to prevent attachment and codependency.
ANS: A
Case management is a process that enhances continuity and appropriateness of care. When using case management with vulnerable
populations, the nurse can be of greatest benefit if he or she is willing to develop long-term relationships with the families served.
This increases trust as well as continuity of care. Care involves a partnership between nurse and client. Nurses who direct and
control the client’s care cannot establish a trusting relationship and may inadvertently foster a cycle of dependency and lack of
personal health control.
MULTIPLE RESPONSE
1. Which statements by a nurse demonstrate understanding of the unique needs of vulnerable groups? (Select all that apply.)
a. “I always address the problem that the client believes is the most important.”
b. “I avoid asking clients for income or financial information, because this is an
invasion of privacy.”
c. “I try to observe the client’s cultural traditions as I complete my assessment.”
d. “I make sure to do a complete assessment, since we often don’t know when the
person will return to the clinic.”
e. “Understanding an individual’s cultural experience is an important factor in
meeting their needs.”
ANS: A, C
The nurse should focus on what data are needed to help the client that day with the problem the client believes is most important. It
is important to keep the client’s cultural traditions in mind when completing an assessment so that the nurse is able to provide
culturally competent care. Because poverty is a primary cause of vulnerability, the nurse should include questions about the client’s
financial status. Nurses should not provide financial or legal advice; however, they should make sure to connect clients with
someone who can and will help them. Although an assessment must be done, a nurse should only collect data that will actually be
used.

Chapter 24: Rural Health and Migrant Health
MULTIPLE CHOICE
1. A 13-year-old resident in a rural community has been diagnosed with asthma. Which of the following providers will most likely
provide care to this client?
a. Advanced nurse practitioner
b. Allergist
c. Pediatrician
d. Pulmonologist
ANS: A
The providers most often seen by rural adults are general practitioners and advanced practice registered nurses (APRNs). Most
urban adults are more likely to seek care from a medical specialist (allergist or pulmonologist). A pediatrician would provide care
specific to children which may or may not be appropriate depending on the age of the resident.
2. Which of the following best describes a health professional shortage area (HPSA)?
a. An area with inadequate health care facilities for residents
b. An isolated area of underserved populations within an urban region
c. A region with insufficient numbers of health care providers
d. A rural region of the United States with a population density of less than 10,000
ANS: C
An HPSA is a geographical area that has insufficient numbers of health professionals according to criteria established by the
federal government. Often, rural areas have a physician, nurse practitioner, or nurse in community health who provides services to
residents who live in several counties. The incorrect responses do not fit the definition of a HPSA.
3. A migrant farmworker has been injured while working on the farm. Which of the following would provide assistance to care for
this injury?
a. Emergency department for immediate care
b. Migrant Health Act clinics
c. OSHA, because the man was injured by farm machinery
d. Workers’ Compensation, because injury was at work
ANS: A
The only source the nurse can count on using is sending injured workers to emergency departments for immediate care. Farming
and ranching do not often fall under OSHA guidelines, because they are considered small enterprises. Therefore, safety standards
are not enforceable, nor is Workers’ Compensation insurance usually available for the agricultural industry. Although there are
migrant health clinics, they are not always geographically convenient.
4. A nurse is caring for a migrant farm worker who has been working in the agricultural industry for the past 10 years. When
questioned about environmental hazards, the client reports regular exposure to pesticides. Which of the following disorders is the
client most at risk to develop?
a. Cancer
b. Memory loss
c. Skin rashes
d. Headaches
ANS: A
Chronic exposure to pesticides and chemicals may lead to cancer. Memory loss, skin rashes, and headaches are all potential side
effects of short-term exposure to pesticides and chemicals.
5. A migrant farmworker presents to the clinic reporting an acute onset dizziness, intense thirst, vomiting, fatigue, and headache with
difficulty concentrating. Which of the following conditions would cause such symptoms?
a. Appendicitis
b. Bacterial gastroenteritis
c. Pesticide poisoning
d. Viral illness
ANS: C
Because a migrant farmworker is employed in agriculture, the most probable cause is pesticide poisoning. Acute health effects of
pesticide exposure include mild symptoms of pesticide poisoning including headache, fatigue, dizziness, nervousness, perspiration,
loss of appetite, thirst, eye irritation, and irritation of the nose and throat. Severe poisoning symptoms include fever, intense thirst,
vomiting, muscle twitches, convulsions, inability to breathe, and unconsciousness. The work setting of a migrant farmer would lead
the nurse to first consider pesticide poisoning as a potential underlying cause of these symptoms. However, some of these
symptoms could potentially be present with appendicitis, bacterial gastroenteritis, or a viral illness.
6. In addition to those barriers faced by many residents in rural areas, what additional barrier to health care is a Hispanic migrant
farmworker likely to encounter?
a. Absence of culturally competent care
b. Availability of specialists
c. Distance of health care facilities from the place of residence
d. High cost of health care
ANS: A
For migrant workers, a language barrier and cultural differences often exist between them and other area residents, including health
care providers. This is an additional barrier that is not faced by other rural residents. Barriers to health care in gen eral affecting all
populations include whether services and professionals are available, affordable, or accessible to rural consumers, not just migrant
workers.

7. Which of the following is the most accurate description of a migrant farmworker?
a. A person who does farm work as the primary means of employment, although
other work may be done when the seasonal work ends
b. A person who immigrates to the United States to “follow the crops” in performing
seasonal farm work
c. A person who moves from place to place to earn money performing seasonal
agricultural work
d. A person who specializes in the development of rural land for the purpose of
farming
ANS: C
The Office of Migrant Health of the US Public Health Service defines a migrant farmworker as a person “whose principal
employment is in agriculture on a seasonal basis, who has been so employed within the last 24 months and who establishes for the
purpose of such employment a temporary abode.” The emphasis in the definition of migrant farmworkers is on moving (temporary
abode), farm work, and seasonal basis. Not all migrant farmworkers are immigrants.
8. An employer provides a migrant farm family the day off to visit the health clinic in a nearby community and tells them to take all
of the time they need. However, the family arrives at the clinic appearing very stressed. In addition to the health issue, which of the
following would most likely be a fear experienced by the family?
a. Their personal belongings may be stolen while they are at the clinic.
b. Immigration officials will send them back to their home country.
c. The clinic personnel will look down on them and be biased against them.
d. They weren’t getting paid for that day, and continued employment is never
certain.
ANS: D
Migrant farmworkers often have an unpredictable and difficult lifestyle. Many must leave home each year and travel to distant
locations to work. They may be uncertain about their work and housing as they go from one possible job to another. An employer
telling them to “take all the time they want” could be interpreted as meaning they may no longer be needed, and their next job may
be very uncertain. Most migrant farmworkers are legal residents or US citizens, not illegal immigrants. If the clinic personnel
provide culturally competent care, they should not be biased or look down on this family when providing care. They should not be
at any greater risk to have their belongings be stolen than on any other day when they leave their home.
9. A migrant farmworker brings his daughter to the clinic with severe heat stroke from being out in the sun. The nurse explains the
danger signs and stresses staying cool and drinking lots of water. The man seems to know this already. Which of the following best
describes the most likely reason that this happened?
a. It was a rare occurrence, which probably won’t be repeated.
b. The daughter either disobeyed her father and went out to play in the sun or just
did not realize how hot she was.
c. Children may work on small farms because the family may need the additional
income.
d. The parents were busy working and didn’t realize the child was outside so long.
ANS: C
Children 12 to 13 years of age can work on a farm with the parents’ consent or if the parent works on the same farm. Children
younger than 12 years can work on a farm with fewer than 7 full-time workers. Children may need to work for the family’s
economic survival. This child may be at risk for this occurring again because the family needs the income that is generated by the
child’s employment. The child is most likely working and not going outside to play. In order for this child to work, the parents also
were working on the same farm with them but again need this child’s income for survival.
10. A nurse is working with Mexican immigrants. Which of the following behaviors would most likely lead to a positive interaction for
the nurse?
a. Avoiding touching the client except when necessary as part of the physical
examination
b. Calling the client by name, socializing before addressing the problem, and being
very respectful
c. Keeping all interactions direct, to the point, and targeted on the reason for
presentation
d. Maintaining a nonconfrontational relationship by avoiding any disagreement even
if the nurse does disagree with what the client is saying
ANS: B
The nurse is considered an authority figure who should respect (respeto) the individual, be able to relate to the individual
(personalismo), and maintain the individual’s dignity (dignidad). Such an approach would be expected for any client, not just with
immigrants. Mexican individuals, like those of many cultures, expect to establish some rapport through talking about personal
matters (chit-chat) for the first few minutes of an encounter before addressing any problems. Touching as a caring gesture is usually
seen as a positive behavior. When interacting with Mexican immigrants, as well as some other cultures, establishing general rapport
through conversation is expected rather than a direct, focused approach. It would be appropriate for a nurse to develop a therapeutic
relationship with the client, not a nonconfrontational one.
11. A Mexican immigrant mother tells the nurse she is concerned that people in the community will give her daughter mal de ojo. To
which of the following folk illnesses is the nurse referring?
a. Evil eye
b. Fallen fontanel
c. Fright
d. Indigestion
ANS: A
A common folk illness that a nurse may encounter with the Mexican client is mal de ojo, or evil eye. Caida de mollera is known as
fallen fontanel, empacho is known as indigestion, and susto is known as fright.

12. Which of the following conditions of the rural environment provides increased opportunities for teaching?
a. Increased interaction among residents due to neighbors visiting neighbors on the
family farms
b. Involvement in rural community activities provides more contact with community
residents than in urban areas
c. Nursing responsibilities in these areas stress the importance of primary,
secondary, and tertiary preventions
d. Increased illnesses and injuries of rural residents require that they see nurses more
often
ANS: B
Rural areas have fewer churches, stores, and schools. Thus, nurses may go to the same church, shop at the same stores, and/or have
children in the same schools as their clients. There are also fewer organizations, so it is easier to become involved and meet
everyone while participating. Visiting neighbors does not increase opportunities for teaching. The fact that nursing responsibilities
include all levels of prevention is true of both urban and rural areas. The statement about increased illness and injuries in rural
residents is wrong, because although illnesses and injuries are increased, rural residents often do not seek care for these conditions.
13. A nurse is implementing a tertiary prevention strategy related to pesticide exposure. Which of the following activities would the
nurse complete?
a. Observe farmworkers for evidence of unsafe handling of pesticides.
b. Provide teaching on how to handle pesticides to avoid or decrease exposure.
c. Teach farmworkers how to recognize signs and symptoms of pesticide poisoning.
d. Treat a client who has pesticide exposure to prevent complications.
ANS: D
Tertiary prevention involves actions taken when a person already has a condition so that complications and worsening of the
condition are avoided. Thus, treating a client with exposure is tertiary prevention. Observing farmers for evidence of unsafe
handling of pesticides is an example of secondary prevention as the nurse is assessing to detect a problem at the earliest stage
possible. Primary prevention occurs when the nurse aims to prevent the problem from occurring which is accomplished when the
nurse teaches about safe handling of pesticides and recognition of signs and symptoms of pesticide poisoning.
MULTIPLE RESPONSE
1. Which of the following best describes why health professionals would be particularly concerned about the health needs of residents
in rural areas? (Select all that apply.)
a. 40% of rural children live in poverty.
b. People in rural areas are especially susceptible to acute illnesses rather than
chronic diseases.
c. Diagnoses in rural areas are usually for physical injuries, not mental health
concerns.
d. The cost of healthcare is strain on rural families.
e. Accessibility to healthcare is limited.
ANS: A, D, E
Nearly 40% of all rural children are impoverished. Poverty and inaccessibility to health care is a major problem for rural
communities. Nearly one half of all rural adults suffer from at least one chronic condition. Stress, stress-related conditions, and
mental illness are prevalent among populations that have economic difficulties, including rural populations.
2. A nurse is caring for Mexican migrant farmworkers. Which of the following conditions are of greatest importance for the nurse to
assess? (Select all that apply.)
a. Tuberculosis
b. Hepatitis
c. High blood level of lead
d. Malaria
e. Diabetes
ANS: B, C, E
Poor quality and crowded housing can contribute to such health problems as tuberculosis (TB) and hepatitis, as well as exposure to
high levels of lead from pesticides. Diabetes is common among this population as well. Malaria is not an illness associated with the
migrant farmer population.
3. A nurse tells her nursing supervisor that her family is moving from the urban area where they both live in a rural area to be near her
spouse’s parents, who are becoming less independent. Which of the following suggestions would the nursing supervisor provide to
the nurse? (Select all that apply.)
a. “Community members will probably hold you in higher regard and will look up to
you.”
b. “Expect to have less autonomy in a small town than you have working as a nurse
in a medical center.”
c. “You may feel like an isolated outsider, because the community may not
immediately accept you.”
d. “You will have to be very sensitive about the differences in the rural lifestyle.”
e. “The church and school will be the centers for socialization.”
ANS: A, C, D, E
Nurses working in rural areas usually have a prestigious status in the community and are viewed as role models. They will be
experiencing a different lifestyle in the rural area and should be sensitive to these differences. Churches and schools are seen as the
socialization centers for the community. Also, moving into a community does require the community to be accepting of the
outsider which may or may not occur quickly. Nurses working in rural areas typically have more autonomy because of the larger
geographic area that is being served.

4. A nurse’s family has moved to a rural area to be near her spouse’s aging parents. Which of the following would the nurse most
likely notice about the family’s new environment? (Select all that apply.)
a. It is very difficult to obtain continuing education, except for online programs.
b. Neighbors seem to expect the nurse to know everything about all health care and
illness conditions.
c. Neighbors ask questions about health concerns any time they see the nurse,
regardless of where they are.
d. People come to the health clinic before their situation becomes relatively serious.
e. Boundaries between personal and professional lives are blurred.
ANS: A, B, C, E
The boundaries between home and work blur because clients are also neighbors and friends of immediate family members. Nurses
are highly regarded by the community and viewed as experts on health and illness. Residents may ask health-related questions and
request recommendations whenever they see the nurse. Nurses in rural areas may also be expected to, in general, know something
about everything, and this can be a demanding expectation. Some of the challenges are professional isolation, limited opportunities
for continuing education, lack of other health personnel or professionals with whom the nurse can interact, heavy workloads, the
need to function well in several clinical areas, lack of anonymity, and for some, a restricted social life. Rural people often develop
independent and creative ways to cope because of the distance, isolation, and sparse resources they encounter. Because of the
sparse resources, rural residents may seek limited preventive care and may only come to the health clinic if their situation is severe.

Chapter 25: Poverty, Homelessness, Teen Pregnancy, and Mental Illness
MULTIPLE CHOICE
1. A nurse was shocked when late one night she saw a former high school friend going through a trash bin outside a fast-food
restaurant and pulling out half-eaten food. Which of the following is the most likely explanation for a healthy young adult engaging
in such behavior?
a. He ate his meal but wanted more and had no more money.
b. He had full-time employment, but with such a low salary it was inadequate to
meet basic expenses.
c. A friend had thrown his meal away, and he thought he could find his friend’s
untouched food.
d. He was doing this to fulfill an obligation of fraternity initiation at the college.
ANS: B
The causes of poverty are complex and include decreased earnings, increased unemployment rates, and inadequate education and
job skills. Thus, it is most likely that he was unable to meet his basic needs through his current employer. If he had already eaten
his meal, it would be unusual to get additional food out of garbage, rather he should be able to afford to purchase additional food if
he was able to purchase his meal. The young adult would most likely not be pulling out half-eaten food if he was looking
specifically for a friend’s meal. There is no reason to assume that he was part of a fraternity.
2. Which of the following clients is most likely to experience a high incidence of poverty?
a. A 65-year-old woman
b. A 14-year-old male
c. A 79-year-old male
d. A 19-year-old female
ANS: B
While gender is not relevant, the poverty rate for children under 18 years of age was 16.2 percent, and the poverty rate for people
aged 65 and older was 9.7 percent.
3. A school nurse was talking to the teacher of an 8-year-old child who was living with her mother in their car. Which of the
following concerns would lead the nurse to talk to the teacher concerning the child’s academic progress?
a. Protentional abuse risk
b. Possible developmental delays
c. Food insecurity
d. Susceptibility to infections
ANS: B
Poverty increases the likelihood of all the options but developmental delays will impact academic progress most severely.
4. Which of the following is the most rapidly growing group experiencing poverty?
a. Hispanic families
b. Women older than 65
c. African-American families
d. Single men of all ages
ANS: B
Under the official poverty measure, in 2017, 4.7 million adults ages 65 and older lived in poverty. The rate of increase among
seniors increases with age and is higher among women, African Americans, and Hispanics.
5. Which of the following statements best describes why health care of the homeless is so expensive to the community?
a. Health conditions of the homeless require increased preventive services.
b. Homeless clients typically make more clinic visits for multiple health problems.
c. Homeless people are a major source of spread for contagious diseases.
d. Most care to homeless people takes place in hospital emergency departments.
ANS: D
Homeless persons have the same problems accessing care as do others in poverty (e.g., lack of money, lack of insurance, lack of
transportation). Therefore, health care of homeless persons is usually crisis oriented and sought in emergency departments, where
the cost of service is high but is not refused as it often is in clinics. It is likely that most homeless people do not seek preventive
care, thus, it is not that they require increased services, but they are less likely to seek these preventive services. Homeless clients
are likely to not be seen in the clinic setting. Homeless people may spread contagious diseases, but this does not explain why
providing health care to this population is expensive.
6. The nurse who works at a homeless clinic wants to improve healing of chronic wounds in clients living on the streets. Which of the
following would be the best action to take to improve client outcomes?
a. Provide antibiotics to all homeless persons with chronic, nonhealing wounds.
b. Offer daily access to a room with soap, water, and bandages.
c. Hand out free bandaging supplies following each clinic visit.
d. Perform regular monitoring of the client’s wound condition.
ANS: B
Health problems faced by the homeless often are related directly to poor access to preventive health care services. Proper wound
care relies on cleanliness; however, those living on the streets do not typically have ready access to soap and water. The nurse can
help by designating a wound room, in which clients can safely carry out wound care activities taught during clinic visits. If the
wound is not kept clean, it is unlikely that antibiotics will be able to prevent an infection, and the antibiotics will not promote
wound healing. Handing out bandaging supplies does not address being able to wash the wound on a regular basis. Monitoring of
the wound will not assist in wound healing.

