A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess?

Socioeconomic factors

Family practices

Cultural background

Perception of functioning

Answer and Explanation

The Correct Answer is D

A) Socioeconomic factors:
Socioeconomic factors, such as income, education, and employment status, are considered external variables that influence a patient's health. These factors impact access to resources and healthcare, but they are not internal variables. Internal factors relate to personal perceptions, behaviors, and beliefs that the patient has regarding their health.

B) Family practices:
Family practices also fall under external variables. These include the health behaviors, habits, and routines practiced by the family, which can influence a patient’s health but are not internal to the individual. The nurse should assess how family practices affect health but not as internal variables.

C) Cultural background:
Cultural background is another external variable that can influence health practices, beliefs, and behaviors. It shapes how patients perceive illness, health care, and healing. While important to assess for understanding a patient's worldview, it does not fall under the category of internal variables.

D) Perception of functioning:
Perception of functioning is an internal variable because it reflects how the patient views their own health status and capabilities. This includes their sense of well-being, physical limitations, and emotional health. A patient’s perception of their functioning can directly impact their decision-making and actions related to their health, and it is essential for the nurse to assess this to guide care effectively.

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Correct Answer is C

Explanation

A) Droplet: Droplet precautions are used for infections that spread through respiratory droplets when an infected person coughs, sneezes, or talks. While measles is transmitted through respiratory droplets, the virus is highly contagious and requires airborne precautions, not just droplet precautions.

B) Contact: Contact precautions are used for infections spread through direct contact with the patient or their environment, such as gastrointestinal or skin infections. Measles is primarily spread through the air and is not classified as a contact transmission infection.

C) Airborne: Measles is an airborne illness, which means that it can be transmitted through small respiratory droplets that remain suspended in the air for long periods of time. Airborne precautions are necessary to protect healthcare workers and other patients from exposure. These precautions include placing the child in a negative pressure room and requiring healthcare workers to wear N95 respirators.

D) Protective environment: Protective environment precautions are used for patients with severely weakened immune systems, such as those undergoing chemotherapy or organ transplantation. These precautions are designed to protect the patient from infections, not to prevent the spread of contagious illnesses like measles.

A. Reach around the pack and open the top flap away from the body. B. Move to the opposite side of the pack to open the fourth flap. C. Place the pack on a sterile work surface. D. Open the right flap with the left hand.

Correct Answer is A

Explanation

A) Reach around the pack and open the top flap away from the body: The nurse should open the top flap of the sterile pack first by pulling it away from the body. This ensures that the sterile contents of the pack are not contaminated by touching the body or clothing. It is important to open the flap away from the body and face to maintain the sterility of the field and prevent any potential contamination.

B) Move to the opposite side of the pack to open the fourth flap: Moving to the opposite side of the pack to open the fourth flap is not necessary. The nurse should open the pack from the side where it is placed, and typically the sterile pack has a specific order for opening the flaps to maintain a sterile field. Opening the fourth flap from the opposite side would not be the most efficient or safest practice.

C) Place the pack on a sterile work surface: While placing the sterile pack on a sterile work surface is important, this step is not directly related to opening the sterile pack. Ensuring the work surface is sterile is crucial, but the question specifically addresses the proper way to open the pack, which involves how to handle the flaps safely.

D) Open the right flap with the left hand: It is essential to avoid crossing over sterile areas or using non-dominant hands for opening the pack's flaps in a manner that could risk contamination. Each flap should be opened in a controlled way, usually with the dominant hand, and this action must follow the correct sequence to prevent any potential contamination, especially when handling the pack’s sterile contents.

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A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess?

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Correct Answer is A

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