Chapter 15: Working with Vulnerable Populations

Question 1

What designation is given to groups at high risk of having poor health outcomes?
a. Cumulative risk groups
b. Health disparity groups
c. Resilient populations
d. Vulnerable populations

Answer 1

ANS: D
Specific populations who are more vulnerable—that is, at-risk populations who are more
susceptible to poor health because of socioenvironmental factors—are often referred to as
vulnerable populations.

Question 1

What is the best intervention a community health nurse (CHN) can initiate to increase lasting
resilience among new immigrants?
a. Directing clients to English-as-a-second-language courses
b. Giving immigrant clients money to help them get settled
c. Identifying areas in the city where housing is less expensive
d. Soliciting donations for food, clothing, and other needs

Answer 1

ANS: A
Resilience refers to the ability of the client to successfully cope when faced with a threat or
hardship. Individuals with low resilience are more inclined to have feelings of hopelessness
and may choose suicide as a method to resolve these feelings. Support needs to be provided to
those with decreased resilience in order to enhance problem-solving skills and give a greater
sense of personal autonomy. When the CHN places emphasis on client strengths and assets
rather than client deficits and susceptibility, resilience is more likely to increase.

Question 2

What CHN intervention would best serve a vulnerable population?
a. Addressing multiple health concerns, including preventive education, when clients
present for treatment of an illness
b. Establishing a system of networks so that clients may be referred to different
services such as preventive care, acute illness care, and chronic treatment
c. Providing acute care services that focus on the client’s main health concern and
setting up appointments at discharge for other concerns
d. Referring clients to specialists to address specific health concerns

Answer 2

ANS: A

When working with vulnerable populations, it is a good idea to arrange to have as many
services as possible available in a single location and at convenient times. Comprehensive
services, a “one-stop shopping” approach to care delivery, are helpful for populations
experiencing multiple social, economic, and health-related stresses. This becomes especially
important if clients have problems accessing health care services.

Question 3

What definition accurately reflects the meaning of the term health inequities?
a. Health inequities are the accumulation of multiple factors that lead to poor health.
b. Health inequities occur when people are more inclined to become ill and usually
do not seek appropriate care.
c. Health inequities are unfair differences in health that could be avoided with
reasonable action.
d. Health inequities are wide variations in health status and services among certain
population groups.

Answer 3

ANS: C
Health inequities refers to differences in health that could be avoided if reasonable action was
taken, and therefore these differences are considered to be unfair and socially unjust.

Question 4

What is a primary cause of vulnerability?
a. Breakdown of family structures
b. Poverty
c. Prejudice
d. Social isolation

Answer 4

ANS: B
Poverty is a primary cause of vulnerability. The lack of financial resources may cause some
people to not seek preventive health services. This leaves them vulnerable and with increased
risk of experiencing the effects of preventable illnesses.

Question 5

Which level of prevention is a CHN practising when she offers homeless clients yearly
tuberculosis (TB) screening and free treatment for those who test positive?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Secondary and tertiary prevention

Answer 5

ANS: B
Screening homeless persons for TB and providing medications to those who test positive are
examples of secondary prevention. The TB screening identifies the disease in its early stages.
Medications work to prevent further development of the disease.

Question 6

A CHN is orienting a new recruit to a health clinic that primarily serves vulnerable
populations. Which statement by the CHN indicates a need for additional information?
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
check the client in, ask about additional concerns.”
c. “You will like working with Filipino immigrants because they have close-knit
family structures.”
d. “You will need to assist the client by scheduling any referral or follow-up
appointments.”

Answer 6

ANS: C
Assumptions are not helpful. Each person and family should be assessed individually. No two
people or groups are alike. Both good and bad stereotyping can create problems. For example,
even though Filipino families are generally close knit, by assuming that all Filipino families
are this way, clinic care providers will likely miss recognizing such issues as family violence.

Question 7

While screening for diabetes at a community clinic, a CHN found out that a new client had
type 2 diabetes. The CHN then provided counselling, referred the client to an endocrinologist
for initial assessment and treatment, helped with arrangements for financial assistance,
arranged transportation, and booked a follow-up appointment. What role does this type of
service exemplify?
a. Case management
b. Client advocacy
c. Holistic care
d. Wrap-around services

Answer 7

ANS: A
Case management involves linking clients with services and providing direct community
health nursing services, including teaching, counselling, screening, and immunizing. Linking
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.