7. A nurse is assessing a young, single pregnant woman. Which of the following findings would be of most concern to both mother
and fetus?
a. Elevated blood pressure
b. First prenatal visit at 5 months’ gestation
c. Homelessness
d. Positive STD test
ANS: C
Pregnant homeless women present several challenges. They have higher rates of sexually transmitted diseases, higher incidences of
addiction to drugs and alcohol, poorer nutritional status, and higher incidences of poor birth outcomes. Thus, being homeless is the
most dangerous sign of those listed. Elevated blood pressure, positive STD test, and seeking prenatal care late in the pregnancy are
all concerns for the nurse. However, most concerning would be homelessness, as homelessness presents many challenges for the
women during and after the pregnancy.
8. A nurse is working to ensure long-term positive health outcomes of poor pregnant teens and their children. Which of the following
actions would the nurse most likely take?
a. Assist teen mothers to learn about their body changes during pregnancy.
b. Develop programs that allow teen mothers to complete their education.
c. Offer courses in proper care of babies and how to be a parent.
d. Monitor pregnant teens to detect early problems with pregnancy.
ANS: B
A direct correlation exists between poverty and poor health outcomes. Poor teens are nearly three times more likely to drop out of
school as their nonpoor counterparts. When programs that assist the mother to complete her education are instituted, chances are
increased for a better future, which improves health care over the long term across the life span. It is important to keep the pregnant
adolescent in school during the pregnancy and have her return as soon as possible after the birth. Teaching about body changes a
proper care of babies and parenting would address short-term health outcomes. Monitoring teens to detect early problems in
pregnancy addresses short-term health outcomes as well.
9. A school health nurse presents a program on preventing teen pregnancy to a group of parents. Following the presentation, which of
the following comments by a parent would cause concern?
a. “I do not know if my son is sexually active; however, I have decided I’m going to
talk to him about it.”
b. “My daughter is too intelligent to get involved with boys, even if her friends do
sleep around.”
c. “My daughter and I have often discussed sexuality, and when she’s ready, I’ll pay
for her birth control pills.”
d. “I have spoken to my son about birth control. He says he’s not ready to be a father
and support a baby. He wants to go to college.”
ANS: B
Teens who are knowledgeable and want to be responsible often find it difficult to access birth control. Parents who do not talk
about sexuality with their teens may find them more at risk for sexual permissiveness and pregnancy. Teens are often ignorant
concerning sexuality and pregnancy and often very embarrassed to discuss such topics. Further, they often believe myths such as
they cannot get pregnant the first time they have sex. The earlier their sexual debut, the less likely a birth control method will be
used, because younger teens have less knowledge. Teens are more likely to be sexually active if their friends are sexually active.
Confidential reproductive health care services may be available for teens, but problems are still associated with transportation,
school absences, and costs of care.
10. A nurse is providing care to a pregnant teenager. Which of the following principles is the most important for the nurse to consider
when providing care?
a. All teen pregnancies are considered high risk.
b. Limited self-care knowledge can lead to pregnancy complications.
c. Pregnant teens are likely to receive prenatal care late in the pregnancy.
d. Pregnant teens may have limited financial resources to pay for care.
ANS: A
It is crucial to consider all pregnant teenagers as high-risk obstetric clients. A number of problems (e.g., poverty, late entry into
prenatal care, and limited self-care knowledge) can lead to complications of pregnancy, so it is important to treat every teen
pregnancy as a special high-risk pregnancy. All of these statements are true; however, it is crucial to consider all pregnant
teenagers as high-risk obstetric clients. Limited self-care, lack of prenatal care, and limited financial resources are all contributors
to the potential for all teen pregnancies to be considered high risk.
11. The nurse is making a postpartum visit to a teenage mother and her month-old infant. Which of the following assessments would be
most important?
a. Assessing for mother’s ability to fulfill her own growth and development tasks
b. Assessing for mother’s knowledge about normal infant growth and development
c. Assessing how much the teenage mother’s own mother is helping her cope with
childcare
d. Assessing whether the baby’s father is being helpful to the mother
ANS: B
The primary goal would be to assess how much the mother knows and understands about the needs of infants and their
development. Such knowledge helps avoid unrealistic expectations and frustrations, which could lead to child abuse. Although the
nurse might assess for any and all of these options, however, the primary goal of a postpartum visit would be to assess knowledge
regarding normal growth and development. A teenager mother’s knowledge about her own growth and development and how much
assistance she is receiving from her own mother and the baby’s father would be secondary concerns.

12. A mother and her son are in the emergency department seeking care after the son had become so angry that he put his hand through
a glass window and had to have stitches. The emergency care provider suggested a psychiatric consult. Now the mother asks, “Do
you think my son is crazy?” Which of the following is the most appropriate response by the nurse?
a. “Absolutely not. But a psychiatrist can help your son realize more appropriate
ways of displaying anger.”
b. “Have you had other reasons to think your son is crazy? Perhaps the psychiatrist
can reassure you that your son is just an adolescent coping with hormones.”
c. “Your son is having problems coping with anger. And naturally you’re upset. Let
the psychiatrist determine whether your son is crazy or not.”
d. “Your son is having problems with behavior, which is distressing all of you. A
psychiatrist may be able to help your son cope with life in a more acceptable
way.”
ANS: D
Mental health is defined as being able to engage in productive activities and fulfilling relationships with other people, to adapt to
change, and to cope with adversity. Mental disorders are conditions characterized by alterations in thinking, mood, or behavior,
resulting in distress and/or impaired functioning. Most persons do not get so angry that they become self-destructive (e.g., putting
their hand through a glass window and requiring medical attention). The nurse can help the mother accept appropriate assessment
and intervention by using positive language and giving hope. In order to respond therapeutically to the mother, the nurse should not
use the words absolutely (which implies that there may not be a problem with the son at all) or crazy (which is not a positive word
to describe the son’s behavior).
13. Which of the following is the leading cause of disability for adult Americans?
a. Accidents
b. Arthritis
c. Anxiety disorders
d. Workplace injuries
ANS: C
Anxiety disorders are common both in the United States and elsewhere. An alarming 31.1 percent of the adult population will
experience an anxiety disorder at some time in their lives (NIMH, 2018). Anxiety disorders may have an early onset and are
characterized by recurrent episodes of illness and periods of disability. While the other options can contribute to disability, none are
as impactful as anxiety.
14. A community mental health nurse is working within the community to help prevent youth violence. Which of the following
interventions would most likely be implemented by the nurse?
a. Distributing literature that associates violence with a lack of intelligence
b. Explaining to youth why youth violence is detrimental to society
c. Partnering with associations to provide alternative activities that improve social
skills
d. Recommending increased funding to prosecute and jail teens associated with
violent activity
ANS: C
Community mental health providers can help prevent a culture of youth violence by creating coalitions and partnerships and
providing activities to increase social skills by helping children learn to stop, think, and act. Distributing literatur e is an ineffective
intervention as community members would need to read the literature that has been provided. Based on the growth and
development of youth, they are unlikely to be able to truly understand the larger scope of youth violence. Recommending increased
funding for prosecution and jail does not provide any measure to prevent the problem from occurring.
15. Which of the following clients is most at risk for suicide involving firearms?
a. A 15-year-old female
b. A 20-year-old male
c. A 56-year-old female
d. A 36-year-old male
ANS: B
Suicide was the second leading cause of death for youth ages 10-24. Males take their lives about four times more often than do
females, yet females are more likely to have suicidal thoughts than males are. Firearms are the most common method of suicide
among males and poisoning among females.
16. A nurse is trying to identify the risk for mental health problems among older adults. Which of the following interventions should
the nurse implement initially?
a. Provide information on mental health resources in the community.
b. Teach the elderly to self-monitor for signs and symptoms of depression.
c. Organize screening programs offered at senior centers.
d. Teach older clients to focus on their strengths rather than their weaknesses.
ANS: C
Early detection and intervention for mental health problems can be increased if persons seeking primary care are assessed for
mental health problems. Nurses are in an ideal position to assess and detect mental health problems. They conduct comprehensive
biopsychosocial assessments as part of screening programs. While the other options are not inappropriate, they do not help identify
mental illness in the older adult population.

17. A nurse is concerned about stress related to the heavy caregiving burden assumed by adult children of older clients. Which of the
following actions by the nurse demonstrates the use of secondary prevention to limit caregiver stress?
a. Asking caregivers how they are doing and suggesting coping strategies
b. Encouraging caregivers to periodically leave the house for a couple of hours
c. Establishing support groups for caregivers of older parents
d. Referring some activities to neighbors and friends
ANS: A
Secondary prevention activities involve screening activities that allow for early recognition of problems so that prompt
interventions can limit disability. By asking caregivers how they are coping (thus screening), the nurse identifies problems early so
that interventions can be employed to limit the extent of stress, thus paving the way for improvement. The other options are either
primary or tertiary activities depending on whether the intervention takes place before or after caregiving stress has developed.
Also, encouraging caregivers to periodically leave the house for a couple of hours could result in negative outcomes for the person
needing care (unless a competent substitute is filling in for the primary caregiver).
18. A nurse would like to increase the accessibility to health care services for mentally ill homeless clients in the community. Which of
the following actions should be taken by the nurse?
a. Apply for a grant to fund a mobile clinic to take health care to the clients.
b. Distribute flyers to the homeless that detail the location of various types of health
care services.
c. Refer homeless clients to areas that provide temporary housing.
d. Solicit donations for food and clothing to be distributed to the homeless.
ANS: A
Accessibility refers to the ability of clients to obtain needed health care services. Only applying for a grant for a mobile clinic can
potentially improve accessibility to a health care clinic. Neighborhood clinics, mobile vans, and home visits can bring health care to
people otherwise unable to access care. Coordinating services at a central location often improves client compliance because it
reduces the stress of getting to multiple places. All of these options lead to opportunities for improvement in health, either directly
or indirectly, but distributing flyers, referring homeless clients, and soliciting donations do not address the issue of accessibility.
19. According to the Federal Register, which of the following is the minimum income needed by a family of four to meet the basic
needs for healthy living (that is, an income below this amount is considered insufficient to provide the food, shelter, and clothing
needed to preserve health)?
a. $16,020
b. $26,200
c. $36,580
d. $40,890
ANS: B
As of 2020 for a family of four, the poverty level—defined as the threshold below which families or individuals are considered to
be lacking the resources to meet the basic needs for healthy living—is $26,200.
20. A nurse is working to improve personal self-awareness in order to provide better client-centered care to clients living in poverty.
Which of the following questions should the nurse self-reflect upon?
a. What would I do if I lived in poverty?
b. What can be done to get poor people motivated to work?
c. How have the media images of poor persons shaped my image of poverty?
d. How can community resources assist those living in poverty?
ANS: C
Self-awareness is a key component of providing authentic, genuine client-centered care. To clarify their own values and
perspectives about poverty, nurses should ask themselves questions about poverty and persons living in poverty. These questions
should cause the nurse to reflect on how his or her ideas of poverty have been developed. The only question that relates to the nurse
reflecting on how personal values and perspectives have been developed is, “How have the media images of poor persons shaped
my image of poverty?” The incorrect responses address how to address the issue of poverty or concerns of the nurse but do not
address increasing the nurse’s self-awareness.
MULTIPLE RESPONSE
1. A teenager who has just come in for her prenatal visit appears to be about 6 months pregnant. Which of the following best describes
why the teenage girl has waited so long to come in for prenatal care? (Select all that apply.)
a. Her friends were suggesting ways to make the problem go away.
b. She knew she could not be pregnant because her boyfriend said he used a
condom.
c. She was afraid her parents would pressure her to terminate the pregnancy.
d. She kept hoping the pregnancy would just go away.
e. She dreads the gynecological examination.
ANS: C, D, E
Most young women suspect pregnancy as soon as a period is late. These young women may still delay seeking care, because they
falsely hope that the pregnancy will just go away. A teen also may delay seeking care because she wants to keep the pregnancy a
secret from her parents, who may pressure her to terminate the pregnancy, or because she does not want to have a gynecological
examination. Barriers to care early in the pregnancy also include the real or perceived costs of care, lack of transportation, dislike
or fear of the needed exams, and apprehension about the attitude of care providers toward her. Having friends suggest that the
pregnancy will just go away is not a common reason why pregnant teens do not seek prenatal care; it is more likely that the teen
herself is thinking that the pregnancy will just go away. Being told that a condom was used doesn’t make it so. The girl should
know whether a condom was used or not without relying on verbal statements.

2. A nurse is concerned about a teenage mother who does not seem to know how to play with an infant. Which of the following
behaviors would the nurse want to role-model as good parenting behaviors? (Select all that apply.)
a. Allow the baby to cry for 10 or 15 minutes before reacting so that the infant can
learn to self-soothe.
b. Cuddle the baby often.
c. Teach the mother to keep her face about 4 or 5 inches from the baby and to gently
blow on the infant’s face.
d. Sing to baby with different melodies until baby seems to listen and shows a
preference for certain tunes.
e. During the assessment, smile and gaze into the baby’s eyes.
ANS: B, D, E
Suggestions for promoting interaction between an adult and a baby include smiling and making eye contact. Singing may also help
soothe a baby when fussy (try different melodies to see what the baby prefers). The mother should be taught to use a distance of 8
to 10 inches from the infant and should not blow on the infant’s face. The mother should soothe the baby and try to provide comfort
before trying to let the infant “cry it out.”
3. A school nurse was caring for an 8-year-old child who had been hurt on the school playground. During the nurse’s assessment, the
child admitted that her mother was working but didn’t make much money, so the girl and her mother were living in their car. Based
on this information, which of the following would the nurse most likely suspect? (Select all that apply.)
a. Food insecurity
b. Target of peer bullying
c. Increased school absences
d. Vision problems
e. Depression
ANS: A, C, E
The health problems of homeless children, although similar to those of poor children, often have more serious consequences and
are at greatest risk for poor health as a result of poor nutrition, inconsistent health care, high levels of anxiety, and an inability to
practice good health behaviors. Homeless children also experience higher rates of school absenteeism, academic failure,
depression, and emotional and behavioral maladjustments. It is possible that this child could be bullied; however, there are also
children who do not live in poverty who experience bullying as well. Vision issues are generally no more a risk than for the general
child population.

Chapter 26: Alcohol, Tobacco, and Other Drug Problems in the Community
MULTIPLE CHOICE
1. Which of the following approaches has research suggested is the most effective way to approach drug addiction?
a. Criminal justice system
b. Harm reduction
c. Punishment approach
d. Substance abuse education
ANS: B
The harm reduction model is a public health approach that recognizes addiction as a health problem and focuses on pragmatic
interventions, especially education, to reduce the adverse consequences of drug use and treatment for addicts. Substance abuse
education is only one part of the harm reduction model. Using an approach of punishment and the criminal justice system has not
been found to be effective based on research.
2. A woman has just delivered a baby and is lamenting that the baby’s father is not with her. She shares with you that he became
involved with drugs and is now in prison for theft. The new mother says, “It’s so sad. He’s clearly no good.” Which of the
following would be the best response by the nurse while demonstrating empathy?
a. “I’m so sorry to hear that. Is your mother able to be with you?”
b. “It’s good that you and the baby are safe from him.”
c. “Is there anyone to help you with the baby until the baby’s father can be released
and encouraged to get treatment for his addiction?”
d. “You must hate him for leaving you alone with a new baby!”
ANS: C
The nurse must express concern and empathy and hold out hope for future improvement. To be therapeutic, the nurse must realize
that any drug can be abused, that anyone may develop drug dependence, and that drug addiction can be successfully treated. It is
inappropriate to assume that the woman wants assistance from her mother. There is no evidence to suggest that the woman or her
baby were in danger before he went to prison. Saying “you must hate him” is not appropriate, as it is not the nurse’s role to tell the
client how she should be feeling.
3. A man who takes a prescribed narcotic for pain on a regular basis reports that he does not like the way the medicine makes him
feel. He has tried to change to an alternate analgesic but experienced withdrawal symptoms when he stopped taking the narcotic.
Which of the following problems is the man experiencing?
a. Drug abuse
b. Drug addiction
c. Drug dependence
d. Substance abuse
ANS: C
Drug dependence is a state of neuroadaptation (a physiological change in the central nervous system) and alterations in other
systems caused by the long-term, regular administration of a drug. People who are dependent on drugs must continue using them to
prevent withdrawal symptoms. Drug addiction is a pattern of abuse characterized by an overwhelming preoccupation with the
compulsive use of a drug and securing its supply and a high tendency to relapse if the drug is removed. Substance abuse does not
apply in this case, because the man is taking a prescribed medication for a legitimate purpose. The term drug abuse is no longer
meaningful.
4. A school health nurse is asked by a parent group to explain risk factors for alcoholism. Which of the following information should
the nurse include?
a. Alcoholism is determined primarily by the family environment.
b. Alcoholism is determined partly by genetic factors.
c. Persons who are alcoholics are usually women.
d. Persons born with fetal alcohol syndrome are alcoholics from birth.
ANS: B
Research demonstrates that genes are responsible for about half of the risk for abuse of alcohol. Multiple genes play a role in a
person’s risk for the development of alcoholism. Research has not shown that the family environment is the main risk factor for
alcoholism. Alcoholism is more common among men than women. Persons who are born with fetal alcohol syndrome are not
alcoholics from birth and are likely to have metabolic or other disturbances.
5. A movie shows a woman and a man having a contest to see who can drink more shots of whiskey. Who is more likely to “win” the
drinking contest when and one is unable to continue drinking?
a. If their alcohol consumption is the same size, they’ll both pass out about the same
time.
b. Whoever has food in their stomach will probably vomit and be unable to continue
drinking.
c. The man will likely win because of an inborn tendency to greater alcohol
tolerance.
d. The woman will likely win due to the tendency to have more adipose tissue.
ANS: C
Women are more affected by alcohol than men, because women have less alcohol dehydrogenase activity than men; thus men have
an increased tolerance for alcohol. It is also unlikely that they will both “win” at the same time because the alcohol will likely
affect the woman factor than the man. The adipose tissue ratio is not a factor in alcohol tolerance. While vomiting may occur, it
will not necessarily affect the ability to continue to consume alcohol.

