Chapter 01: Health: A Community View
Nies: Community/Public Health Nursing, 7th Edition

MULTIPLE CHOICE

	1.	Which best describes the primary reason that Americans are concerned about health care?
a.	Politicians are discussing how to improve health care.	
b.	The media has provided mixed messages about the health care system.	
c.	Our national health care costs keep increasing.	
d.	The new health care system offers free services to Americans.	

ANS:	C
The primary reason for the focus on health care is the constantly increasing costs, which cannot be sustained. The costs of caring for the sick accounted for the majority of escalating health care dollars, which increased from 5.7% of the gross domestic product in 1965 to 17.8% in 2015. Politicians and the media both influence Americans’ perceptions about health care; however, they are not the primary reason why Americans are concerned. The new health care system will change the health care access and availability, but will not necessarily be offering any free services to Americans.

DIF:	Cognitive Level: Understand (Comprehension)

	2.	A nurse has begun to lobby with politicians for changes to the health care system. Why is this involvement important?
a.	Nurses, as central characters in several popular TV series, are currently very visible in American media.	
b.	Nurses are primarily responsible for managing the various units in our health care system.	
c.	Nurses are the largest segment of health care providers.	
d.	Nurses are the only group that is employed both inside and outside of hospitals.	

ANS:	C
As the largest segment of health care providers, nurses are informed about the current health care system and all the problems that result from people not seeking care until they are desperately ill. Nurses, as the American Nurses Association (ANA) emphasize, usually believe that health care is a right, not a privilege. Therefore, nurses, whose work is central to our current health care delivery system, can also be instrumental in working politically to create a health care delivery system that will meet health needs. While nurses are in several current TV series and are employed both inside and outside of hospitals, physicians and other health care providers are as well. Nurses are often managers, but managers often have other backgrounds, such as business administration.

DIF:	Cognitive Level: Understand (Comprehension)

	3.	What conclusion can be drawn from examining where nurses are employed?
a.	There is a trend toward consolidation of health care into large central medical centers.	
b.	There is an increased emphasis on community-based health care.	
c.	There is an obvious need to decrease health care costs by cutting positions.	
d.	Managed care organizations (MCOs) are employing nurses to improve customer relations.	

ANS:	B
MCOs are employing nurses in many capacities. Although hospitals are closing and acute care is increasingly found in central medical centers, the same trend may be seen in an increase in neighborhood-based practice centers. While positions are cut in most industries, health care is recognized as an area where growth in employment is expected. However, nurses are increasingly employed in community settings as opposed to hospitals. This change reflects the move toward community-based care rather than hospital-based tertiary care. To help decrease the continued rise in health care costs, the increased emphasis is on disease prevention rather than high-cost treatment.

DIF:	Cognitive Level: Understand (Comprehension)

	4.	Which ethical belief would be most helpful in the current health care crisis?
a.	Emphasis should be on individual and corporation freedom in the marketplace.	
b.	Emphasis should be on individual autonomy and freedom of choice.	
c.	Emphasis should be on social justice and collective responsibility.	
d.	Emphasis should be on the effectiveness of technology in resolving problems.	

ANS:	C
Public health recognizes the necessity of collective action in keeping the environment safe and in egalitarian tradition and vision. An overinvestment in technology and seeking of cures within the market justice system has stifled the evolution of a health system to protect and preserve the health of the population. Although individual autonomy and freedom of choice are important, so is the recognition of collective responsibility in ensuring social justice, which entitles all people to basic necessities.

DIF:	Cognitive Level: Apply (Application)	

	5.	What is the primary problem seen in Healthy People 2020’s emphasis on choosing healthy lifestyle behaviors, such as daily exercise or healthy food choices?
a.	Emphasis on other lifestyle choices, such as not smoking and minimal use of alcohol or drugs, is also needed.	
b.	All of us must work together to make unhealthy behaviors socially unacceptable.	
c.	It costs more to make healthy choices, such as buying and eating fresh fruits and vegetables as opposed to quick and cheap fast-food choices.	
d.	Public policy emphasizes personal responsibility but ignores social and environmental changes needed for well-being.	

ANS:	D
Although all responses are accurate, the primary problem is the emphasis on personal choices in the Healthy People 2020 objectives. Emphasis on personal choices ignores the need for community responsibility and action that addresses environmental or cultural restraints to health.