Question 8

CHNs at a clinic for homeless people are concerned that clients rarely return for follow-up
after their TB skin (Mantoux) tests. What policy would be the most appropriate one for
addressing this situation?
a. Call all homeless clients 48 hours after testing to remind them to return to the
clinic for follow-up.
b. Have the homeless persons read the test result themselves and then mail in the
results on a postage-paid card coded to protect privacy.
c.Readminister the test if the client returns later than scheduled for follow-up.
d. Routinely refer all homeless clients for chest X-rays.

Answer 8

ANS: B
Secondary preventive activities are aimed at reducing the prevalence or pathological nature of
a condition. They involve early diagnosis, prompt treatment, and the limitation of disability.
CHNs can work with homeless and near-homeless aggregates to provide education about
existing services and strategies for influencing public policy that will provide more
comprehensive services for homeless and near-homeless persons. If necessary, CHNs should
develop a method for homeless individuals to read the reaction to the TB skin test themselves
and send the results to the facility where the skin test was administered.

Question 9

What action should a CHN take when using the case management approach with vulnerable
populations?
a. Be willing to enter into a long-term relationship with families.
b. Direct and control the client’s care because the CHN 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.

Answer 9

ANS: A
Case management is a process that enhances continuity and appropriateness of care. When
using case management with vulnerable populations, the CHN can offer the greatest benefit

when she or he is willing to develop long-term relationships with the families served. Long-
term relationships create trust and ensure continuity of care. Care involves a partnership

between the CHN and the client. CHNs 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 measures.

Question 10

Which one of the following is an example of tertiary prevention by a CHN?
a. Administering the Mantoux (skin) test to identify persons with TB
b. Assessing for signs and symptoms of active TB
c. Directly observing clients with active TB as they take their antituberculosis
medications
d. Interpreting TB skin test results

Answer 10

ANS: C
Tertiary prevention is implemented when CHNs provide directly observed therapy (DOT) to
those with active TB.

Question 11

What is the cause of the greatest overall costs to the community for providing health care to
people who are homeless?
a. The need for increased preventive services to address the health conditions of the
homeless population
b. The need for more frequent clinic visits by homeless clients for multiple health
problems
c. The spread of contagious diseases by people who are homeless to those they pass
on the street
d. The fact that most of the care for people who are homeless takes place in hospital
emergency departments

Answer 11

ANS: D
People who are homeless encounter the same problems accessing health care (e.g., lack of
money, lack of housing, lack of transportation) that others do in impoverished conditions.
Therefore, health care of people who are homeless tends to be crisis oriented and sought in
emergency departments. Low-income Canadians have the highest mortality rates and the
highest rates of hospitalizations and emergency visits.

Question 12

A CHN presents a proposal for a program for preventing teen pregnancy to a group of parents.
In the discussion that follows the presentation, which statement by a parent indicates the need
for additional teaching by the CHN?
a. “I do not know if my son is sexually active; however, I have decided that I am
going to talk to him about birth control, just in case.”
b. “I have found that being very strict and checking on my daughter whenever she is
out are the best ways to prevent trouble.”
c. “I plan to sit down with my daughter and have an honest talk about sexuality and
potential risks.”
d. “I will start spending more time with my teens when I get home from work.”

Answer 12

ANS: B
Parenting style is a contributing factor to adolescent pregnancy. Parents who are extremely
demanding and controlling or neglectful, and who have low expectations, are the least
successful in instilling good values in their children. Children of parents who are neglectful
are the most sexually active, followed by children of parents who are very strict. Furthermore,
parents who discuss birth control, sexuality, and pregnancy with their children can positively
influence delaying initiation of sexual activity and use of effective birth control. Parents who
do not talk about sexuality with their teens may find them more at risk for sexual
permissiveness and unwanted pregnancies.

Question 13

What CHN action would best ensure long-term positive health outcomes in pregnant teens
from low-income groups and their children?
a. Help teen mothers learn about body changes during pregnancy.
b. Develop programs that enable teen mothers to complete their education.
c. Offer courses in proper care of babies.
d. Monitor pregnant teens for early detection of problems in pregnancy.