6. Students at first-day orientation at the local community college are discussing alcohol and drug abuse with their freshmen advisor.
During a break, some students go outside for soft drinks and snacks. Soon after, the advisor walks by and notices several of these
students smoking cigarettes. Based on this, which of the following topics of the drug and alcohol orientation would be most
important for the advisor to reemphasize after the break?
a. A discussion of which drugs are commonly used on campus
b. How students can learn to “just say no” when offered drugs or drinks
c. How to recognize and overcome peer pressure to continue bad habits
d. The fact that tobacco smoking causes more premature deaths than any other
behavior
ANS: D
The most relevant action in this case is making it clear to students that tobacco is a drug—and that smoking cigarettes accounts for
one in five deaths in the United States. Smoking is the foremost preventable cause of death in the United States. Because the
students are engaging in tobacco use, this is the most important topic to address with them at this time. If the students were not
engaging in this behavior, the other topics of commonly used drugs on campus, just “saying no”, and overcoming peer pressure
may have been just as appropriate.
7. A nurse sees the father of a newborn baby push his wife in a wheelchair out onto the patio. The man and woman each smoke a
cigarette while the baby sleeps in the mother’s arms. Which of the following information should the nurse share with the parents?
a. Fetal nicotine syndrome may cause complications in the newborn.
b. The sidestream smoke that the baby is exposed to is more dangerous than the
mainstream smoke that the parents are inhaling themselves.
c. The baby will eventually develop tolerance to tobacco smoke.
d. The parents should switch to chewing tobacco as long as the child lives in the
home.
ANS: B
Sidestream smoke contains higher concentrations of toxic and carcinogenic compounds than mainstream smoke. Sidestream smoke
contains higher concentrations of toxic and carcinogenic compounds than mainstream smoke. Fetal alcohol syndrome is a cause of
newborn congenital dysfunctions. There is not known tolerance to tobacco smoke. While chewing tobacco doesn’t produce smoke,
the parents would still be at a considerable health risk from the nicotine.
8. Which of the following addictive drugs is both legal and culturally acceptable throughout almost all of the United States?
a. Beer
b. Caffeine
c. Cigarettes (nicotine)
d. Mixed alcoholic beverages
ANS: B
Caffeine is in commonly served beverages such as coffee, tea, and soft drinks, as well as in some commonly used pain medications.
Beer, cigarettes, and mixed alcoholic beverages are not as culturally acceptable as caffeine, as there are regulations that limit the
age that these products can be used.
9. A school nurse stops a student in the hall and expresses concern that, “Your eyes look rather red and dry.” The student yawns and
denies eye problems but does mention having gained 15 pounds since smoking “special cigarettes.” Which of the following is the
student most likely smoking?
a. Tobacco
b. Crack cocaine
c. Ice methamphetamine
d. Marijuana
ANS: D
Side effects of marijuana include increased appetite, dry and reddened eyes, and drowsiness. Side effects of crack cocaine and ice
methamphetamine are similar and include increased breathing, rapid heart rate, high blood pressure, and increased body
temperature. Tobacco use is associated with many chronic diseases but a person smoking tobacco would not necessarily display the
student’s symptoms.
10. Which of the following is an accurate concern about the marijuana?

a. Strength of most available marijuana is weaker than in the past.
b. Paranoia is a known side effect of marijuana use.
c. Marijuana has no effect on a fetus.
d. Psychological and physiological dependence are seldom experience with
marijuana use.
ANS: B
Marijuana’s diverse reactions include anxiety, disorientation, and paranoia. The risks of marijuana are not being discussed as much
as in the past. Today’s marijuana is stronger than ever before, and people can become addicted. The Substance Abuse and Mental
Health Services Administration (SAMHSA) says “approximately 1 in 10 people who use marijuana will become addicted.” The
rate increases to 1 in 6 if the youth is under age 18. Marijuana use has known effects on fetal development.
11. Which client may be able to safely detoxify and manage their withdrawal symptoms with only minimal medical supervision?
a. A 50-year-old who uses diazepam to “manage my anxiety”
b. The 30-year-old reporting a “weekend cocaine habit”
c. A 60-year-old who takes a secobarbital “most nights to help me sleep”
d. A 70-year-old who usually drinks “3-4 beers in the evening”
ANS: B
Stimulants, e.g., cocaine or opiates, may produce withdrawal symptoms that are uncomfortable but not life threatening.
Detoxification from these drugs does not require direct medical supervision, but medical management of the withdrawal symptoms
increases the comfort level. On the other hand, drugs such as alcohol, benzodiazepines, e.g., diazepam, and barbiturates, e.g.,
secobarbital, can produce life-threatening withdrawal symptoms. These clients should be under close medical supervision during
detoxification and should receive medical management of the withdrawal symptoms to ensure a safe withdrawal.

12. Research as shown that vaping increases an individual’s risk of contracting what disease five-fold?
a. Gingivitis
b. Mouth cancer
c. Oral herpes
d. COVID-19
ANS: D
Vaping increases the risk of contracting COVID-19. This is due to the fact that e-cigarettes affect the lungs and immune system,
and that makes the user more susceptible to the virus. The seriousness is increased when teens or other uses share the e-cigarettes.
Research has found that people who vaped and smoked were five times more likely to develop COVID-19. The other options are
potential risks but have not been shown to be so directly associated with vaping.
13. Three female clients were brought to the emergency department by ambulance after a two-car accident at a busy intersection.
Which of the following tests should automatically be done under such circumstances?
a. Alcohol blood level
b. Cardiac workup
c. Pregnancy test
d. STI tests
ANS: A
Approximately 40% to 50% of people seen in trauma centers were drinking at the time of their injuries. Hence, blood alcohol
testing should be routinely done for patients admitted to the emergency department for traumatic injuries. Because of the high rate
of alcohol involvement in injuries seen in trauma centers, an alcohol blood level would be most important. A cardiac workup,
pregnancy test, or STI test would not be the priority.
14. An IV drug abuser admits to the nurse he has no desire to stop using drugs, so rather than lecture the individual on the dangers of
drug addiction, the nurse provides information how to sterilize his needles. Which of the following prevention efforts is the nurse
attempting to achieve?
a. Primary prevention by educating about safe injections
b. Primary prevention by avoidance of future legal complications
c. Secondary prevention to reduce the risk for infection or other complications
d. Tertiary prevention to reduce the transmission of blood-borne diseases
ANS: D
Tertiary prevention is for people who already have a disease or problem (in this instance, someone already abusing IV drugs) to
prevent complications (harm reduction). In this instance, because the client does not plan to stop taking drugs, the nurse is trying to
prevent complications related to use of contaminated needles and reduce the transmission of disease through sharing contaminated
needles with others. Using the harm reduction model, the nurse should provide education on cleaning needles with bleach between
uses and inform the addict about needle exchange programs to decrease the spread of the blood-borne pathogens. This client is
already using IV drugs, thus, the nurse will be intervening at the tertiary level of prevention. Secondary and primary prevention
strategies would not be appropriate when working with this client who already has a known problem.
15. In which of the following scenarios is a family member enabling an individual to continue to abuse alcohol?
a. The husband asks the nurse to explain why his wife’s continued drinking is
dangerous.
b. The son threatens to leave home because he finds the father’s behavior
embarrassing.
c. The teenage daughter of an alcoholic turns to a favorite teacher for emotional
support.
d. The wife tells her husband’s boss that her husband is sick when he is actually
inebriated.
ANS: D
Enabling is the act of shielding or preventing the addict from experiencing the consequences of the addiction. When someone lies
for the abuser, the individual is enabling the abusing behavior to continue. The other options do not demonstrate the behavior of
enabling, since none are shielding the abuser from experiencing the consequences of the addiction.
16. Which of the following statements accurately describes why methadone is used to treat heroin addiction?
a. Addicts come to prefer methadone instead of heroin.
b. Methadone blocks the effects of heroin and reduces the craving.
c. Methadone prevents further dependence on drugs.
d. Methadone gives an enjoyable high, so addicts continue treatment.
ANS: B
Methadone, when administered in moderate or high daily doses, produces a cross-tolerance to other narcotics, thereby blocking
their effects and decreasing the craving for heroin. The advantages of methadone are that it is long acting and effective when taken
orally, it does not produce a “high,” it is inexpensive, and it has few known side effects. The main effect of this medication is that it
decreases the craving for heroin; it is not a drug that clients come to prefer nor does it prevent further dependence on drugs.
17. A client requests help to stop smoking. Which of the following methods would be the best for the nurse to suggest to the client?
a. A combination of interventions, beginning with changing the environment
b. Acupuncture to reduce the nicotine cravings
c. Behavior modification through hypnosis
d. Nicotine replacement products
ANS: A
The most effective way to get people to stop smoking and prevent relapse involves multiple interventions and continuous
reinforcement, and most smokers require several attempts at cessation before they are successful. Making changes to the smoker’s
environment helps by eliminating cues to smoking, such as ash trays, lighters, and cigarette cases. Acupuncture, behavior
modification, and nicotine replacement products may all assist the client in stopping smoking. However, it has been demonstrated
that the most effective method involves a combination of strategies.

18. A nurse is reviewing with a client the importance of the diabetic diet to maintaining control of blood glucose levels. The client
states, “I went to the classes and learned how to count carbohydrates. I have even started to write down what I eat for each meal.”
Which of the following would be most appropriate response from the nurse?
a. “I’m so glad you’re beginning to recognize the need to control your blood sugar.”
b. “Now you just have to make sure you don’t give that habit up!”
c. “Sounds like you’re not ready to really plan your eating yet.”
d. “That is great. You’ve started to take action and make changes.”
ANS: D
There are five stages of change: (1) precontemplation—or resisting that there is a problem, (2) contemplation—or thinking about
the problem, (3) preparation—preparing for action and taking some initial steps, (4) action—or making modification in behavior
and environment, and (5) maintenance—or preventing relapse. The client prepares for action by learning to recognize the
importance of eating and needed changes. Therefore, the nurse should encourage and recognize that the client has begun serious
change. This comment by the client demonstrates readiness to take action and needs to be encouraged by the nurse. The incorrect
responses are not encouraging replies that would promote the client to continue to move forward with these actions.
19. At a county board meeting, a nurse reports statistics related to the increasing problem of substance abuse in the county. The nurse
then requests funding for an after-school recreation program that promotes age-appropriate fun activities and sports. Which of the
following objectives is the nurse attempting to meet through this action?
a. Help prevent obesity and boredom.
b. Offer alternatives to being “on the streets.”
c. Prevent children from getting in trouble before their parents get home from work.
d. Promote healthy lifestyles with physical activity.
ANS: D
The nurse is engaging in primary prevention efforts against substance abuse by helping to promote healthy lifestyles and resiliency
factors. The purpose of the nurse requesting this funding is to address the problem of substance abuse, not obesity. This program
may offer an alternative to children and keep them safe and off the streets; however, the primary objective is to address the overall
healthy lifestyle of these youth.
20. A school health nurse is conducting drug screening to detect drug use by students before serious problems develop. Which of the
following levels of prevention does this action represent?
d. Primary and secondary prevention
ANS: B
One means of secondary prevention is to institute early detection (screening) programs in schools, workplace, and other areas in
which people gather to determine the presence of substance abuse. Primary prevention involves education before a problem occurs.
Tertiary prevention occurs after the problem has occurred and aims to assist the client to the highest level of functioning. It is not
likely for a single intervention to be both primary and secondary in prevention foci.
MULTIPLE RESPONSE
1. A mother is concerned that her daughter may be considering experimentation with drugs and alcohol. Which of the following
strategies would the nurse suggest the mother implement? (Select all that apply.)
a. Provide opportunities for her daughter to develop her talents.
b. Provide realistic feedback to the daughter about her performance at school.
c. Encourage her daughter to become involved in extracurricular activities.
d. Encourage her daughter to develop new friendships.
e. Encourage her to discuss her dreams for the future.
ANS: A, B, C, E
Prevention guidelines to teach parents and teachers how to increase resiliency in youths include the following strategies: help them
develop an increased sense of responsibility for their own success; help them identify their talents; motivate them to dedicate their
lives to helping society rather than believing that their only purpose in life is to be consumers; provide realistic appraisals and
feedback, stress multicultural competence, and encourage and value education and skills training; and increase cooperative
solutions to problems rather than competitive or aggressive solutions. Based on the information provided, there is no reason to
suggest the child needs to develop new friendships. Keeping consistent friendships may provide the support the child needs to
avoid engaging in these behaviors.
2. A nurse is helping a client’s family prepare to have an intervention that hopefully will encourage the alcoholic father to realize the
need for change. Which of the following instructions by the nurse to the client’s family members would be most effective? (Select
all that apply.)
a. “Express your belief in him and his ability to change.”
b. “Point out that his behavior is his choice and his responsibility.”
c. “Let him know that you understand how much he loves being with his drinking
pals.”
d. “Remind him that entering treatment is better than going to prison.”
e. “Let him know that he is loved by his family and friends.”
ANS: A, B, E
Using FRAMES as a guideline, the nurse would provide Feedback about problems with using drugs, emphasize the person’s own
personal Responsibility for any changes made, and give Advice on how to change behaviors, including a Menu of options from
which to choose while expressing Empathy. Finally, the nurse would provide encouragement and belief that the person can change,
hence increasing feelings of self-efficacy. Having the client’s family members tell the father that they understand his behavior does
not encourage him to realize the need for change. Threatening a future possibility of prison would not provide encouragement to
the father and may even challenge him to continue his behavior.

3. A nurse is developing a community-based activity aimed at preventing substance abuse in the community. Which of the following
interventions would the nurse most likely implement? (Select all that apply.)
a. Supporting an increase in the availability of recreational facilities
b. Lobbying to state legislators to approve a higher cigarette tax
c. Educating all middle school students about the long-term side effects of drugs and
alcohol
d. Providing general screenings for substance abuse
e. Identifying community-based resources that deal with substance abuse issues
ANS: A, C, D, E
Supporting an increase in additional recreational facilities would engage the community members in healthy activities rather than
having them potentially turn to substances for relaxation. Providing screenings for substance abuse in the community may assist
community members in recognizing the problem sooner. It would be appropriate to educate middle-school students about the
long-term side effects of drugs and alcohol since they would be able to understand the information. Early intervention with
education is a proven deterrent to substance abuse. Lobbying state legislators for increase in a higher cigarette tax may be
beneficial, but this intervention is focused on the state rather than the community where the nurse is working. Identifying local
resources where assistance and addition information about substance abuse issues can be found is an appropriate community-based
intervention.
4. A home health client has been prescribed acetaminophen with codeine every 4 hours for pain following a hip arthroplasty. Which
of the following statements made by a nurse to the client’s primary health care provider indicates a need for further education on
narcotics related to the goals of safe pain management? (Select all that apply.)
a. “Please consider decreasing the time interval between doses to every 3 hours so
that my client will maintain pain relief.”
b. “I’m really concerned my client will become addicted to the codeine.”
c. “Consider prescribing a different medication so that my client will achieve
adequate pain relief.”
d. “My client needs a prescription for PRN medication for ‘breakthrough’ pain.”
e. “This medication is expensive; please prescribe something less costly.”
ANS: A, B, D
It would not be appropriate to ask to decrease the time interval in between doses as the increased use of acetaminophen may be
damaging to the client’s liver and kidneys. There is no evidence that this client is at risk for developing an addiction. Thus,
demanding that this medication be discontinued may be a premature action by the nurse. However, the nurse should monitor the
patient closely for signs and symptoms of potential addiction. It would be appropriate to ask the primary care provider for an
additional medication in the form of a PRN prescription to possibly assist with the client achieving optimal pain relief rather than
changing medications entirely. Although it is a factor, the cost of pain medication isn’t a consideration when addressing safe pain
management interventions.

Chapter 27: Violence and Human Abuse
MULTIPLE CHOICE
1. Which of the following statements is the best explanation as to why some countries are more violent than others?
a. Civilized societies are less violent than primitive societies.
b. Geographical differences are the primary factor.
c. Population differences are the main determinant—for example, having more
males than females.
d. Violence is a learned behavior controlled or allowed by social norms.
ANS: D
Some societies are basically nonviolent, and for them violence is not a significant health problem. Violence is a learned behavior,
and social norms can keep violence at low levels or even eliminate it. The learned culture of the society is the best indicator for
violence, not the differentiation between civilized or primitive, geographic location, or population differences among males and
females.
2. Which of the following statements best explains the primary reason why violence is so high among young male parents?
a. Men tend to be more violent than women.
b. They are young and thus lack maturity.
c. Unemployment is higher in this population.
d. Violent tendencies are transferred genetically along racial lines.
ANS: C
Most analyses conclude that the differential rates of violence in the United States have more to do with economic realities, such as
poverty, unemployment, and overcrowding, than with race. Although violence among men may be higher than among women, this
question specifically addresses “young men.” Economic realities are more indicative of this rate of violence than age and maturity.
Violence is a learned behavior; it is not transferred genetically along racial lines.
3. Which of the following is the top risk factor for intimate partner homicide?
a. There is a gun in the house.
b. The husband has made threats against wife before.
c. The wife has previously reported being physically abused.
d. The woman’s young daughter also lives with them.
ANS: C
The top risk factor for intimate partner homicide (IPH) is previous domestic violence. Other risk factors are access to guns,
estrangement, threats to kill or threats with a weapon, nonfatal strangulation, and a stepchild in the home if the victim is a female;
however, these are not the top risk factor.
4. Which of the following persons is most likely to be assaulted?

a. A young man
b. A young woman
c. An older man
d. An older woman
ANS: A
Men are far more likely to be assaulted or killed than are women. The greatest risk factor for an individual’s victimization by
violence is age; youths are at significantly higher risk.
5. Which of the following is the most likely reason for a man to rape a woman?
a. Because the woman was asking for it
b. For power and control
c. Provoked by the woman’s dress and behavior
d. Sexual pleasure and release
ANS: B
The underlying issues of rape are hostility, power, and control. Sexual desire is not an underlying issue of rape, nor is provocative
dress and behavior. Rape occurs because of power and control, not because the woman is asking for it.
6. A nurse is counseling a woman following a rape. Which of the following feelings is the woman most likely to state she felt while
being raped?
a. Confusion
b. Satisfaction
c. Sexual release
d. Victimization
ANS: D
During the act of rape, survivors are often hit, kicked, stabbed, and severely beaten. It is this violence, as well as the violation of the
sense of self, that most traumatizes the person because of the fear for her life and her feelings of helplessness, lack of control,
victimization, and vulnerability. Because of the violence associated with rape, it is highly unlikely that the victim will report
satisfaction or sexual release. The woman may be confused about what to do next, but it is more likely that the trauma will cause
feelings of helplessness which could contribute to the confusion.