DIF:	Cognitive Level: Apply (Application)	

	6.	What responsibility does the American Nurses Association (ANA) Code of Ethics require of the nurse beyond giving excellent care to patients?
a.	Accept longer work schedules to ensure that professional care is always available to clients.	
b.	Recognize the need for experienced nurses to mentor new graduates to help increase and expand the number of professionals available.	
c.	Support health legislation to improve accessibility and cost of health care.	
d.	Volunteer to work overtime as needed to ensure maximum quality of care.	

ANS:	C
The ANA Code of Ethics promotes social reform by focusing on health policy and legislation to positively affect accessibility, quality, and cost of health care. The code does not directly address workplace issues, such as work schedules or need for overtime.

DIF:	Cognitive Level: Analyze (Analysis)		

	7.	What is the community health nursing definition of health?
a.	Health is a person’s goal-directed purposeful process toward well-being or wholeness.	
b.	Health is an individual’s physical, mental, and social well-being, not merely the absence of disease or infirmity.	
c.	Health is the mutual adaptation between a person and his or her environment in meeting daily existence.	
d.	Health is families and aggregates choosing actions to ensure safety and well-being.	

ANS:	D
The text stresses that health is not just the result of an individual’s choices, but choices and actions of individuals, families, groups, and communities that lead to better health.

DIF:	Cognitive Level: Apply (Application)	

	8.	How does community health nursing define community?
a.	A group of persons living within specific geographic boundaries	
b.	A group of persons who share a common identity and environment	
c.	A group of persons who work together to meet common goals	
d.	A group of persons who resolve a community concern	

ANS:	B
Community health nurses work with both geopolitical groups (within specific geographic boundaries) and phenomenological groups (who have a common identity based on culture, history, or goals). A particular phenomenological group may or may not have been a planned group—that is, a group that came together to resolve a recognized common problem or to meet a common goal. However, of all the choices, a group of persons who share a common identity (phenomenological group) and environment (which implies a specific geographic setting) is the broadest and most complete definition.

DIF:	Cognitive Level: Apply (Application)	

	9.	Which variable has a major influence on a community’s health?
a.	Behavior choices made by persons in the community	
b.	Number of health care providers and hospitals in the community	
c.	Quality of the public safety officers (police officers, firefighters, etc.)	
d.	The number and credentials of public health officials in the community	

ANS:	A
Individual behavior choices are responsible for about 50% of health outcomes. Individual choices are affected through interaction with other individuals, and their mutual social and physical environments. The number of health care providers has not played a major role in the health outcomes in the community in comparison to individual health behaviors. The quality of public safety officers and number of public health officials have not been identified as major contributors to the determinants of health.

DIF:	Cognitive Level: Apply (Application)	

	10.	What change could most effectively lead to a longer life span in Americans?
a.	Parenting and sexual behavior classes in all public school systems	
b.	Legislation restricting alcohol and drug use	
c.	Notably reducing speed limits on all state and federal highways, and changing the age limit for driving to 21 years of age	
d.	The belief that smoking is shameful and disgusting, as well as expensive, becoming the social norm	

ANS:	D
Smoking is responsible for almost 20% of all deaths in the United States. Although smoking is an individual’s choice, all people are affected by social norms. Parenting and sexual behavior classes and legislative changes may influence health, but may not necessarily lead to a longer lifespan. Community health nurses should recognize that health is influenced by a web of factors, some that can be changed and some that cannot. Influencing social norms may better promote change among Americans.

DIF:	Cognitive Level: Apply (Application)	

	11.	What is the health issue causing the most concern in the United States today?
a.	Diabetes epidemic	
b.	Increase in cardiac disease	
c.	Increase in obesity	
d.	Rise in cancer rates	

ANS:	C
The widespread increase in incidence of overweight and obesity has led to calls for population-based measures to address this issue. The overarching problem of obesity has led to an increase in diabetes as well as cardiac disease. If this health issue was controlled, there should be in a decrease in the other health issues.

