Author Question: The nurse is caring for a patient in hospice. As she observes the family dynamics, she notes that ... (Read 86 times)

NguyenJ · **on:** Jul 22, 2018

The nurse is caring for a patient in hospice. As she observes the family dynamics, she notes that the patient is getting adequate care, but the wife is not sleeping well and needs rest.

The nurse also assesses the need for better family nutrition and meals assistance. The nurse discusses these assessments with the patient and his family and formulates a plan of care with them to address these issues. The nurse is utilizing which approach to family nursing practice? a. Family as context
b. Family as patient
c. Family as system
d. Autocratic determination

Question 2

The nurse obtains the following results after measuring the patient's vital signs: blood pressure 180/100 mm Hg, pulse 82 beats per minute, respiratory rate 16 breaths per minute, and rectal temperature 37.5C.

Which of the following actions should the nurse take? a. Retake the blood pressure.
b. Retake the temperature.
c. Report all of the findings immediately.
d. Record the findings as within normal limits.

josephsuarez · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
In family as context, the primary focus is on the health of an individual member. In family as patient, family processes and relationships are the primary focus. Often, the nurse will use the two simultaneously, as with the perspective of family as system. Because the plan of care was developed with family input, autocratic determination was not used.

Answer to Question 2

A

Feedback
A A normal blood pressure reading is considered to be 139/89 mm Hg or lower. This patient's blood pressure reading is significantly higher at 180/100 mm Hg and may be an indication of hypertension. (One elevated blood pressure measurement does not qualify as a diagnosis of hypertension; it would have to be elevated on at least two separate occasions.) The nurse should retake the blood pressure.
B The patient's temperature is within normal limits for a rectal temperature. The average rectal temperature is 37.5C.
C The nurse should retake the blood pressure to confirm the reading before reporting the findings.
D The blood pressure reading is not within normal limits. The pulse, respiratory rate, and temperature are within normal limits.