7. A nurse is concerned about the possibility of suicide in a teenage boy. Which of the following characteristics has the boy most
likely displayed?
a. He has threatened harm to his school peers.
b. He is between the ages 15 and 19.
c. He is depressed and has a history of being sexually abused.
d. He has been accused of abusing an animal.
ANS: C
Leading risk factors for suicide are depression and other mental disorders or substance-abuse disorders. Other risk factors (that are
not as common as the leading risk factors) include prior suicide attempt, family history of suicide, mental disorder, substance abuse
or violence, firearms in the home, incarceration, and exposure to the suicidal behavior of others (family, peers, or figures in the
media). Children who threaten to harm others or who abuse an animal are more likely to hurt others than themselves.
8. Which of the following is a common factor typically found in those who abuse others?
a. Fear and belief that others are “out to get them”
b. Poor self-esteem and unawareness of alternatives
c. Previous observations of violent behaviors to manage conflict
d. Difficulty keeping commitments
ANS: C
People who become involved in violence typically had previous exposure to some form of violence. Abusers were often beaten
when they were children, or they witnessed siblings or one of their parents being beaten. They learned that violence is a way to
manage conflict. The incorrect responses are not commonly found among those who typically abuse others.
9. A public health nurse is hosting an informational meeting for young parents about how to balance their multiple responsibilities.
Which of the following parents in attendance would be most at risk for abusing his or her own child?
a. A new mother who has joined a parents’ support group
b. A father who is overwhelmed and exhausted by overtime work
c. A depressed father who was laid off from work and is missing his work
colleagues
d. A mother who is missing her career challenges and friends but enjoying being
home with her baby
ANS: C
Parents with low social support, a tendency toward depression, multiple stress factors, and a history of abuse are at risk for abusing
their own children. Abusive parents often have unrealistic expectations of a child’s developmental abilities. A new mother who has
joined a parents’ support group is displaying positive coping behaviors. Although a mother is missing her career challenges, she is
finding enjoyment in being home with her child which displays that she has a positive emotional health. A father who is
overwhelmed and exhausted is at risk for abusing his children; however, he is not displaying as many risk factors and stressors as
the father who is depressed, laid off from work, and missing his colleagues.
10. A teacher asks the school health nurse to assess a child for neglect. Which of the following assessment findings could indicate
neglect?
a. Bruises in various stages of healing
b. Failure of parent to attend parent–teacher conferences or return teacher phone
calls
c. Lack of weight gain and wearing dirty clothes
d. Lice in the hair
ANS: C
Physical neglect refers to failure to provide adequate food, clothing, shelter, hygiene, or necessary medical care; emotional neglect
refers to the omission of basic nurturing, acceptance, and caring essential for health development. Lice are a common problem
among schoolchildren, and the presence of lice does not indicate neglect. Failure to attend parent–teacher conferences should not
be construed as neglect, because various reasons, such as employment requirements, may prevent parents who care from attending.
Bruising is a sign of physical abuse rather than neglect.
11. Which of the following statements by a parent indicates a need for increased learning regarding appropriate (nonabusive) discipline
of a child?
a. “I have stopped using a switch on my child, and I am learning to count to 10
before reacting.”
b. “I never spank or hit; I yell at them to stop being stupid, and if they don’t, I tell
them no one is ever going to love them if they act like that.”
c. “I use time-outs when my child acts out or is naughty. Sometimes my child
doesn’t cope well with this, but I am persistent.”
d. “When my child misbehaves, I distract him and focus his attention on other
things. If he throws a tantrum, I have been known to just pick him up and leave
from wherever we are.”
ANS: B
Emotional abuse involves extreme debasement of feelings and may result in the child feeling inadequate, inept, uncared for, and
worthless. Yelling at a child and threatening loss of love are devastating. Counting to 10 before reacting, using time-outs, and
distraction all display positive methods of discipline.

12. A mother cannot understand why her daughter ran away from home. When the police locate the daughter, she complains of a severe
headache, so the police take both of them to the emergency department for assessment. Which of the following potential problems
should be assessed by the nurse?
a. The daughter’s inability to do well in school
b. Intimacy problems with the daughter’s boyfriend
c. The mother’s abuse of the daughter over a long period of time
d. Sexual abuse by the father
ANS: D
Nurses must be aware of the incidence, signs and symptoms, and psychological and physical trauma of incest. Symptoms include
headaches, as well as other physiological problems. Children often try to avoid or escape the abusive behavior. Intimacy problems
with her boyfriend, abuse by the mother, and the daughter’s inability to do well in school could all be potential reasons why the
daughter ran away. However, the nurse’s primary concern should be the potential for sexual abuse because of the behaviors that are
being displayed by the daughter.
13. The wife of an abusive husband reports to the nurse that her husband has been increasingly more abusive over the past year. Which
of the following should be the first action that is taken by the nurse?
a. Arrange for the couple to attend marital counseling.
b. Develop a plan for the wife’s escape if the violence starts again.
c. Teach the client how to avoid initiating her husband’s anger.
d. Work with the client on development of self-esteem.
ANS: B
Unfortunately, abuse tends to escalate in frequency and severity over time, and the man’s remorse tends to lessen. A nurse
encountering severe abuse needs to consider the safety of the woman and her children as the priority. The woman will need an
order of protection and help in getting to a safe place. At the very least, the woman must design a carefully thought-out plan for
escape and arrange for someone to call the police if another violent episode occurs. Although marital counseling may be useful at
an early stage of abuse, it is generally contraindicated at all other stages because of the risk to the woman’s safety. After first
developing an escape plan, it may be beneficial for the nurse to speak with the woman more about potential triggers for the
husband’s abuse as well as her own self-esteem and how that may be influencing the continuation of the relationship.
14. During a group counseling session for perpetrators of intimate partner violence, which of the following statements made by a client
indicates a lack of insight into his violent behavior?
a. “I have been taking out my frustrations with work on my girlfriend.”
b. “I love my girlfriend and didn’t want to hurt her; it was an accident.”
c. “It might be a good idea for me to temporarily leave the house when I feel myself
becoming angry.”
d. “When I drink alcohol, I become more abusive toward my girlfriend.”
ANS: B
Violence is defined as those nonaccidental acts that result in physical or psychological injury. Although this client may now be
feeling remorse, at the time the violent act was committed against the girlfriend, the intent was to inflict harm and maintain control.
It was not an accident. The incorrect statements indicate an admission of a problem—at least on the surface.
15. Which of the following statements, made by a caregiver of an older client, should alert the nurse to assess for evidence of elder
abuse?
a. “Mom is always into something and can’t seem to stay still, so I’ve been giving
her half a Valium to get her to relax so I can get some rest.”
b. “Mom wanted to stay at her home, but we were scared for her safety, so we
moved some of her personal things into our home and brought her to live with
us.”
c. “She has not been having incontinence problems since we have been taking her to
the toilet every 2 to 3 hours when she is awake.”
d. “We have to feed Mom baby food now because she has trouble chewing and
swallowing regular food.”
ANS: A
Giving medication to induce confusion or drowsiness so that the elders will be less troublesome or will need less care is considered
a form of elder abuse. Such medication may also make it easier for adult children to control the elder’s assets. The incorrect
responses are all examples of proper care.
16. A nurse is implementing a primary prevention strategy to address abuse in the community. Which of the following actions is the
nurse most likely taking?
a. Encouraging others to interfere when they see children hit or hurt in a public
place
b. Referring caregivers to community respite centers if abuse is beginning to occur
c. Lobbying for passage of legislation to outlaw physical punishment in schools
d. Screening each pregnant woman privately for intimate partner abuse
ANS: C
Primary prevention involves action before damage has occurred. The other options are all screening for abuse or reactions to abuse
that has already taken place. Encouraging others to interfere when they see children hit or hurt in a public place and referring
caregivers to community respite if abuse is beginning to occur are examples of tertiary prevention because the abuse is already
occurring. Screening pregnant women for intimate partner abuse is secondary prevention as it is a screening aimed at early
detection of the problem.

17. A nurse is working with a family to reduce the incidence of home violence. Which of the following actions by the nurse would
most likely have a positive effect?
a. Being assertive and taking control of decisions because family members cannot
be expected to have this ability
b. Focusing attention on family weaknesses that need to be fixed before healing can
begin
c. Pointing out things that victims should do differently to avoid antagonizing the
abuser
d. Soliciting ideas from the family regarding what they feel will improve their
situation
ANS: D
To empower the family, the nurse needs to recognize and capitalize on the violent family’s strengths and to guide the family in
recognizing and dealing with its problems. The nurse must use a nurse–family partnership rather than a paternalistic or
authoritarian approach. Families often can generate many of their own solutions—in fact, the family’s own solutions tend to be
more culturally suitable and individualized than those the nurse generates.
18. Which of the following best describes a principle of care that the nurse should abide by when working with abusive families?
a. Confront the abuser and shame him into penitence and a desire to change.
b. Demonstrate respect for all family members, including the abuser.
c. Exclude the abuser from family meetings because the abuser is the one creating
problems.
d. Notify the abuser’s clergyman, boss, and others who can exert pressure for
change.
ANS: B
Principles of giving care to families who are experiencing violence include the following: intolerance for violence; respect and
caring for all family members; safety as the first priority; absolute honesty; and empowerment. Confrontation and exclusion would
not be therapeutic techniques for the nurse to implement. Notification of others would violate HIPAA laws, as the nurse should be
keeping this information confidential.
19. A mother confides to the nurse that her live-in boyfriend knocked down her 2-year-old child because he was crying too much. She
begs the nurse not to tell anyone because her boyfriend has agreed to take anger management classes. Which of the following
actions should be taken by the nurse?
a. Abide by the mother’s wishes because this information was provided in
confidence.
b. Arrange for counseling for the boyfriend at the earliest possible availability.
c. Encourage the mother to take the child and find alternate housing right away.
d. Report the incident to child protective services or other appropriate legal
authority.
ANS: D
Nurses are mandatory reporters of child abuse, even when only suspected, in all states. The incorrect options put the child’s welfare
at risk, including encouraging the mother to seek alternatives, since encouraging an action will not ensure that it will happen.
MULTIPLE RESPONSE
1. Which of the following factors may lead to increased violence? (Select all that apply.)
a. Minimal social support
b. Feelings of powerlessness
c. Violence shown in the media
d. Living in a crowded environment
e. A history of depression
ANS: A, B, C, D
Factors that increase violence include seeing violence in daily life or in the media, living in poverty with few opportunities for
employment, and feelings of powerlessness. Crowded environments can be a factor but can also lead to banding together for the
common good. While social support is a positive factor, an insufficient amount may lead to increased violence. Depression is not
necessarily a trigger for violence.

Chapter 29: The Faith Community Nurse
MULTIPLE CHOICE
1. Which of the following best describes the primary difference between parish nursing and all other nursing positions?
a. Affiliation with a church or congregation
b. Incorporation of spiritual aspects into nursing care
c. Provision of holistic nursing care
d. Residence within the community of service
ANS: A
In 1998, the American Nurses Association accepted parish nursing as the most recognized term for the practice of nurses working
with congregations or faith communities. All nurses may choose to incorporate spiritual aspects into holistic nursing care.
2. To help congregation members better meet their nutritional needs, the parish nurse organized members to participate in activities
that focused on fellowship while providing healthy meals to homebound members and serving “healthy heart” church suppers.
Which of the following activities is being completed?
a. Holistic care
b. Health ministries
c. Partnerships
d. Pastoral care practices
ANS: B
Health ministries are those activities and programs in faith communities organized around health and healing to promote wholeness
in health across the life span. These services include activities such as visiting the homebound, providing meals for families in
crisis or when returning home after hospitalization, organizing prayer circles, serving “healthy heart” church suppers, and holding
regular grief support groups. Holistic care is concerned with the relationship of body, mind, and spirit in a constantly changing
environment. Providing a healthy meal does not address these multiple components. Partnerships may be among individuals,
groups, and health care professionals within the congregation. It may involve partnerships to provide these meals; however, the
focus is on the overall health ministry provided by this activity, not the partnerships which may be necessary to develop the
program. Pastoral care practices involve stressing the spiritual dimension of nursing, lending support during times of joy and
sorrow, guiding the person through health and illness throughout life, and helping identify the spiritual strengths that assist in
coping with particular events. These practices related to pastoral care are not provided through this meal.
3. Which of the following best describes why it is helpful to be a member of a faith community?
a. Belief and traditions help with coping.
b. Members can ask others in the group for help.
c. It is a social outlet.
d. Members are able to get others to contribute to the causes they support.
ANS: A
Persons who encounter assaults with physical and emotional illness and brokenness and who are able to call upon their faith beliefs
and religious traditions are able to increase coping skills and realize spiritual growth even during adversity. Family communities do
allow for a social outlet, asking others for help, and getting others to contribute to causes the support. However, the common
connect of faith and traditions is what connects the members together and allows them to accomplish these other things.
4. Which of the following principles is central to the role of the parish nurse?
a. Advanced nursing practice education and skills
b. Faith consistent with the community and its leadership
c. Spiritual dimension of care
d. Willingness to serve anyone in need
ANS: C
The spiritual dimension of health care is central to the practice of parish nursing. Advanced nursing practice education and skills,
although helpful, is not necessary for a nurse to become a parish nurse. Having a faith that is consistent with those who the nurse is
working with is helpful, but not essential to the role of the parish nurse. Willingness to serve others is not specific to the role of the
parish nurse, but rather a role that all nurses should embrace.
5. A young woman had been away from home several years before she returned home sick and disheartened. Her mother called a
nurse to help. Which of the following behaviors would suggest that the caregiver who arrived was a parish nurse?
a. Advanced nursing practice education and skills
b. Compassionate, skilled, dedicated touch
c. Offered a prayer with the daughter and mother
d. Willingness to do whatever was needed by mother or daughter
ANS: C
The spiritual dimension of health care is central to the practice of parish nursing. Both nursing functions and pastoral care functions
are performed by parish nurses, whose visits often involve prayer and reference to scripture, symbols, sacraments, and liturgy of the
faith community. Advanced nursing practice is not required for a parish nurse, so this would not suggest that the nurse was a parish
nurse. All nurses should demonstrate compassionate, skilled, and dedicated touch; thus, this would not be specific to the role of the
parish nurse. Nurses should be willing to complete tasks that are within the scope of their practice, and this does not specifically
describe what that scope of practice would be for a parish nurse.

6. Which of the following statements best describes how clients and parish nurses typically perceive spiritual health?
a. It exists at the point that cure is attained.
b. It has a tangential relation to well-being.
c. It is part of an ongoing dynamic process.
d. It is usually unchanging across the life span.
ANS: C
Health, spiritual health, and healing are considered parts of an ongoing, dynamic process. Because spiritual health is central to
well-being, influences are evident in the total individual and noted in a healthy congregation. Well-being and illness may occur
simultaneously; spiritual healing or well-being can exist in the absence of cure. Spiritual health and its definition is an ongoing and
dynamic process; thus, it changes across the life span.
7. Which of the following statements suggests that faith community nursing is a nationally recognized specialty of nursing?
a. Academic programs now offer a clinical specialty in parish nursing.
b. Faith community nurses are increasingly receiving salaries for their efforts.
c. Faith community nursing is being adapted in other countries and to non-Christian
faiths.
d. Scope and standards of faith community practice have been developed and
revised.
ANS: D
The 2005 Faith Community Nursing: Scope and Standards of Practice revised the original 1998 document in describing the who,
what, where, when, why, and how of the practice of faith community nursing. Specialty areas within professional nursing achieve a
major milestone when the standards and scope common to that practice are recognized. Academic programs do not offer a clinical
specialty in parish nursing; however, there may be ways to obtain specialty certification in the practice after becoming a registered
nurse. Many faith community nurses work as volunteers. The majority of parish nurses are found in Protestant congregations, but
they can be found around the world and in other faiths; however, there is nothing to suggest that the practice needs to be adapted
when working with these other populations.
8. A group of parish nurses affiliated with a number of faith-based communities located in different regions across the state are
attending a quarterly meeting. Which of the following statements made by one of them indicates a lack of understanding of parish
nursing?
a. “I always make sure to have new clients sign a release of information form to
obtain their health record from their previous parish nurse.”
b. “Because I work for and within the church, I am immune from civil laws.”
c. “The pastor and I work together for the spiritual health of the community.”
d. “Yes, I am happy to pray with my clients and help them worship.”
ANS: B
A nurse stating immunity to civil laws does not understand the role of the parish nurse. Parish nurses must abide by all of the
parameters of the nurse practice act of the state just as other registered nurses. The nurse must personally and professionally abide
by the parameters of the nurse practice act of the jurisdiction and maintain an active license of that state.
9. A nurse is considering accepting the parish nursing position within their congregation. Which of the following educational
preparation is crucial for the nurse to have received?
a. Baccalaureate education including community health nursing experience
b. Graduate education in community health nursing
c. Passing the national certifying examination for parish health nursing
d. Worship experiences for the process of ministry
ANS: A
Current educational preparation for the parish nurse includes the successful completion of extensive continuing education contact
hours or designated coursework in parish nurse preparation at the baccalaureate or graduate level, as well as a thorough grasp of the
scope and standards of the practice. These basic programs provide an orientation to the role and functions of the parish nurse, as
well as worship experiences for the process of ministry. Graduate education is not necessary to be employed as a parish nurse. A
national certification examination for parish health nurses does not exist at this time. The parish nurse must be a member of the
faith community and be comfortable with worship practices and traditions to function; however, the main function of the parish
nurse is not ministry.
10. A family shared their concerns, including sexual issues, in strictest confidence with a faith community nurse. When the nurse
returned to the church office, the pastor asked why the family wanted to see the nurse. Which of the following statements would be
the best response by the nurse?
a. “Because you are my supervisor, I will summarize what was said for you.”
b. “I will include that information in my report to our church’s wellness committee.”
c. “They just wanted me to assess their health needs and make some suggestions.”
d. “The family had some issues they wanted to discuss in confidence, which I will
keep in confidence.”
ANS: D
Issues of privacy and confidentiality as well as record management should be discussed upon accepting a position. Regardless, if
the nurse agreed to keep the information confidential, the nurse is morally obligated to do so. If the practice is to share all
information with the pastor, then the family must be told this before they choose to share any information with the nurse. In order
to keep this information confidential, the nurse should not disclose to the pastor that the nurse spoke with them about their health
needs, as this may lead to further questions by the pastor. Additionally, because of confidentiality, the nurse would not share this
information with the church’s wellness committee.