DIF:	Cognitive Level: Understand (Comprehension)

	12.	What factors are most responsible for the increasing length of life of Americans over the past 100 years?
a.	Better nutrition and family planning options	
b.	Education concerning the need to reduce salt and fat in the diet	
c.	Improved medical care, including exciting new technologies	
d.	More efficient cancer screenings and early intervention	

ANS:	A
Average increased life span over the past 100 years can be largely attributed to higher standards of living, better nutrition, a healthier environment, and having fewer children. Public health efforts such as immunization and medical care have also contributed.

DIF:	Cognitive Level: Understand (Comprehension)

	13.	Why would a public health nurse want to know about morbidity and mortality statistics on the local, state, and national level?
a.	To be able to share current trends in health problems with the community	
b.	To be able to observe the community’s statistics over time and compare the community with other communities	
c.	To justify local budgets and the need for increased income from citizens	
d.	To publicize current health issues and suggest appropriate actions to citizens	

ANS:	B
Although being informed and being able to educate the public is always preferred and nurses often do have to justify budgets, data are needed to compare the local community with itself over time and with other communities so that problems may be recognized and action taken to confront health issues. The first step is always to recognize problems as they develop.

DIF:	Cognitive Level: Apply (Application)	

	14.	How do public health efforts differ from medical efforts in improving the health of our citizens?
a.	Medical care providers autonomously choose appropriate interventions, whereas public health care providers must engage in whatever actions legislation requires.	
b.	Medical care providers are self-employed or agency employed, whereas public health care providers are employed by and paid through the government.	
c.	Medical care providers focus only on individuals, whereas public health care providers focus only on aggregates.	
d.	Medical care providers focus on disease diagnosis and management, whereas public health care providers focus on health promotion and disease prevention.	

ANS:	D
Medical care providers are restricted by insurance and government regulations. Providers may also be employed in government facilities, such as Veterans Administration facilities. However, medical care providers primarily focus on diagnosis and treatment of disease, whereas public health care providers try to promote health and prevent disease. Although medical care providers primarily focus on individuals and public health care providers primarily focus on aggregates, their practice is not limited to only individuals or only aggregates.

DIF:	Cognitive Level: Apply (Application)	

	15.	Which primary prevention would the school nurse choose to address the school’s number of unwed pregnancies?
a.	Create a class on parenting for both the moms-to-be and the dads-to-be.	
b.	Convince the school board to allow sex education classes to include birth control measures.	
c.	Employ the moms-to-be as 1-hour-a-day employees in the school daycare center for children born to school students.	
d.	Establish a class where all the unwed moms-to-be can learn infant care.	

ANS:	B
Primary prevention relates to activities directed at preventing a problem before it occurs by altering susceptibility or reducing exposure for susceptible individuals. Primary prevention consists of two elements: general health promotion and specific protection. Health promotion efforts enhance resiliency and protective factors and target essentially well populations. Specific protection efforts reduce or eliminate risk factors. Although all choices would be appropriate actions in a school, only education regarding sexuality and birth control would help prevent future pregnancies.

DIF:	Cognitive Level: Apply (Application)	

	16.	What would be the proper term for the action of the school health nurse arranging for all the students in the elementary school to receive H1N1 immunizations?
a.	Health education	
b.	Secondary prevention	
c.	Specific protection	
d.	Tertiary prevention	

ANS:	C
Immunizations are a specific protection effort as part of primary prevention. Primary prevention relates to activities directed at preventing a problem before it occurs by altering susceptibility or reducing exposure for susceptible individuals. Primary prevention consists of two elements: general health promotion and specific protection. Health promotion efforts enhance resiliency and protective factors and target essentially well populations. Specific protection efforts reduce or eliminate risk factors. Secondary prevention refers to early detection and prompt intervention during the period of early disease pathogenesis. Tertiary prevention targets populations that have experienced disease or injury and focuses on limitation of disability and rehabilitation. Health education would relate to educating the students about the immunization not making the arrangements for the immunization to be given.

DIF:	Cognitive Level: Understand (Comprehension)

	17.	Which action would probably result in the largest change in health care outcomes for Americans?
a.	Establish large numbers of scholarships for education of nurses, physicians, and other health care providers.	
b.	Fund a one-time extremely large stimulus to allow all health care providers and agencies to create and integrate computer network systems for client health care records.	
c.	Increase funding for hospitals and medical centers to expand their neighborhood clinics.	
d.	Redirect a large portion of federal funding from acute care to health promotion activities.	