Answer 13

ANS: B
Programs that enable the teen mother to complete her education increase her chances for a
better future and improved health care over the long term, across the lifespan. Issues to
discuss include education and career plans, family finances and qualifications for outside
assistance, and personal values about pregnancy and parenting at this time in her life.

Question 14

A CHN who works at a clinic for homeless persons wants to institute a more efficient
treatment for chronic wounds. What CHN action offers the best way to improve outcomes for
these clients?
a. Administer antibiotics to all homeless persons with chronic, nonhealing wounds.
b. Facilitate daily access to a room with soap, water, and bandages.
c. Provide free bandaging supplies to clients at each clinic visit.
d. Regularly monitor the wound condition of clients.

Answer 14

ANS: B
Health problems faced by homeless people often are related directly to poor access to
preventive health care services. The CHN can implement tertiary prevention by designating a
wound room in which clients can carry out wound care activities taught during clinic visits.
Only infected wounds would need treatment with antibiotics, not all wounds. Free bandaging
only addresses one part of the problem, and monitoring does not improve outcomes; only
treatment does.

Question 15

What information is most important to keep in mind when caring for a pregnant teen?
a. All teen pregnancies are considered high risk.
b. Limited knowledge can lead to pregnancy complications.
c. Pregnant teens are less likely to focus on proper prenatal nutrition.
d. Pregnant teens who are poor are more likely to have poorer health outcomes.

Answer 15

ANS: C
The nutritional needs of a pregnant teenager are especially important. The CHN needs to
assess the pregnant teenager’s current eating pattern and provide creative guidance to address
the issue of the demands of pregnancy on a normally changing teenager’s body and a
teenager’s usual nutritional habits of fast foods and snacking.

Question 16

What CHN action can help prevent depression in older adults who are at high risk for it?
a. Encourage them to move to a nursing home where they will have the company of
others in the same age group.
b. Monitor for signs and symptoms of depression.
c. Organize a health promotion program for older adults at the local centre.
d. Encourage older adult clients to focus on their strengths rather than their weaknesses.

Answer 16

ANS: C
It is important for CHNs to recognize that older adults who are depressed usually have a
clinically different presentation from that of clients in other age groups. Older adults who are
depressed tend to present with many bodily complaints, such as chronic pain, nausea and
vomiting, and insomnia, and usually do not express feelings of sadness, guilt, or
worthlessness. The depression rate among older adults is half that among younger people, but
the presence of a physical or chronic illness increases rates of depression. Activities to
improve the mental health status of older adults include public education programs,
prevention approaches, and the provision of mental health services in primary care.
Depression rates for older adults in nursing homes range from 15% to 25%, and thus this
would not be a good place to recommend for social networking. Encouraging older clients to
focus on their strengths rather than their weaknesses can sound insensitive if (1) the
weaknesses are, indeed, profound, and (2) the necessary tools for coping are not provided
along with the advice. Monitoring for signs and symptoms of depression only monitors health
issues, rather than preventing them.

Question 17

A CHN is concerned about caregiver stress in the children of older clients with health
concerns. What secondary prevention strategy can the CHN implement to limit caregiver
stress?
a. Asking caregivers how they are coping with their role
b. Encouraging caregivers to periodically take a few hours away from their duties
c. Establishing support groups for caregivers of older adult parents
d. Referring some caregiving responsibilities to home health nurses (HHNs) or
professional caregivers

Answer 17

ANS: A
Secondary prevention includes screening that allows for early recognition of health concerns
so that prompt interventions can prevent long-term disabilities. By asking caregivers how they
are coping (thus screening), the CHN can identify problems early so that interventions can be
made to limit the extent of stress, thus paving the way for improving the situation. The other
options are either primary or tertiary activities, depending on whether the intervention takes
place before or after development of caregiver stress.

Question 18

What CHN action could potentially increase accessibility to health care services for clients
experiencing mental illness and housing instability?
a. Apply for a grant to fund a mobile clinic to take health care to the clients.
b. Distribute flyers to homeless persons that detail the location of various health care
services.
c. Refer homeless clients to temporary housing facilities.
d. Solicit donations for food and clothing to be distributed to the homeless.

Answer 18

ANS: A
Accessibility refers to the ability of clients to access needed health care services. While all of
the options listed lead to opportunities for achieving better health outcomes, either directly or
indirectly, only a mobile health clinic can potentially improve accessibility to health care.
Neighbourhood clinics, mobile vans, and home visits can bring health care to people unable to
access health care units. Coordinating health care services from a central location often
improves client compliance because it reduces the stress of getting to multiple places.