11. A father confides to the parish nurse that his wife has been hurting their 3-year-old daughter. The nurse examines the daughter and
finds evidence of physical abuse. In the parish nurse role, which of the following actions should the nurse take first?
a. Contact the pastor for guidance in handling this situation.
b. Recommend that the family be removed from the faith community.
c. Refer the family to pastoral services for counseling.
d. Report the findings to child protective services.
ANS: D
As an advocate of client and group rights, the nurse identifies and reports neglect, abuse, and illegal behaviors to the appropriate
legal sources. This is necessary regardless of the feelings of the pastor or the father because the nurse is bound legally to report
abuse to a child, confirmed or suspected. Referral for counseling is appropriate; however, the child’s present state of well-being is
paramount. Parish nurses must obey the nurse practice act and laws of the state. The nurse should not need to contact the pastor, as
it is within the scope of nursing practice to report suspected abuse.
12. A faith community nurse is partnering with a local public health department to develop programs for primary, secondary, and
tertiary prevention activities. Which of the following should be used as the primary guide for development?
a. Contemporary articles in nursing journals
b. Evidence-based practice guidelines for treatment of disease
c. Healthy People 2030 goals and objectives
d. Preferences of partners who are funding the programs
ANS: C
Healthy People 2030 guidelines are basic to the planning of health care. Contemporary nursing articles may be limited in scope and
it may be very time consuming for the nurse to search multiple articles to find examples of these various levels of prevention.
Evidence-based practice is for treatment, not for program development. Preferences of partners should not be used as the primary
guide for development, rather after reviewing Healthy People 2030, the nurse may want to decide on which community partners
would be appropriate for program development.
13. A parish nurse is evaluating health programs that provide holistic care across the life span. Which of the following methods would
be the most appropriate approach?
a. Bringing families together to plan programs to meet the needs of individuals
b. Establishing a wellness committee to assist in the evaluation process
c. Matching financial resources with program objectives and goals
d. Revisiting assessment data to be certain that planning reflects actual problems
observed
ANS: B
The nurse and members of the congregation assess, plan, implement, and evaluate programs. The process of providing holistic care
is enhanced by an active wellness committee or health cabinet. These incorrect options deal with factors other than program
evaluation.
14. Which of the following statements by a parish nurse exhibits a lack of understanding of the concept of pastoral care?
a. “By working with my clients to help them identify their spiritual strengths, I am
drawing on pastoral care aspects of practice.”
b. “To incorporate pastoral care, I should involve the pastor in ministering to the
members of the congregation.”
c. “I use pastoral care when I emphasize the spiritual dimension of nursing when
providing care.”
d. “When I lend support to my clients during times of joy, as well as during their
times of sorrow, it illustrates an important aspect of pastoral care.”
ANS: B
Pastoral care is a service ministry formalized by a church or faith community, not necessarily involving the pastor. The nurse
fulfills the role of pastoral care through stressing the spiritual dimension of nursing, lending support during times of joy and
sorrow, guiding the person through health and illness throughout life, and helping identify the spiritual strengths that assist in
coping with particular events.
15. A parish nurse is using the institution-based model to plan care for a client with a chronic illness. Which of the following activities
would the nurse most likely implement?
a. Bringing in family members to work with the client and nurse in decision making
b. Partnering with outlying health care centers for coordinating optimal care
c. Pulling from the collective strengths of faith-based community members for
social support for the client
d. Relying on congregational prayer as a component of healing
ANS: B
The institution-based model includes greater collaboration and partnerships. The nurse may be in a contractual relationship with
hospitals, medical centers, long-term care establishments, or educational institutions. Thus, based on the institution-based model,
partnering with outlying health care centers is appropriate. The other options are better examples of the nurse implementing the
congregation-based model. In this practice, the nurse usually practices autonomously and is accountable to the congregation and its
governing body. There are not specific partnerships in this model.

16. A nurse would like to maximize autonomy in their parish nursing practice. Which of the following models would most likely be
preferred by the nurse?
a. Congregation-based model
b. Institution-based model
c. Teamwork model
d. Partnership model
ANS: A
In the congregation-based model, the nurse is usually autonomous. The development of a parish nurse/health ministry program
arises from the individual community of faith. The nurse is accountable to the congregation and its governing body. The
institution-based model includes greater collaboration and partnerships. The nurse may be in a contractual relationship with
hospitals, medical centers, long-term care establishments, or educational institutions. The teamwork and partnership models are not
models of parish nursing.
17. A parish nurse organizes the annual health fair for the congregation, inviting community agencies to attend the event and display
the health resources that are available in the community. What function of the parish nurse is being demonstrated?
a. Health advocate
b. Referral agent
c. Health educator
d. Coordinator of volunteers
ANS: D
As the coordinator of volunteers, the parish nurse recruits, trains, and supervises volunteers to expand ministry and outreach;
organizes a health ministry team to guide and direct faith and health initiatives; and utilizes the gifts and talents of congregation
and community members. As a health advocate, the parish nurse empowers congregation members to obtain needed health care
services. Using the function of referral agent, the parish nurse provides information for referrals to appropriate agencies and
services. As a health educator, the parish nurse focuses on the teaching role of the nurse; organizing a health fair enables others to
complete that health teaching, not the parish nurse.
18. A parish nurse is implementing a primary prevention measure related to obesity among the school-age members of the church.
Which of the following activities is most likely being used by the nurse?
a. Establishing a walking program that is sufficiently challenging yet not too
strenuous for those who are obese
b. Partnering with youth camp cooks to ensure that food is nutritious
c. Supervising height and weight measurements taken by clinic assistants
d. Working with parents of obese children to implement family lifestyle changes
ANS: B
An example of primary prevention is encouraging healthy snacks and meals for youth outings and at educational hour and
parenting sessions. The incorrect options all deal with secondary prevention activities, which are focused on decreasing obesity.
MULTIPLE RESPONSE
1. The parish nurse is working with the wellness committee to develop health programming for the congregation. Which of the
following activities would the nurse most likely include? (Select all that apply.)
a. Provide regular blood pressure screening for members of the congregation.
b. Create a bulletin board to display information about the signs and symptoms of
stroke.
c. Implement a program to speak with adolescents about stress management.
d. Research evidence-based approaches for chronic wound healing.
e. Provide healthy recipes for holiday baking.
ANS: A, B, C, E
As a member of the wellness committee, the parish nurse is concerned with reducing the risk of development of disease or disorder
among all of the members of the congregation. Thus, implementing strategies that are related to health promotion would be
appropriate for the nurse to implement. These would include blood pressure screenings, creation of bulletin board about stroke,
healthy eating-related information, and implementation of stress management program for adolescents. Researching evidence-based
guidelines for chronic wound healing would not address health promotion strategies within the congregation. Also, it is unlikely
that the parish nurse is providing direct care services, such as caring for chronic wounds, for members of the congregation.
2. A parish nurse has been using pastoral activities when providing care to clients. Which of the following interventions is the nurse
most likely using? (Select all that apply.)
a. Helping families plan healthy nutritious meals and get plenty of rest
b. Giving health education classes to the congregation
c. Using hymns and scripture as a source of guidance and comfort
d. Helping identify spiritual strengths that may assist in coping
e. Visiting home-bound parishioners
ANS: C, D, E
When the nurse fulfills pastoral care, the nurse stresses the spiritual dimension, lends support during times of joy and sorrow,
guides the person through health and illness, and helps identify the spiritual strengths that assist in coping with particular events.
The incorrect responses represent nursing functions, not functions of pastoral care.

Chapter 30: The Nurse in Public Health, Home Health, Palliative Care, and Hospice
MULTIPLE CHOICE
1. Which of the following statements best describes the most essential difference between home health care and acute client care?
a. Acute client care is individualized for the client and family.
b. Home health care is provided in the client’s environment.
c. Reimbursement for home health care varies from that of care provided in
institutions.
d. The focus of acute client care is on community health.
ANS: B
Home health differs from other areas of health care in that health care providers practice in the client’s environment. All nurses
give individualized care to clients. Reimbursement for home health care is different than that provided in an acute care setting;
however, this is not the most essential difference. The focus of acute client care is typically on care provided in a hospital setting,
not in the community.
2. A nurse has just received word that Medicaid will reimburse for care provided to a homeless man with schizophrenia who is afraid
to come to the clinic to receive health care. Which of the following best describes this type of nursing?
a. Community-oriented nursing
b. Home health nursing
c. Hospice nursing
d. Private duty nursing
ANS: B
Home health nursing is provided in the client’s environment, regardless of where that may be. “Home” may be a house, apartment,
trailer, boarding house, shelter, car, makeshift shelter under a bridge, or cardboard box. Community-oriented nursing refers to any
care that is provided in a community setting. Hospice nursing is care that is provided to a client and his or her family who has a
terminal illness. Private duty nursing is care that is primary care that is paid for by an individual who is requesting the care.
3. A hospital nurse wants to know why home health nurses often take more time with assessment than nurses do in the hospital.
Which of the following is the best explanation for this?
a. Home care assessment includes not only the client but also the supplies and
equipment the family may have available for use.
b. The home environment is less organized and equipped for the nurse’s use.
c. Family members must also be assessed for possible problems that could interfere
with the primary client’s recovery.
d. To be effective, the home health nurse must earn the family’s trust and work in
partnership with them.
ANS: D
The primary reason that assessment may take longer for the home health nurse is because when working in a client’s home, the
nurse is a guest. To be effective, the nurse must earn the trust of the family and establish a partnership with client and family. The
home care assessment includes many aspects which are broader in scope than only the client, supplies, and equipment. The home
environment varies and may or may not be organized for the nurses’ use. The primary focus of home care is the care of the
individual, not the care of other family members.
4. Which of the following events led to the emphasis on home care nurses caring for acutely ill clients and the increased demands for
extensive documentation?
a. Advances in medical technology and pharmacology
b. Increased number of lawsuits for substandard care
c. Introduction of Medicare
d. Social Security Act of the 1930s
ANS: C
The combination of preventive services and illness care followed the introduction of Medicare in 1966. The Medicare program
emphasized care for more acutely ill people rather than illness prevention and health promotion. Medicare was a provision of the
Social Security Act that was implemented in 1965. It was not part of the original legislation of the 1930s. There have not been an
increased number of lawsuits based on substandard care. Advances in medical technology have been available to the population to
extend their longevity, but this has not changed the need for homecare or extensive documentation.
5. In the agency, one of the nurses spent all available time visiting a group of persons with mental health problems who were trying to
remain functional in the community. Which of the following types of assignments did the nurse most likely have?
a. Home-based primary care
b. Population-focused home care
c. Proprietary home care
d. Transitional care
ANS: B
Population-focused home care is directed toward the needs of specific groups of people, including those with high-risk health needs
such as mental health problems, cardiovascular disease, or diabetes; families with infants or young children; and older adults. Such
care commonly includes structured regular visits with assessment protocols, focused health education, counseling, and
health-related support and coaching. Home-based primary care emphasizes delivering primary care in the homes of people who
have difficulty going to a primary care clinic because of functional or other health problems. Proprietary agencies are ones that are
profit making; it does not describe the care model that is being implemented. Transitional care programs are designed for
populations who have complex or high-risk health problems and are making a transition from one level of care to another.

6. A new client has just been released from the hospital after intensive treatment for multiple injuries following a motorcycle accident.
Which of the following types of care will the client most likely receive?
a. Home-based primary care
b. Population-focused home care
c. Proprietary home care
d. Transitional care
ANS: D
Transitional care programs in the home are designed for populations who have complex or high-risk health problems and are
making a transition from one level of care to another. Assessing, planning, teaching, making referrals, and following up on referrals
foster independence and self-care. Besides intensive teaching about self-care, telephone calls help ensure that the client understands
and is able to implement instruction. Home-based primary care emphasizes delivering primary care in the homes of people who
have difficulty going to a primary care clinic because of functional or other health problems. Population-focused home care is
directed toward the needs of specific groups of people, including those with high-risk health needs such as mental health problems,
cardiovascular disease, or diabetes; families with infants or young children; and older adults. Proprietary agencies are ones that are
profit making; it does not describe the care model that is being implemented.
7. Which of the following types of home health agencies emphasizes health promotion and illness prevention?
a. Combination agencies
b. Hospital-based agencies
c. Official agencies
d. Proprietary agencies
ANS: C
Official or public agencies include those agencies operated by the state, county, city, or other local government units, such as health
departments. Nurses employed in these settings provide well-child clinics, immunizations, health education programs, and home
visits for preventive health care. Consequently, they include a focus on health promotion and illness prevention as well as giving
direct care. The merging of official and voluntary home health agencies has led to the development of combination agencies. One
of the main purposes of hospital-based agencies is to provide for the continuity of care from the acute to the home care setting as all
care is provided by the same organization. Proprietary agencies are home care agencies that are for profit.
8. Which of the following is a potential advantage of hospital-based home health agencies over other types of home care agencies?
a. Administration and management benefits are gained from the expertise of two
boards of experts.
b. Continuity of care is enhanced.
c. Health promotion and illness prevention concerns take precedence over acute care
and rehabilitation.
d. They are eligible for tax exemptions through affiliated agencies.
ANS: B
Hospital-based agencies emerged in response to the recognized need for continuity of care from the acute care setting. Having two
boards of experts relates to care that is provided by a combination agency (combining an official and voluntary agency). Health
promotion and illness prevention are typically the focus of official agencies. Non-proprietary agencies are eligible for tax
exemptions because they do not make a profit.
9. Which of the following is the primary focus of hospice care?

a. Curing or controlling the client’s chronic disease
b. Decreasing the waste of acute care (hospital) resources
c. Providing palliative care to maintain comfort until death
d. Teaching the client and family how to care for themselves
ANS: C
The primary goal of hospice care is to help maintain the client’s dignity and comfort. Alleviating pain: encouraging the client,
family, and friends to communicate with each other about essential sensitive issues and coordinating care to ensure a comfortable,
peaceful death all contribute to palliative care. Curing the disease is not part of hospice care; patients who have begun hospice care
are no longer seeking a cure for their disease or illness. Hospice care focuses on providing safe and effective care so that the client
is able to maintain dignity and comfort during the dying process; it does not relate to decreasing the use of hospital resources. The
purpose of hospice care is not to teach self-care.
10. Which of the following best describes why it is more challenging for most nurses to meet the needs of a dying child and his or her
family than to meet the needs of a dying adult?
a. Children don’t understand what it means to die.
b. A child’s death is harder for anyone to accept.
c. Society does not expect death to occur in children.
d. Families are not prepared to deal with death.
ANS: C
The needs of the dying child and family are unique because society does not expect death to occur to the young or to have the child
die before the parent. Because society does not expect death to occur in children, death among children is not discussed. Thus,
families are then unprepared to deal with the death; it becomes harder to cope with because it is a subject that is not openly
discussed. It is true that children have a limited understanding of dying; however, this can be related back to society’s view on
death in children as well as the growth and development stage of the child.

11. When meeting with a client and family, the home health nurse says, “We have discussed your health problems and limitations. Now
tell me what level of health and function you hope to achieve.” In which of the following phases of the nursing process is the nurse
engaging?
a. Assessment
b. Diagnosis
c. Outcome identification
d. Planning
ANS: C
By steering the conversation toward goals, the nurse is now able to work with the client to mutually identify outcomes. When
discussing health problems and limitations, the nurse was gathering a history as part of the assessment phase. This allowed
formulation of a nursing diagnosis. The planning would occur after the outcomes have been identified so that a plan can be
established as to how the outcomes will be met.
12. A home health nurse asks a client diagnosed with arthritis to attend a demonstration in which an assistive device is used to put on
shoes. Which phase of the nursing process is the nurse’s current focus?
a. Outcome identification
b. Planning
c. Implementation
d. Evaluation
ANS: C
Implementation is the phase in which the home health nurse implements the interventions identified in the plan of care. When the
nurse discusses the development of goals with the client, they are identifying outcomes. The planning phase occurs after outcomes
have been identified, as a plan to reach those outcomes is created. If the client is able to use the device, the process can progress to
evaluation, in which the nurse will assess the usefulness of the device when incorporated into the client’s activities of daily living.
13. A home health nurse is caring for a client who has right-sided paresis secondary to a stroke. Which of the following would be the
best approach for the nurse to take?
a. Arrange for private duty nurses to assist the client with daily needs.
b. Assist the client with activities of daily living.
c. Teach the client to participate in self-care activities.
d. Teach the family how to care for the client.
ANS: C
Because home health care is often intermittent, and because a reliance on others is not always possible over the long term, a
primary objective for the nurse is to facilitate self-care so that clients may remain in their home. This allows clients to have some
control over their life and can help prevent hopelessness and a loss of self-esteem. Although assistance may be needed, such as
from a private duty nurse, the home care nurse, or family members, this assistance should come after helping clients to help
themselves.
14. Which of the following do community-based nurses typically use to organize, sort, and document pertinent client data?
a. NANDA
b. NIC & NOC
c. Nursing Diagnosis Taxonomy
d. The Omaha System
ANS: D
Although all four are recognized nursing taxonomies, in community health, especially home nursing, the Omaha System is
typically used. This system was developed by a visiting nurses’ association in Omaha and based on home nursing documentation
needs. The Omaha System is most relevant to home health nursing and is most typically used by home health nurses. NANDA is a
standardized nursing language, but it is not known for its usage specific to the home health setting. NIC & NOC are standardized
languages for the development of interventions and outcomes for clients but are not well known for being used in the home care
setting. The Nursing Diagnosis Taxonomy refers to the use of nursing diagnoses.
15. Which of the following should be the minimum requirement for a nurse to be prepared for home health nursing?
a. An RN license and a baccalaureate degree in a health-related field
b. A baccalaureate degree in nursing and RN licensure
c. An associate degree in nursing and RN licensure
d. Eligibility for certification as a home health nurse
ANS: B
A baccalaureate degree in nursing should be the minimum requirement for entry into professional practice in any community health
setting. The baccalaureate degree should be in nursing, not in a health-related field. Additional education, beyond an associate
degree, is necessary for a home health nurse. Certification as a home care nurse is not available until after working in this setting,
so this would not be an option.