ANS:	D
Of the choices given, health promotion activities would make the largest difference. Increased expenditures on acute care will not notably change the health of the population, whereas funding that addresses health promotion such as education and safe environments would improve the health of the aggregate.

DIF:	Cognitive Level: Apply (Application)	

	18.	Which task will be most helpful in meeting the public health agency’s goals?
a.	Complete staff evaluations in preparation for individual meetings to plan their agency and individual goals for the next year.	
b.	Actively participate in community agencies’ collaborative action plan to meet the community’s health goals for the year.	
c.	Meet with the college of nursing faculty to finalize student objectives and schedules for the next semester.	
d.	Teach a free course in healthful living for community residents.	

ANS:	B
Although all tasks may be necessary and important, intra-agency cooperation to meet the health goals of the community as a whole is more central to the agency’s mission than other choices that meet the needs of individuals or groups rather than the community as a whole.

DIF:	Cognitive Level: Analyze (Analysis)		

	19.	A community health nurse is overwhelmed with all that needs to be done in one day. Which task could most easily be postponed?
a.	Reviewing the most recent hospital patient data collected by the local college of nursing	
b.	Deciding which of several possible new clinic options would be most effective in better meeting the needs of the local community	
c.	Evaluating the results of the most recent community-wide screening program before planning for the next community health program	
d.	Giving testimony to the state legislature on a new health and safety bill	

ANS:	A
All of the tasks are related to assessing needs, implementing new care options, or evaluating health outcomes measures in the community except reviewing hospital patient data. Hospital patient data may be helpful but not directly related to the agency’s ability to promote primary health and prevent disease.

DIF:	Cognitive Level: Analyze (Analysis)		

	20.	A nurse who works on the surgical unit at the local hospital was asked by the home health unit to make a home visit to a patient who had been discharged the previous day and to give follow-up care (for overload pay). What kind of nursing would this nurse be doing?
a.	Acute care hospital nursing	
b.	Community-based nursing	
c.	Community health nursing	
d.	Public health nursing	

ANS:	B
The nurse is caring for a patient in the home. Community-based nursing is nursing somewhere in the community. Community-based nursing practice refers to “application of the nursing process in caring for individuals, families and groups where they live, work or go to school or as they move through the health care system” (McEwen and Pullis, 2009, p. 6). Community-based nursing is setting specific, and the emphasis is on acute and chronic care and includes such practice areas as home health nursing and nursing in outpatient or ambulatory settings. As the nurse is not focusing on the health of the community but on an individual, it is not community or public health nursing. It is not acute care hospital nursing because the nurse is seeing the patient in his or her home.

DIF:	Cognitive Level: Apply (Application)	

	21.	Which task is most crucial for the community health nurse to do well?
a.	Review the most recent morbidity and mortality data.	
b.	Create a new clinic to better meet local health needs.	
c.	Evaluate the results of the recent screening program.	
d.	Give testimony regarding proposed state health legislation.	

ANS:	D
Public health’s core functions are assurance, assessment, and policy development. Giving testimony regarding legislation directly reflects policy development, which would have a wider impact than the other options, which are more local and narrow in focus.

DIF:	Cognitive Level: Analyze (Analysis)		

	22.	A new public health nurse carefully assessed all the local mortality and morbidity data in preparation for making appropriate planning suggestions at a meeting next week. What other action is crucial before the nurse can feel prepared?
a.	Ask other nursing staff their perceptions of the community’s needs.	
b.	Assess the nurse’s own assets, strengths, and ability to contribute.	
c.	Meet members of the community to determine their culture and values.	
d.	Review discussions and decisions from previous meetings.	

ANS:	C
Community health nurses must work with the community. It is essential to assess an aggregate’s needs and resources and identify its values. The best way to do this is by meeting with the members of the community to determine their culture and values. Assessing one’s own assets, asking other nursing staff, and reviewing previous discussions will not allow the nurse to assess the needs of the community.

DIF:	Cognitive Level: Apply (Application)	

	23.	Why are high-risk and vulnerable subpopulations identified by public health nurses before deciding on appropriate interventions?
a.	It is easiest to make improvements among these groups.	
b.	Populations are not homogeneous, and resources are limited.	
c.	Such groups are most vocal about their needs and wants.	
d.	These groups are often recipients of special funding.	