16. A nurse orienting to the home health role states, “I don’t understand why we have to collaborate with so many other disciplines;
this conflicts with the concept of nurses providing all direct care to the client in the home?” Which of the following would be the
best response?
a. The nurse still provides direct care for the client; however, interdisciplinary
collaboration is necessary to prevent fragmentation of care.
b. Direct nursing care is a concept applied to care in tertiary facilities, such as
hospitals, where materials are centrally located in one facility. In home health,
this is not possible.
c. Even though home health nursing does not provide as much direct care as other
nursing specialties in the community, each discipline contributes to client needs
from its special knowledge base.
d. Yes, it does create conflict, but Medicare mandates interdisciplinary
collaboration.
ANS: A
The responsibilities and functions of other health professions in home care are dictated by Medicare regulations, professional
organizations, and state licensing boards. Many of these services can be provided on a consulting basis. The plan of care should be
implemented and reinforced by all involved disciplines. Therefore, interdisciplinary collaboration is required in the home health
setting. Interdisciplinary collaboration does not conflict with the concept of providing direct care services. Direct ca re refers to the
actual physical aspects of nursing care anything requiring physical contact and face-to-face interactions. In home care, direct care
activities include performing a physical assessment on the client, changing a dressing on a wound, giving medication by injection,
inserting an indwelling catheter, or providing intravenous therapy. Direct care also involves teaching clients and family caregivers
how to perform a certain procedure or task.
17. A nurse completes a self-assessment of performance as part of the home health nurse’s annual evaluation. Which of the following
terms best describes this activity?
a. Collaboration
b. Quality of care
c. Performance appraisal
d. Resource utilization
ANS: C
As part of a performance appraisal, the home health nurse evaluates his or her own nursing practice in relation to professional
practice standards, scientific evidence, and relevant statutes, rules, and regulations. Collaboration means working with others to
achieve a common goal; completing a self-assessment does not require collaboration. Using the Standards of Care is a way that the
nurse can provide quality care, but a self-assessment does not guarantee that quality care is being provided. Resource utilization
refers to using a variety of resources effectively to provide safe and quality care; this is not demonstrated by completing a
self-assessment.
18. Which of the following best describes when the home health nurse must document required Outcome and Assessment Information
Set (OASIS-C2) data?
a. Before any episode of hospitalization
b. After each home health visit
c. For all incidences of error or mistake in care
d. On first admission to home health care
ANS: D
OASIS-C2 data are measured and reported to CMS (1) on admission to home health care, (2) after an episode of hospitalization, (3)
at the time of recertification, and (4) on discharge from care or death at home. Data are submitted by each agency to a national
databank, and agencies receive both results and comparisons with similar agencies to determine areas needing improvement. The
data reported from OASIS determine the payment received by the home health agency for the client’s total episode of care.
OASIS-C2 data are measured and reported to CMS after each episode of hospitalization, not before, and at the time of
recertification, not after each home health visit. The submission of OASIS-C2 data is not required when an error or mistake is
made.
19. The board of directors is examining various submitted reports concerning its home health agency. Which of the following reports
represents an example of benchmarking?
a. A report by the administrator regarding how the home health agency’s
performance compares with that of other local and national home health agencies
b. A report by the chief financial officer regarding a cost-benefit analysis related to
technological advances
c. A report by the chief nursing officer regarding client outcomes
d. A report by the medical director regarding implementation of evidence-based
practice into standards of care
ANS: A
Performance improvement programs are based on measurable data, including benchmarking, which means comparing oneself with
national standards and guidelines and with other agencies. A cost-benefit analysis relates to the use of technology and its impact on
the home care agency and is not related to benchmarking. A client outcomes report would need to be compared to other data in
order for benchmarking to occur. The implementation of evidence-based practice does not demonstrate the use of benchmarking.

20. Which of the following comments was most likely stated by a home health nurse?
a. “Every time I see a client, it costs $80.”
b. “Health care costs are killing our economy.”
c. “I can’t believe how much clients are charged for things.”
d. “Medicaid costs are such a large portion of our state’s budget.”
ANS: A
Nurses in many settings are not directly exposed to the financial aspects of health care, although as citizens they should be aware of
the overall effects of high health care costs. In home health, nurses must be cost-conscious so that they can accurately explain to
clients what Medicare will or will not cover and discuss other financial concerns. In addition, home care nurses must be
knowledgeable about which medical supplies are covered. Health care costs are impacting the economy, but it is not only home
care that is influencing these high costs. Both Medicare and Medicaid costs are a large portion of a state’s budget. The home care
nurse probably not only recognizes the costs of supplies, but also realizes the need to be cost conscious to keep these costs at a
minimum when possible.
21. Which of the following best describes one of the outcomes of the incentives and pressures for cost control and improved health
outcomes?
a. Expansion in alternative health care agencies
b. Improvements in client teaching materials
c. Public pressure to improve health professionals’ education
d. Development and increased use of telehealth technology
ANS: D
The incentives and pressures for cost control and improved health outcomes have increased the development and use of telehealth
technology in home care. Simultaneously, technologies have been simplified and their reliability increased, facilitating their safe
use in the home. There has not been an expansion in alternative health care agencies, most likely because there is not adequate
reimbursement available. Improved client teaching materials has not been influenced by the need to control costs. Improving health
professionals’ education may improve health outcomes, but this may also drive up costs as the care is being provided by those who
are more highly educated.
22. Which statement made by the nurse best confirms the achievement of goals related to the Omaha System conceptual model?
a. The nurse confirms to the client that, “Your appointment can be rescheduled.”
b. The occupational therapist emails the nurse confirming, “I got the client’s files.”
c. The client thanks the nurse saying, “I appreciate knowing what the procedure will
cost.”
d. The pharmacist calls the client to say, “Your prescription is going to be delayed
by one day.”
ANS: A
The Omaha System was intended for use by nurses and all members of the health care delivery team. The goals of the research
were to develop a structured and comprehensive system that could be both understood and used by members of various disciplines
in order to foster collaborative practice. The correction option best demonstrates collaboration between team members.
23. What example of information sharing is most important when managing a client’s transition from acute care to home care?
a. Working directly with the client’s insurance provider
b. Arranging for emotional support for both client and caregivers.
c. Communication between acute care and home health agency staff
d. Providing the client with information regarding available community resources
ANS: C
The sharing of information from one health care setting or provider to another is critical for community-based care, especially as
clients make the transition between hospital and home. While the other options are valid, the sharing of information between acute
and home care providers is most directly involved in the successful transition of care for the client.
24. Which interdisciplinary service member is most important to the achievement of autonomy for a client who experienced a lumbar
located spinal cord injury?
a. Occupational therapist
b. Physical therapist
c. Home health aide
d. Social worker
ANS: A
An occupational therapist will focus on upper extremities to restore muscle strength and mobility for functional skills and
performance of activities of daily living supporting autonomy. While the other options are relevant, they are not as directly focused
on self-care and autonomy.
25. A family member asks a home health nurse to explain the concept of hospice care. Which of the following would the nurse need to
include as the fundamental underlying philosophy of hospice?
a. Enabling the client to die at home
b. Ensuring that the client’s living will is upheld
c. Placing experts in the position of power of attorney
d. Providing comfort measures before death
ANS: D
The hospice philosophy of care means providing comfort measures to an individual before death. Death may occur in the
individual’s home, in a hospital setting, or in an uncontrolled setting such as the community. The philosophy of hospice does not
relate to what happens with the client’s living will or power of attorney, rather it focuses on providing a dignified death.

MULTIPLE RESPONSE
1. Which of the following aspects of a home health agency would most likely be examined during the accreditation process? (Select
all that apply.)
a. Cost of each service rendered
b. Credentials of each employee
c. Organizational structure
d. Outcomes of care
e. History of clients
ANS: C, D
Both The Joint Commission (TJC) and the Community Health Accreditation Program (CHAP) of the National League for Nursing
(NLN) look at the organizational structure through which care is delivered, the process of care through home visits, and the
outcomes of client care, focusing on improved health status. Performance improvement must be ongoing in the agency. It is
assumed the credentials of each employee were confirmed before employment. Accreditors are not as concerned with client history
or with the costs of the services rendered as they are with the other quality indicators.
2. A family is concerned about the medical bills of their father, age 63, who is unemployed and has almost no savings. Which of the
following statements by the nurse accurately explain how Medicaid and Medicare would work in this family’s situation? (Select all
that apply.)
a. “All your father’s medical bills will be paid by whichever program is
appropriate.”
b. “Choose any physician and just show them your Medicare or Medicaid card.”
c. “Your father must be homebound to qualify for Medicare assistance but less so
for Medicaid.”
d. “Medicare is a federally funded program, but Medicaid is administered by your
state.”
e. “Your father’s age disqualifies him from both programs.”
ANS: C, D
Medicare, for those age 65 and over or disabled, is a federal insurance program administered by the Social Security Administration,
whereas Medicaid, based on a client’s lack of financial resources, is a federal and state assistance program administered by the
state. Medicare will only pay for home health care by skilled professionals while the client is homebound, whereas Medicaid does
not necessarily require homebound status and may reimburse for home health aides and other nonskilled supportive services. Many
physicians will not accept a client on Medicare or Medicaid because of the low reimbursement rates. A deduction from Social
Security is made for Medicare premiums, and clients are still responsible for deductibles and copays, so it is misleading to tell the
family that all their father’s medical bills will be paid.
3. What are examples of telehealth applications? (Select all that apply.)

a. A cardiac client’s heart function being monitored daily
b. A client calling their provider’s office to make an appointment
c. A client discussing a skin reaction with a telephone triage nurse
d. A surgeon accessing a client’s electronic health record when a referral was made
e. A “Zoom” meeting between an advanced practice nurse and mother regarding a
well-baby visit
ANS: A, C, D, E
Telehealth supports long-distance health care, client and professional health-related education, and public health and health
administration using electronic information, medical devices, and telecommunication technologies. The technology used varies to
include live videoconferencing, the Internet, store-and-forward imaging, streaming media, satellite, wireless communications, and
plain old telephone systems. Telehealth equipment and program components include telephone triage and advice, and biometric
telemonitoring equipment to measure vital signs, weight, cardiac function, and point-of-care diagnostics. The system may or may
not include video technology for live interaction.

Chapter 31: The Nurse in the Schools
MULTIPLE CHOICE
1. Which of the following activities are expectations for a school health nurse?
a. Ensuring that children with health problems are accepted by their peers
b. Driving children home if parents can’t pick them up
c. Giving emergency care in the school or during school events
d. Giving medications as needed if children are ill
ANS: C
School nursing responsibilities include making sure that children get the health care they need, including emergency care in the
school; keeping track of the state-required vaccinations that children have received; carrying out the required screenin g of the
children based on state law; and ensuring that children with health problems are able to learn in the classroom. The nurse cannot
convince children to accept other children as peers, although certainly efforts should be made. HIPAA would not allow individual
examples of health problems to be shared, other than providing group statistics. It would not be appropriate for the school nurse to
provide transportation services to the students attending the school.
2. Which of the following statements best explains why many school nurses are not able to ensure that all children receive needed
health care in the schools?
a. There is a shortage of baccalaureate-prepared nurses with national school health
nurse certification.
b. Most nurses prefer to be employed in hospitals giving direct care.
c. Most school districts are unable to afford a nurse in every school.
d. School districts and taxpayers see no need for nurses in schools.
ANS: C
The Healthy People 2030 Objective AH-R08 recommends an increase in the proportion of secondary schools with a full-time
registered nurse (US Department of Health and Human Services, 2020). But such a recommendation is expensive and not a
possibility for all school districts presently. School districts may see that the need for nurses is important but may have insufficient
funds to be able to afford to pay for their services. There is not a national requirement that school nurses must have baccalaureate
preparation or school nurse certification. Preference of employers by nurses does not impact why school nurses are unable to
ensure that adequate care if provided.
3. A school health nurse is requested by the board of education to assist in choosing new playground equipment for an elementary
school that meets safety standards. Which of the following best describes the nurse’s role in this scenario?
a. Case manager
b. Consultant
c. Counselor
d. Health educator
ANS: B
The school nurse is the person best able to provide health information to school administrators, teachers, and parent–teacher
groups. As a consultant, the school nurse can provide professional information about proposed changes in the school environment
and their effect on the health of the children. The nurse also can recommend changes in the school’s policies or ask community
organizations to help make the children’s schools healthier places. As a case manager, the school nurse helps to coordinate the
health care for children with complex health problems. As a counselor, the school nurse is considered a trustworthy person to
whom the children can go if they are in trouble or when they need to talk. In the health educator role, the school nurse may be
asked to teach children both individually and in the classroom.
4. At the annual community health fair, the school health nurse displays a science booth that examines the hazards of ineffective hand
washing. Which of the following best describes the nurse’s role in this scenario?
a. Consultant
b. Community outreach
c. Counselor
d. Researcher
ANS: B
When participating in community outreach, nurses reach out to residents in the community. One common way this occurs is when
nurses are involved in activities such as community health fairs or festivals in the schools. As a consultant, the school nurse can
provide professional information about proposed changes in the school environment and their effect on the health of the children.
As a counselor, the school nurse is considered a trustworthy person to whom the children can go if they are in trouble or when they
need to talk. As a researcher, the nurse can study outcomes related to school nursing services which may advance the practice of
school nursing.

5. Which of the following best explains why school nurses are involved in helping teachers with the task of teaching children how to
practice problem solving, communication, and other life skills?
a. Teacher shortages have required nurses to be increasingly involved in teaching
life skills.
b. Because so many nurses want to be employed in schools, this responsibility was
assumed to increase employment opportunities.
c. States are requiring nurses to screen and to teach life skills.
d. Nurses have been enlisted in this role to help reduce risk factors for future health
problems in schoolchildren.
ANS: D
Nurses fulfilling the health educator role assist in teaching children both individually and in the classroom. This teaching should
assist in helping reduce the risk factors among children in the future. Potential teacher shortages have not impacted the role of the
school nurse as a health educator. Use of the role of health educator has not changed the need for school nurses in the school
setting. There are not state requirements for required school screening or teaching life skills.
6. Which of the following best describes services that are offered at a school-based health center?
a. Employee care at a discounted cost at the school
b. Family-centered care for preK-12 grade students
c. Sex education, birth control, family planning, and care throughout pregnancy
d. Referral and networking with other health care services in the community
ANS: B
These are family-centered, community-based clinics that are run within school, often in low-income populations. These centers
provide primary care services to students of preK-12 and may offer expanded health services, including mental health and dental
care. The intention of school-based health centers is to provide care specific to preK-12 grade students, not employees. These
clinics provide a variety of services, depending on the clinic. Based on the size and services of the clinic, they may not provide
family planning services, referral, or networking with other health care services.
7. The school health nurse has enlisted the assistance of high school role models in the areas of sports and scholarship to provide an
antidrug presentation to their peers. Which of the following levels of prevention is being implemented?
a. Primary
b. Secondary
c. Tertiary
d. Both primary and secondary
ANS: A
Primary prevention interventions by the school nurse include educating children and adolescents about the effects of drugs. In
preventing use, students are taught by the school nurse to stay away from drugs such as marijuana, cocaine, crack, heroin, and
alcohol. Secondary prevention involves screening and intervening with at risk populations. Tertiary prevention aims for
rehabilitation and returning to the highest functioning possible.
8. Which of the following best describes the primary reason that school health nurses spend so much time on educational programs
that teach children the importance of water and fire safety, using a seatbelt in the car and wearing a helmet when biking or
skateboarding?
a. Because children won’t know if someone doesn’t tell them
b. Because injuries are the leading cause of death in children and most injuries are
preventable
c. Because it is a dangerous world and someone has to warn children about the
dangers
d. Because teaching is easy and more fun than passing out bandages and
documenting care
ANS: B
The school nurse, as the trusted person at school, is able to quickly give information to help prevent injuries from occurring, since
most injuries are preventable. Injuries are the leading cause of death in children and teenagers. The nurse is a trustworthy person,
but the children may likely have heard this information from someone else. The role of health educator is an appropriate and
important role of the school nurse which is the same as the role of the direct caregiver in caring for injured children and
documenting care.
9. A nurse would like to implement a primary prevention effort to decrease the leading cause of death among children and teenagers.
Which of the following actions would the nurse most likely take?
a. Educate students about injury prevention measures.
b. Provide free condoms to sexually active students.
c. Screen for signs and symptoms of cancer.
d. Invite a guest speaker to talk about living with HIV.
ANS: A
Injuries are the leading cause of death in children and teenagers; therefore, preventive measures should focus on injury prevention.
Because the question asks for primary prevention efforts, the intervention must occur before injury. Common interventions by the
school nurse include educational programs reminding children to use their seatbelts or bicycle helmets to prevent injuries. Other
classes can be on crossing the street, water safety, and fire safety. Providing free condoms to sexually active students would be a
secondary prevention intervention as these students are at risk to contract a sexually transmitted disease. Screening for signs and
symptoms of cancer is an example of secondary prevention, aimed at early detection. Inviting a guest speaker to speak about HIV
would address primary prevention, but it does not address the leading cause of death among children.

10. The school nurse has arranged for volunteers to help assess each child’s hearing and vision. Any child that the volunteers feel did
not “pass” will be sent to the nurse for follow-up. The nurse will then send a note to the parents that a physician should be seen.
Which of the following levels of prevention is being implemented?
a. Primary
b. Secondary
c. Tertiary
ANS: B
Because secondary prevention involves caring for children when they need health care, this is the largest responsibility for the
school nurse. This includes caring for ill or injured students and school employees. It also involves screening and assessing
children and referral to appropriate health agencies or providers. Primary prevention involves providing education before a problem
or disease occurs. Tertiary prevention aims at rehabilitation after the disease or problem has occurred and intends to get the client to
the highest possible level of functioning.
11. Which of the following would be the best way for the school nurse to fulfill his or her responsibilities in an emergency situation?
a. Tell all staff to call 911 if the nurse is not in the building.
b. Arrange to always be available, even if only by phone.
c. Create and share an emergency plan with all teachers and staff.
d. Wear a pager so that the nurse can come as soon as humanly possible.
ANS: C
It is recommended that the school nurse create an emergency plan with at least two different staff members identified and
responsible for implementing the plan if the nurse is not in the building at the time of the emergency. The plan would include when
to call 911 and how to get a child to the hospital via ambulance if needed. Depending on the emergency, it may or may not be
appropriate to call 911; thus, having an emergency plan in place is a more appropriate response. It is impossible for the nurse to be
available at all times. Depending on where the nurse is and what other roles the nurse is fulfilling, it may not be possible for the
nurse to respond quickly to an emergency.
12. A school nurse is administering medications at the school. Which of the following guidelines should be followed?
a. A current drug reference should be available in case information is needed.
b. The nurse should administer medications brought in from home by the child in a
plastic bag.
c. Medications cannot be administered without a physician order.
d. Narcotics and controlled substances should be kept in a locked cabinet.
ANS: A
A current drug reference should always be available so that it can be consulted for information. The nurse should develop a series
of guidelines to help with the legal administration of medications in the school. The prescribed drugs should have the original
prescription label on it and be in the original container. There should be a current, signed parental consent form for giving the
medication, and the nurse should have a means of contacting a pharmacist to ask questions. A primary care provider’s order is not
needed to administer the medications. All medications, including narcotics, should be kept in a locked container so that they are not
accessible to others.
13. An upset mother calls the school nurse and says, “How dare you say my child has lice? My child is clean and I keep a clean house!
You’ve obviously made an error.” Which of the following would be the best response by the nurse?
a. “I’m sorry you’re upset, but your child cannot return to school until this problem
is addressed.”
b. “Most lice are found in clean hair. Children often share combs. Let me tell you
how to fix the problem.”
c. “You may have been traveling. Lice are often found in motels.”
d. “I’m sure you’re correct; one of my volunteers probably made an error. I’ll
recheck.”
ANS: B
The nurse must reassure the mother that no insult was intended; in fact, lice are most often found on middle-class children with
clean hair. Lice travel easily when children share items such as combs or other property in school. Lice are not life threatening, and
the necessary shampoo and other items to treat lice are widely available over the counter. Most school policies are more caring and
less exclusionary and allow children with lice to attend school. It is more likely that the student contracted the lice from another
student than from traveling to a motel. If the nurse has delegated the responsibility of assessing for lice to a volunteer, the nurse
should reassess the findings of the volunteer to confirm that the child has lice before contacting the parent.
14. A school nurse listens as one student talks about another student being upset because his father frequently spanks him with a
leather belt that leaves big marks on the student’s back. But the student begs the nurse not to tell anyone because he promised the
friend that the information would never be shared. Which of the following actions should be taken by the nurse?
a. Ask the student if abuse has occurred.
b. Call in the named student and ask him to remove his shirt.
c. Discuss the conversation with the student’s parents.
d. Notify the legal authorities.
ANS: D
When the nurse identifies a child, who may be abused or who receives information from someone else that a child may have been
abused, the nurse must contact the appropriate legal authorities and the school’s principal. Asking the student about the abuse will
not always elicit a truthful answer, because children will protect their parents. A confidential file should be made about the
incident; however, the nurse should let the government authorities, usually the state or county child protection department, look
into the suspected case. In all cases, the child should be protected from harm, and those who have no right to know that child abuse
or neglect is suspected should not be given any information.

15. A school nurse suggests to teachers that they have a session on coping strategies and stress management techniques. The nurse also
sets up a peer counseling program for teens. Which of the following is the school nurse most likely trying to prevent?
a. Suicide
b. Bullying
c. Obesity
d. Violence
ANS: A
Among teenagers, more than 17 percent have considered suicide and more than 8 percent have actually attempted to take their own
lives (Substance Abuse and Mental Health Services Administration). To reduce the incidence of suicide in teenagers, the nurse can
emphasize coping strategies and stress management techniques and organize a peer assistance program to help teenagers cope with
school stresses. Bullying may result in adolescents feeling that suicide is the only answer. However, the strategies that the nurse is
completing would not necessarily promote a decrease in bullying. The strategies suggested would not impact the prevalence of
obesity or the incidence of violence.
16. A disaster has occurred in the community. Which of the following actions should be taken by the school nurse?
a. Continue activities as much as possible as if nothing had happened.
b. Continue to assess for shock and stress.
c. Help teachers discuss the disaster with their class.
d. Maintain school routines and activities.
ANS: B
After a disaster, the school nurse has many responsibilities—for instance, continuing to assess the school community for the
presence of shock and stress; encouraging parents to minimize how much their children view the disaster coverage on TV;
providing grief counseling; continuing to communicate with the children, parents, and school personnel; and following up with
assessment of children for anxiety, depression, regression, and posttraumatic stress disorder. It would not be appropriate for the
nurse to ignore that a disaster has occurred or to assume that routines will remain the same; it is important for the nurse to assist the
community to cope with the disaster. The nurse may use counselors in the community to assist the children to cope with the disaster
as this may not be an appropriate role for the nurse or for the teacher to perform.
17. Which of the following is the leading cause of children being absent from school because of a chronic illness?
a. Allergies
b. Asthma
c. Diabetes
d. Upper respiratory infections
ANS: B
Asthma is one of the leading causes of children being absent from school because of a chronic illness. Upper respiratory infections
are an acute problem, not a chronic one. Diabetes and allergies are not leading causes of chronic disease that result in children
being absent from school.
18. A school nurse is demonstrating the use of a peak flow meter to help children with chronic asthma recognize when they need to use
a rescue inhaler. Which of the following levels of prevention is being used by the nurse?
a. Primary
b. Secondary
c. Tertiary
ANS: C
Tertiary prevention includes caring for children with long-term health needs, including asthma and disabling conditions. The nurse
is teaching disease management (i.e., when to use an inhaler). Primary prevention involves providing education before a problem or
disease occurs. Secondary prevention addresses screening and early detection of the disease or problem.
19. A school nurse has developed a special class for pregnant teens to teach them everything from anticipated body changes to methods
for managing common pregnancy-associated problems. The classes also allow the nurse to be in close frequent contact with the
students to monitor their health status. Which of the following levels of prevention is being used by the nurse?
d. Both primary and secondary prevention
ANS: C
Many teenage girls who are pregnant attend school; therefore, the school nurse may provide ongoing care to the mother. Although
this may appear to be secondary prevention, it is tertiary prevention because adolescent pregnancies are considered to be high risk.
Primary prevention involves providing education before a problem or disease occurs. Secondary prevention addresses screening
and early detection of the disease or problem. Because the teenager is already pregnant, the nurse is addressing how to assist the
teen to achieve the highest level of functioning possible (tertiary prevention).

20. A pregnant teen asks the school nurse to provide information on abortion and a list of health care providers who offer such services.
If the school nurse has very strong personal beliefs against abortion, which of the following actions should be taken by the nurse?
a. Call in another nurse to care for this client.
b. Explain, from the nurse’s perspective, all the reasons that abortion should be
made illegal.
c. Offer the student a combination of oral contraceptives to induce spontaneous
abortion.
d. Provide information on alternatives to abortion and give the client information on
adoption agencies.
ANS: A
This creates an ethical dilemma for the nurse. If the nurse feels so strongly that he or she cannot work with the situation, another
school nurse should be called for help or the student should be referred to other health providers who can provide the care the
student needs. It is important that the nurse be able to keep an open mind when working with this teen, and if that is not possible,
another nurse needs to be asked to care for this client. The incorrect options all address the nurse discussing his or her personal
beliefs against abortion which may not be therapeutic for the teen.
21. Which of the following is most important for school nurses to master in order to prepare for health care delivery in the future?
a. Complementary and alternative therapies
b. Computer and technology use
c. Psychoanalytical techniques
d. Self-defense techniques
ANS: B
In the future, school nursing will use telehealth and telecounseling to teach health education. School nurses will use the Internet to
work with children and parents. Complementary and alternative therapies are already being widely used; most likely the nurse will
not be the one providing such care, so it would not be necessary for the nurse to master these skills. Psychoanalytical techniques
would not be necessary for the nurse to master as the nurse is able to refer students who require this type of care to appropriate
providers. There would not be a need for school nurses to master self-defense techniques.
22. The principal of a school was upset over a rumor that one of the children had engaged in a violent activity that injured a younger
sibling. The principal asked the nurse who the children were so that the involved teachers could both support the injured child and
guard other children from the violent child. Which of the following would be the best response by the nurse?
a. “I’ll get the names to you and the involved teachers immediately.”
b. “Let me get the parents’ consent, and then I’ll get you the names.”
c. “Rumors are often inaccurate; let me follow up and see what happened and what
needs to be done.”
d. “Why don’t we coordinate a school-wide program on preventing accidents
instead?”
ANS: C
The school nurse is responsible for maintaining school health office policies, including privacy and safety of health records. When
a rumor is involved, it is always wise to check its accuracy. If a child was indeed hurt, the nurse needs to make sure both children
involved receive (or have already received) appropriate care. The nurse must follow the HIPAA privacy rules while also ensuring
the safety of children at school. The question about having a school-wide program may be appropriate, but this behavior was
apparently purposeful, not accidental.
23. The mother of a high school student newly diagnosed with a condition that will require special health care services is concerned
that the student will be required to be homeschooled away from the friends he has developed. Which of the following would be the
most appropriate response by the school nurse?
a. “Federal legislation requires that the school make provisions for those with
various challenges, so your child will be able to remain in school as long as he is
able.”
b. “I realize that this will be a difficult adjustment, but homeschooling has improved
over recent decades and the Internet will allow your child to connect with
friends.”
c. “Whether your child can remain in school will depend on state funding for those
with disabilities. You might want to contact your congressman on this issue.”
d. “Your child may remain in school as long as he can manage the course
requirements and doesn’t flunk out.”
ANS: A
Federal legislation specifies that children cannot be excluded from schools because of a disability. The school must provide health
services that each child needs. Legislation further requires the school district’s committee on the disabled to develop individualized
education plans (IEPs) for children. Federal legislation will support this child continuing in the current school; thus, it would not be
necessary to counsel the parents about concerns related to the child needing to be homeschooled. Depending on the diagnosis,
special educational needs may need to be addressed for the child through an IEP which may assist the child in being successful in
the coursework.
24. A group of nursing students are scheduled to present a program on healthy hearts to various community groups, with a day care
center being the first location. What of the following advice should be given to them by their instructor?
a. Base the program on the audience’s development and maturity.
b. Bring (borrow if necessary) a model of the heart to help explain its functioning.
c. Focus on entertaining the learners.
d. Have lots of handouts to reinforce the lesson.
ANS: A
For younger learners, it is important to keep the lesson to no more than 20 minutes in length; to use plenty of examples, pictures,
and stuffed animals in the talk; and to remember the developmental stage of the children when teaching them. It will be important
for the nurse to assess the developmental level of the audience in order to determine if models or handouts are appropriate to be
used. Keeping the presentation short should assist in keeping the learner’s attention.

MULTIPLE RESPONSE
1. Which of the following activities are included in the Centers for Disease Control and Prevention’s school health program? (Select
all that apply.)
a. Ensuring a healthy school environment
b. Assisting teachers with education related to health
c. Encouraging nutritious school meals
d. Giving immunizations to students, staff, teachers, and their families
e. Providing mental health counseling
ANS: A, B, C, E
The federal government, through the coordination of the Centers for Disease Control and Prevention, developed a plan that school
health programs should follow, including health education, physical education, health services, nutrition services, counseling,
psychological and social services, healthy school environment, health promotion for staff, and family/community involvement.
Unfortunately, schools cannot afford to give immunizations to everyone who might want such a benefit.
2. Which of the following best explains why the federal government is beginning to fund school-based health centers? (Select all that
apply.)
a. These centers help young children avoid becoming addicted to drugs while still in
elementary school.
b. Attendance and learning are higher in schools with health clinics.
c. These centers help keep children in school longer by distributing birth control and
thus avoiding pregnancies.
d. Many children have no other source of health care services.
e. To ensure parents are compliant with meeting the health needs of their children.
ANS: B, D
The US government began funding school-based health centers essentially because many schoolchildren may not receive health
care services otherwise. These are family-centered, community-based clinics run within the schools. Certainly, avoiding pregnancy
and drug addiction are among the goals of school-based health centers, but these are not reasons the government began funding
them. Ensuring compliance is not a governmental responsibility in this situation since no federal laws apply.
3. A new student’s parents had not yet submitted an immunization record, although the nurse had sent a reminder home with the
student twice. Which of the following actions should be taken by the nurse to keep the child in school? (Select all that apply.)
a. Call the parents or mail another reminder.
b. Report the problem to the teacher and the principal.
c. Send the child home with a note saying the child cannot return until the
immunization record is received.
d. Determine whether the family has health care insurance.
e. Offer assistance in replacing a lost immunization record.
ANS: A, D, E
There are many problems with children not being immunized or having incomplete vaccination records, especially in families who
have moved many times or who may not have a regular physician. The parents may have no idea whether the child has received the
required shots. Families may also be without health care insurance to pay for the immunizations, or they may have insurance that
does not pay for preventive care. In these cases, they may lack the resources to pay for the immunizations themselves. Therefore,
the nurse’s role is to be sure parents are aware of the problem, to help them obtain the records if they have been misplaced, and to
suggest ways to obtain the injections without charge, even if there is no obvious evidence that lack of funds is the problem. Telling
the teacher or principal won’t resolve the problem. Sending home a note saying the child cannot return to school does not assist the
family with obtaining the immunization for the child which may be a burden for the family or a potential underlying reason why the
child has not received the immunization.
4. Which of the following emergency supplies or equipment should a nurse have available in the school health office? (Select all that
apply.)
a. Cervical spine collars
b. Complete emergency kit that fulfills American Hospital Association requirements
c. Epinephrine autoinjector kit
d. Material for splints
e. Supplemental oxygen
ANS: A, C, D, E
The school nurse needs much equipment to deal with emergencies in the school. Basic necessary equipment includes full oxygen
tanks with oxygen masks of different kinds, splints, cervical spine collars, sterile dressings, and an epinephrine autoinjector kit in
case a child goes into anaphylactic shock after exposure to an allergen. A hospital-oriented emergency kit would become quickly
outdated (medications) and extremely expensive.

5. A school nurse would like to improve the safety of everyone at the school by creating policies to decrease the likelihood that
violence will occur. Which of the following actions would the nurse likely take to minimize risk of school violence? (Select all that
apply.)
a. Engaging parents in school activities
b. Creating a zero tolerance police for weapons on school property
c. Encouraging children to participate in the after-school program at a local
community center
d. Developing mentoring programs for at-risk youth
e. Initiating a student hot line for discussing possible violence risks
ANS: A, B, D, E
Interventions that are aimed at preventing violence from occurring are: engaging parents in school activities that promote
connections with their children; fostering communication, problem solving, limit setting, and monitoring of children;
supporting/assisting with creating policies of zero tolerance for weapons on school property, including school grounds; and
developing mentoring programs for at-risk youth and families. Encouraging students to attend the after-school program at a local
community center may assist with the students having additional supervision, but it does not contribute to the students having an
increased loyalty or connection to the school. It is important to facilitate student connectedness to the school community.
6. A child has multiple disabilities, and caring for the child has been both expensive and time consuming for the school. Once the
child turns 16, which of the following actions is the school responsible for? (Select all that apply.)
a. None, since the child is no longer eligible for school services
b. Continuing to provide needed appropriate education for the child
c. Excluding the child from selected extracurricular activities
d. Continuing to prepare an updated individualized education plan
e. Arranging for reimbursement for services provided
ANS: B, D
Educational services must be offered by the schools for all disabled children from birth through age 22 years. Children cannot be
excluded from activities because of a disability. The school must always develop an individualized education plan for each child
and update it at appropriate intervals. Turning 16 does not make a child an adult; thus, the child is still able to receive services of
the school and participate in extracurricular activities.

Chapter 32: The Nurse in Occupational Health
MULTIPLE CHOICE
1. An occupational health nurse sees the various injuries and diseases that persons can acquire from employment. Which of the
following recommendations would the nurse most likely provide about safety in the workplace?
a. Find employment in physical labor; at least your body will be in good condition.
b. Professional positions are the safest choice for employment.
c. White collar positions provide the least risk for injury.
d. There is no “safe” occupation or profession.
ANS: D
Most adults spend about one-third of their time at work. No work is completely risk free. Every single industry grapples with
serious hazards related to work.
2. A nurse who works for a hospital in employee health notes that several nurses from one unit have missed work after contracting a
communicable disease from a patient. Which of the following best describes the host factor?
a. Each sick nurse
b. The communicable disease
c. The hospital
d. The patient
ANS: A
Each worker represents a host within the worker population group. The communicable disease and the patient are considered the
agent, the factor associated with the illness or injury. The hospital is part of the physical environment.
3. Which of the following groups should the occupational health nurse devote the most time to regarding education and follow-up
evaluation?
a. New workers employed less than 1 year
b. Older workers with chronic illnesses
c. Older workers with diminished hearing
d. Women in their childbearing years
ANS: A
The population group at greatest risk for experiencing work-related accidents with subsequent injuries is new workers with less
than 1 year of experience on the current job. Because of the inherent risks, the nurse should spend extra time with this group to
decrease risk. Older workers with more experience are less likely to experience injury even if they have underlying issues of
chronic disease. Women of childbearing age are not at any greater risk than the general population of employees.
4. An employee in a laboratory drops a flask, resulting in a chemical splash into the employee’s eyes, which in turn results in burns to
the eyes. Which of the following would be considered the agent?
a. The chemical
b. The employee
c. The flask
d. The laboratory
ANS: A
Agents represent potential dangers or risks to the health and safety of workers. However, in the case given, the chemical itself
caused the damage. If the flask had broken and glass got into the employee’s eye, then the flask would be an agent. However, in the
case given, the chemical itself caused the damage. The employee is considered the host and the laboratory is considered part of the
environment.
5. Which of the following hospital employees are most at risk for being exposed to and possibly developing active drug-resistant TB?
a. Housekeeping staff
b. Medical staff
c. Nursing staff
d. Ward clerks
ANS: A
Transmission of tuberculosis (TB) within health care settings has reemerged as a major public health problem. Outbreaks of this
type of TB have been reported in hospitals, and some workers have developed active drug-resistant TB. Many workers in these
settings are employed as maintenance workers, security guards, aides, or cleaning people, who tend not to be well protected from
inadvertent exposures, which include contaminated bed linen in the laundry, soiled equipment, and trash containing contaminated
dressings or specimens. Ward clerks have limited contact with acutely ill patients. Medical and nursing staff are more likely to have
the proper equipment and education to be well-protected from inadvertent exposures.
6. Which of the following is the most common disabling condition when measured by days away from work?
a. Bruises
b. Cuts and lacerations
c. Mental illnesses
d. Sprains and strains
ANS: D
In 2014, sprains, strains, and tears were by far the most frequent disabling conditions, accounting for 420,870
days-away-from-work cases and an incidence rate of 38.9 cases per 10,000 full-time workers (Bureau of Labor Statistics, 2015d).
Bruises, cuts and lacerations, and mental illness are not among the most common disabling conditions that are reported.