ANS:	B
Populations are not all the same. The needs of subpopulations must be assessed. The high-risk and vulnerable subpopulations must be identified early. Those individuals who do not receive service early become very expensive high-cost users later.

DIF:	Cognitive Level: Understand (Comprehension)

	24.	A nurse works hard to develop alliances among various community organizations toward improving health in the community. What are actions such as this called?
a.	Building coalitions	
b.	Collaboration	
c.	Communication	
d.	Community cooperation	

ANS:	A
By definition, the nurse’s actions are coalition building. Although collaboration has a very similar meaning, Table 1.4 stresses that collaboration is focused more on enhancing the capacity of an individual or a group. The nurse is establishing cooperative alliances, but not yet working with them toward a goal.

DIF:	Cognitive Level: Understand (Comprehension)

	25.	After completing a master’s degree, a nurse took a course in marketing. Should the agency reimburse the nurse’s tuition costs?
a.	No, courses taken for personal enjoyment are not eligible.	
b.	No, courses taken outside the professional’s responsibilities are not eligible.	
c.	Yes, the nurse is demonstrating professional commitment by continuing education.	
d.	Yes, the nurse could use such information in social marketing for the agency.	

ANS:	D
Social marketing tools using marketing principles and technologies are designed to influence the knowledge, attitudes, values, beliefs, and behaviors of populations. Such information would be extremely helpful for agency personnel in improving community health and lifestyle choices.

DIF:	Cognitive Level: Apply (Application)	

	26.	Which factor is most responsible for differences in an individual’s health?
a.	Culture of the majority of the community’s citizens	
b.	Individual’s education and income	
c.	Number of physicians and other health care providers in the community	
d.	Quality of the community health agency and hospital in the community	

ANS:	B
Factors that contribute to wide variations in health disparities are education, income, and occupation. This is best addressed by looking at an individual’s education and income. The culture, number of physicians, and quality of agencies in the community do not play as important of a role in individual health.

DIF:	Cognitive Level: Understand (Comprehension)

MULTIPLE RESPONSE

	1.	What are the leading health indicators found in Healthy People 2020? (Select all that apply.)
a.	Financial issues	
b.	Health system issues	
c.	Individual behaviors	
d.	Issues related to legal and illegal immigration	
e.	Legislative issues	
f.	Physical and social environmental factors	

ANS:	B, C, F
Ten leading health indicators are identified in Healthy People 2020, including individual behaviors, physical and social environmental factors, and health systems issues. Financial issues, issues related to legal and illegal immigration, and legislative issues are not found in Healthy People 2020.

DIF:	Cognitive Level: Understand (Comprehension)

	2.	What historically have been public health nurses’ two most important priorities? (Select all that apply.)
a.	Establishing school nursing to improve care of children	
b.	Engaging in political activity to improve living conditions	
c.	Giving superb clinical bedside care in the home	
d.	Increasing funding to public health efforts	
e.	Teaching family members how to care for their family	
f.	Working with the community to confront health issues and poverty	

ANS:	B, F
Neither administering bedside clinical nursing nor teaching family members to deliver care in the home has adequately addressed the true determinants of health and disease. The early public health nurses resolved that collective political activity should focus on improving social and environmental conditions such as poverty.

DIF:	Cognitive Level: Understand (Comprehension)

	3.	Based on Healthy People 2010, what are the two primary goals of Healthy People 2020? (Select all that apply.)
a.	Eliminate health disparities.	
b.	Expand health promotion activities in every community.	
c.	Improve funding, including diverting funds from other priorities to health care.	
d.	Improve health outcomes measures to be more consistent with other developed nations’ outcomes.	
e.	Increase quality and years of healthy life.	
f.	Reduce mortality and morbidity figures nationwide.	

ANS:	A, E
As published, the two goals are to increase quality and years of healthy life and eliminate health disparities. Expanding health promotion activities in every community, improving funding and improving health outcomes, and reducing mortality and morbidity are not the primary goals of Healthy People 2020.

DIF:	Cognitive Level: Understand (Comprehension)