7. A nurse makes the suggestion that the 2-week shift rotations should be set up so that the next rotation in shifts is later rather than
earlier. Which of the following is the nurse attempting to prevent through this suggestion?
a. Anxiety, depression, and exhaustion
b. Family turmoil
c. Physical illnesses
d. Sleeping disorders
ANS: A
An estimated 10% of Americans do some form of shift work that has the potential to lead to a variety of psychological and physical
problems, including exhaustion, depression, anxiety, and gastrointestinal disturbance. Strategies to minimize the adverse effects of
shift work, such as rotating shifts clockwise, are beneficial. Family turmoil, physical illnesses, and sleeping disorders all have the
potential to occur. However, there is evidence that anxiety, depression, and exhaustion are the more prevalent physical and
psychological problems that are reported.
8. In which of the following settings have nurses most often reported being the victims of violence, especially by patients and their
families?
a. Acute care inpatient settings
b. Community clinics and physicians’ offices
c. Emergency departments and psychiatric units
d. In homes during home health visits
ANS: C
Nonfatal violence in the health care worker’s workplace is a serious problem that seems to be underreported. Much of the study of
health care worker violence has been in psychiatric settings and emergency departments. Violence is not reported in as high of an
incidence in acute care settings, community clinics, or in client homes in comparison to emergency departments and psychiatric
units.
9. The occupational health nurse makes certain all employees have and know how to use personal protective equipment (PPE). Which
of the following factors will most likely determine how effective the PPE is in keeping employees safe?
a. Comfort level of the PPE
b. Effectiveness of the nurse’s teaching
c. Knowledge level of the employee
d. Psychosocial norms of the setting
ANS: D
The employee will only be safe if the employee uses the PPE. If the employee doesn’t use the PPE or uses only part of the
equipment, then the employee will be at risk. The primary determination of whether the PPE is used correctly and used all the time
is the psychosocial norms of the setting. If others are careless in PPE use, then such carelessness is the norm. If everyone is
extremely careful to use their PPE, then that is the norm in that setting. Through education, employees have the knowledge and
skills available to correctly use PPE. The educational session should also make the employees comfortable with its use. The use of
PPE does not depend on the effectiveness of the teaching, rather the employees’ choice to correctly put into practice the knowledge
and skills that they have received.
10. Which of the following is the primary reason that large companies are becoming more involved in their employees’ personal health
and well-being?
a. It is an ethical and moral responsibility.
b. It improves public relations within the community.
c. It allows managers to better understand their employees.
d. It provides a cost savings to the company.
ANS: D
A significant increase in the number of health promotion and employee assistance programs offered has occurred. Health
promotion programs focus on lifestyle choices that cause risks to health such as obesity or smoking. Employee assistance programs
are designed to address personal problems (e.g., marital/family issues, substance abuse, financial difficulties) that affect the
employee’s productivity. Such efforts are cost effective for businesses. Becoming more involved in employees’ health and
well-being would most likely not change the relationship between the manager and the employee. This also would not change the
public relations in the community. Becoming more involved is the right thing for companies to do; however, the main motive
behind this shift is to save the company money.
11. The occupational health nurse continually reminds employees to wear their safety goggles and ear plugs. Which of the following
levels of prevention is being implemented?
a. Both secondary and tertiary prevention
b. Primary prevention
c. Secondary prevention
d. Tertiary prevention
ANS: B
Delivery of primary prevention services to employees is directed toward promoting health and averting a problem. Primary
prevention is attempting to avoid harm through protecting measures, in this case reducing ear damage due to high noise levels and
eye damage from flying particles or fluids. Secondary prevention involves screening for the disease or detecting the disease at the
earliest stage possible. Tertiary prevention aims at rehabilitation and restoring the client to the highest possible lev el of functioning.

12. An occupational health nurse is removing a foreign body from a patient’s eye. Which of the following levels of prevention is being
implemented?
a. Injury prevention
b. Primary prevention
c. Secondary prevention
d. Tertiary prevention
ANS: C
The nurse is engaging in secondary prevention when providing treatment for the injury. This does not meet the criteria for injury
prevention because the injury has already occurred. Primary prevention would occur to prevent the injury from occurring, such as
teaching the employee about use of protective eyewear. Tertiary prevention strategies would follow treatment to prevent recurrence
and to prevent more serious problems related to the foreign body from developing.
13. An occupational health nurse periodically conducts spirometry testing of employees who work around hazardous gases. Which of
the following levels of prevention is being implemented?
d. Tertiary care prevention
ANS: B
Secondary prevention involves health surveillance and periodic screening to identify an illness at the earliest possible moment in its
course and elimination or modification of the hazard-producing situation. Primary prevention would occur to prevent the injury
from occurring, such as teaching the employees about how to protect themselves from exposure to hazardous gases. Tertiary
prevention strategies would follow treatment to prevent recurrence and to prevent more serious problems related to the exposure to
the hazardous gas.
14. The occupational health nurse suggests that an employee work only half-days for three weeks and then return to full-time
employment. Which of the following best describes the rationale for this suggestion?
a. To provide an example to other employees to ensure future cooperation with
safety measures
b. To enforce an economic penalty for not obeying nurse’s instructions regarding
safety measures
c. To ensure that all employees keep their positions during an economic downturn
d. To continue employment and income with limited duty as a rehabilitation effort
after an injury
ANS: D
Rehabilitation strategies such as return-to-work programs after a heart attack or limited duty programs after a cumulative trauma
injury are examples of tertiary prevention. Tertiary prevention is intended to restore health as fully as possible and assist
individuals to achieve their maximum level of functioning. The method described is focusing on an effective method of
rehabilitation. Rehabilitation strategies are not used as a form of punishment to employees or to ensure employment for all workers.
15. An occupational health nurse is working with the manager to change the assignment of an employee from working with heavy
metal to using machinery to assist with loading and unloading boxes at the truck dock. Which of the following best explains the
rationale for this change?
a. To prevent injury
b. To limit disability
c. To provide primary prevention
d. To provide tertiary prevention
ANS: B
Interventions aimed at disability limitation are intended to prevent further harm or deterioration, and they include referral for
counseling and treatment of an employee with an emotional or mental health problem whose work performance has deteriorated
and removal of workers from heavy metal exposure who manifest neurological symptoms. The repetitive work with handling heavy
metal may have already caused harm or previous injury to this employee. Thus, the goal is to limit disability rather than to prevent
injury. Primary prevention would occur to prevent the injury from occurring, such as teaching safe lifting or operation of the
equipment. Tertiary prevention strategies would follow treatment to prevent recurrence and to prevent more serious problems
related to any incident or injury.
16. A nurse is completing a health history on a client during a routine physical examination. Which of the following questions, which is
often omitted, should be asked by the nurse?
a. “How is your family doing?”
b. “What problems have you been having?”
c. “What health concerns do you have today?”
d. “Where do you work and what do you do there?”
ANS: D
The question often omitted is, “Where do you work and what do you do there?” The occupational health history is an indispensable
component of the health assessment of individuals. Because work is a part of life for most people, including an occupational health
history in all routine nursing assessments is essential. All of these questions are appropriate during a routine physical examination.
However, it is likely that the nurse asks about family, current problems, and current health concerns to clients on a routine basis.

17. A nurse is interviewing a person who has stated on their entry health form that they are retired. Which of the following is the most
crucial question for the nurse to ask?
a. “Have you had any problems since leaving your employment?”
b. “How do you spend your time now?”
c. “What has retirement been like for you?”
d. “Where were you previously employed and what did you do there?”
ANS: D
The most crucial question is, “Where were you previously employed and what did you do there?” The occupational health history
is an indispensable component of the health assessment. All persons should be questioned about their employment history. To
describe only a current status of “retired” may lead to the omission of needed data. Even for retired persons, the nurse must ask
about employment history, because many problems take years to manifest in signs and symptoms. All of these questions are
appropriate during a routine physical examination for a person who has retired because they relate to current problems, recreation,
and mental health. However, they are not as crucial as asking for additional information about employment history. The client’s
answer to this question may alert to potential problems that the nurse should focus on.
18. A nurse keeps ongoing documentation of all the clients seen at the community health clinic. The nurse enters the demographic data
and the primary diagnoses into the computer to have a comprehensive perspective of the clinic’s clients. Which of the following
best explains why the nurse is collecting this data?
a. This data will be useful in a research study the nurse is conducting.
b. This data will provide evidence of clinic resources being wasted on minor health
problems.
c. This data will help identify patterns in the risk factors associated with a particular
subgroup.
d. This data can be used to show trends that can be included in the next grant
proposal for further funding.
ANS: C
When health data are considered collectively, the nurse may determine some patterns in risk factors associated with the occurrence
of particular injuries and illnesses in a total population of clients. There is no mention of consent, so the nurse should not be
collating research data. Grants for funding typically require current client data rather than trends.
19. As the single occupational health employee at a company, a nurse is busy with safety programs and first aid when employees are
hurt. However, the nurse still finds time to walk through the entire facility once a day. Which of the following best explains the
rationale for this action by the nurse?
a. To document employee efficiency and effectiveness at their jobs
b. To look for evidence of personal protective equipment being torn or destroyed
c. To observe whether employees are taking their rest periods as scheduled and
drinking adequate fluids during the day
d. To observe effectiveness of safety education and equipment
ANS: D
The nurse may conduct an assessment of the workplace itself, which is known as a worksite walk-through or survey. Direct
observation allows the nurse to learn about the work processes and the materials; the requirements of various jobs; the presence of
actual or potential hazards; and the work practices of employees. Such information is directly useful in planning programs,
assessing their effectiveness, and reinforcing safety with individuals who have been seen behaving in a less than safe manner. It is
not within the scope of the occupational health nurse’s role to document employee efficiency and effectiveness. The nurse may
observe how PPE is being used or if employees are taking care of themselves while on the job; however, this is not the main
purpose of a worksite walk-through assessment.
20. Which of the following interventions regarding worker safety would be the least effective?
a. Using job rotation and workplace monitoring
b. Designing equipment so that employee exposure to hazards is minimized
c. Having employees use safety measures and personal protective equipment
d. Designing the environment to encourage employees to follow workplace
procedures
ANS: C
Personal protective control is the last resort and requires the worker to actively engage in strategies for protection s uch as use of
gloves, masks, and gowns to prevent blood/body fluid exposure. Various control strategies are used to eliminate or reduce exposure
and hence risk. Engineering controls can reduce worker exposure by modifying the exposure source. Administrative controls
reduce exposure through job rotation, workplace monitoring, and employee training and education. External controls—the way
equipment is built or manufacturing processes are established—are controllable and much more effective than asking a great many
individuals to engage in behaviors that they may not want to do (such as using personal protective equipment). Humans are much
less programmable than external controls.
21. Which of the following best describes the mission of OSHA?

a. To create an inspection system to avoid preventable loss of life
b. To ensure safe and healthful working conditions
c. To establish rules for employee safety
d. To share factory illness and injury rates with the public
ANS: B
The Occupational Safety and Health Act of 1970 had as its purpose to ensure “safe and healthful working conditions for working
men and women.” OSHA enforces occupational health standards; its mission is not to have an inspection system. Safe and healthful
working conditions are ensured because of the standards that have been enforced by OSHA. OSHA does maintain a databased of
work-related injuries, illnesses, and death, but its mission is not to share this information with the public.

22. Which of the following statements best describes how workers’ compensation legislation has changed employer behavior?
a. Employers have improved safety of working conditions because safety data is
now public information.
b. Companies have improved safety of working conditions because workers’
compensation insurance premiums are now based on previous claims.
c. Employers were legally required to implement safety changes.
d. Companies have become more involved in the legislative process.
ANS: B
Workers’ compensation acts are important state laws that govern financial compensation of employees who suffer work-related
health problems. Each state sets rules for the reimbursement of employees with occupational health problems for medical expenses
and lost work time associated with the illness or injury. Workers’ compensation claims and the experience-based insurance
premiums paid by industry have been important motivators for increasing the health and safety of the workplace. The financial
incentive of having reduced claims is much more important to the employer than if the safety data may be available for the public
to view. Workers’ compensation legislation did not mandate safety changes or cause companies to become more involved with the
legislative process.
23. Which of the following would most likely be one of the first steps taken in employer disaster planning?
a. All employees are invited to attend sessions on disaster planning.
b. Employers stress the importance of disaster drills and encourage active
participation.
c. Exhaustive inventory of chemicals and industrial hazards is completed.
d. Written disaster plans are distributed to each employee and each worksite.
ANS: C
The goals of a disaster plan are to prevent or minimize injuries and deaths of workers and residents, minimize property damage,
provide effective triage, and facilitate necessary business activities. A disaster plan requires the cooperation of company and
community. The nurse is often a key person on the disaster planning team. The potential for disaster must be identified; this is best
achieved by completing an exhaustive chemical and hazard inventory of the workplace. The MSDSs and plant blueprints are
critical for correctly identifying substances and work areas that may be hazardous. Worksite surveys are the first step to completing
this inventory. After potential hazards have been identified, it would be appropriate for the other events to occur. This would
include providing employee education, circulating a written disaster plan, and encouraging participation in disaster planning drills.
MULTIPLE RESPONSE
1. Which of the following describes how occupational health nursing differs from other nursing specialties? (Select all that apply.)
a. It is autonomous because the occupational nurse works independently.
b. The major focus is on the environment.
c. Nurses focus on health promotion and disease prevention.
d. Nursing care is given in the community.
e. A focus is directed toward restoration of health.
ANS: A, B, E
Occupational health specialty practice focuses on the promotion, prevention, and restoration of health within the context of a safe
and healthy environment. It involves the prevention of adverse health effects from occupational and environmental hazards. It
provides for and delivers occupational and environmental health and safety services to workers, worker populations, and
community groups. It is an autonomous specialty, and nurses make independent nursing judgments in providing health care. All
nurses should engage in health promotion and disease prevention, and many specialties provide care in the community.
2. An occupational health nurse should be aware of which of the following trends in the marketplace? (Select all that apply.)
a. A majority of new jobs will be in service-oriented employment.
b. Employees will often have longer hours within a compressed work week.
c. Jobs are shifting from service to manufacturing.
d. Many employees will be older and suffer chronic health problems.
e. Reduced job security is common.
ANS: A, B, D, E
Longer hours, compressed work weeks, shift work, reduced job security, and part-time and temporary work are realities of the
modern workplace. The workforce will become older, including many employees with chronic health problems. The US economy
was once based on agriculture, then primarily on manufacturing, and now on highly technological positions. Currently,
service-providing positions account for virtually all job growth; soon almost one of every two worker jobs will be in service
positions.
3. Which of the following explains why some occupational health specialists are very concerned about chemicals in the workplace?
a. All chemicals are inherently dangerous to humans.
b. Chemicals are often used when natural substances are equally effective.
c. Effects of chemicals can be cumulative.
d. Interactions of chemicals are typically unknown.
e. It is difficult to accurately predict the reaction of chemical contact.
ANS: C, D, E
Most chemicals have not been studied epidemiologically to determine the effects of exposure on humans. A variety of chemicals
are found in the body tissues of the general population. Daily, low-level doses of chemicals may be below the exposure standards
but may still carry a potentially chronic and perhaps cumulative assault on workers’ health. Predicting human responses to such
exposures is further complicated because several chemicals are often combined to create a new chemical agent. Human effects may
be associated with the interaction of these agents rather than with a single chemical. Another concern about occupational exposure
to chemicals is reproductive health effects. Not all chemicals are dangerous; however, less than 0.1% of them have been adequately
studied for their effects on humans. There is no evidence to support the statement that chemicals are being used when there are
other natural substances available.

4. Which of the following are the primary reasons that employers have increasingly focused on ensuring a healthy and safe
environment for workers? (Select all that apply.)
a. To fulfill their ethical and moral responsibility
b. To avoid the cost of liability suits, workers’ compensation, etc.
c. To maintain good public relations
d. To meet enacted legislated standards
e. To avoid significant penalties for noncompliance
ANS: B, D, E
Legislation at the federal and state levels has had a significant effect on efforts to provide a healthy and safe environment for all
workers. OSHA employees have distributed citations to companies that do not meet minimal occupational health and safety
standards. Criminal charges have been filed against business owners when preventable work-related deaths have occurred. Another
important stimulus for health and safety programs is the desire to avoid the cost of liability and workers’ compensation claims and
other expenses when employees are injured or killed. Having a healthy and safe environment for workers should provide the public
with a positive image of the company; however, this is not a primary reason employers ensuring this type of an environment.
5. An occupational health nurse wants to know the NAICS code of a prospective employer. Which of the following best explains why
the nurse would be interested in this information? (Select all that apply.)
a. To assess how others have rated the company in relation to employment there
b. To compare the prospective employer’s injury rate with similar employers’ rates
c. To learn more about the usual processes and products of the company as well as
typical hazards
d. To learn how employees feel about their employer
e. To identify useful information about the employer
ANS: B, C, E
All business organizations are classified within the North American Industry Classification System (NAICS) with a numerical code
indicating a company’s product and, therefore, the possible types of occupational health hazards that may be associated with the
processes and materials used by its employees. NAICS codes are used to collect and report data on businesses. For example, illness
and injury rates of one company are compared with the rates of other companies of similar size with the same NAICS code to
determine whether the company is having an excess of illness or injury. By knowing the NAICS code of a company, a health care
professional can access reference books that describe the usual processes, materials, and by products of that kind of company. The
NAICS code indicates a company’s product, not how others or their employees have rated them as an employer.

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Chapter 01: Public Health Nursing and Population Health

1. Which statement best describes community-based nursing?

2. Which statement best describes the goal of community-oriented nursing?

3. Which of the following is the primary focus of public health nursing?

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9. Which of the following best defines aggregate?

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2. The Elizabethan Poor Law of 1601 is similar to which current law?

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7. What was the outcome of the Shattuck Report?

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4. Which statement best describes ideal primary health care?

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1. Which of the following best defines the word politics?

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1. Which of the following is generally considered to be nursing’s first code of ethics?

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17. How are ethics and public policies similar?

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1. Which of the following is the number one cause of death worldwide?

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8. Which population is best protected against pertussis by the DTaP vaccine?

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