Question 19

A CHN suspects that an elementary school student is being physically abused. Which action
would be the most appropriate one for the CHN to take?
a. Ask the student about the abuse.
b. Document findings in the student’s school record.
c. Discuss the suspicions of abuse with the student’s teachers or the family’s spiritual
leader.
d. Notify legal authorities.

Answer 19

ANS: D
All individuals in Canada who suspect child abuse are required to report it to the proper child
protection agencies, as mandated by law. First Nations peoples have their own child protection
agencies.

Question 20

Which action by a case manager would be classified as primary prevention?
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 they are ever
needed
d. Resolving conflict between a primary care clinic and a tertiary care facility

Answer 20

ANS: C
Primary prevention involves the use of the information exchange process to increase the
client’s understanding of the health care system. Remember that primary prevention occurs at
a point before an illness or a problem occurs. In all of the other options, the client’s health
concern already exists and interventions have been employed.

Question 21

A client reports that the narcotic she took for pain on a regular basis made her feel bad and
that when she tried an alternative analgesic, she experienced withdrawal symptoms. What is
this client suffering from?
a. Drug abuse
b. Drug addiction
c. Drug dependence
d. Substance abuse

Answer 21

ANS: C
The terms drug dependence and drug addiction often are used interchangeably, but they are
not synonymous. Drug dependence is a state of neuroadaptation caused by the chronic,
regular use of a drug. People who are dependent on drugs must continue using them to prevent
withdrawal symptoms. Drug addiction, in contrast, is a pattern of abuse characterized by an
overwhelming preoccupation with the use (compulsive use) of a drug and securing its supply,
and a high tendency to relapse if the drug is removed.

Question 22

A CHN is asked by a parent group to explain the risk factors for alcoholism. What statement
should the CHN include in the explanation?
a. Alcoholism is determined solely by environment.
b. Alcoholism is determined partly by genes.
c. Alcoholism is higher in women.
d. Persons born with fetal alcohol syndrome are alcoholics from birth.

Answer 22

ANS: B
Research has shown conclusively that alcoholism is, at least in part, genetic and not just the
result of family environment.

Question 23

At a district board meeting, the CHN requests funding for an after-school recreation program
that promotes healthy, fun activities in an effort to decrease substance abuse. Which level of
prevention does this exemplify?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Primary and secondary prevention

Answer 23

ANS: A
Primary prevention includes the promotion of healthy lifestyles and resiliency factors. The
harm reduction approach to the issue of substance abuse focuses on health promotion and
disease prevention.

Question 24

A client who abuses intravenous (IV) drugs admits to the CHN that he has no desire to change
this behaviour, so the CHN counsels him on the importance of sterilizing his needles to
prevent infection and transmission of blood-borne diseases. Which level of prevention does
this action represent?
a. Primary prevention
b. Secondary prevention
c. Tertiary prevention
d. Primary and tertiary prevention

Answer 24

ANS: C
Tertiary prevention is implemented in people who already have a health concern or problem
(in this instance, someone who is already misusing substances) to prevent complications
(harm reduction). In this instance, because the client does not plan to stop the drug abuse, the
CHN is trying to prevent complications arising from use of contaminated needles. Emphasis is
placed on reducing the transmission of blood-borne diseases through contaminated needles.
Giving up the addiction is the best solution but is unrealistic for many addicts. Using the harm
reduction model, the CHN should provide education on cleaning needles with bleach between
uses and about needle exchange programs to decrease the spread of blood-borne pathogens.

Question 25

A CHN suspects that a new client may have a substance use disorder. When getting the health
history of the client, the CHN needs to keep in mind that the client may not admit to drug use.
What is a primary symptom of substance use disorder?
a. Confusion
b. Denial
c. Forgetfulness
d. Mental status changes

Answer 25

ANS: B
A primary symptom of substance use disorder involves a refusal to acknowledge that a
substance use problem exists.

Question 26

What action is the best example of enabling in a family with an alcoholic father?
a. The father asks the CHN to explain why his continued drinking is dangerous.
b. The son threatens to leave the home because he finds his father’s behaviour
embarrassing.
c. The teenage daughter turns to a favourite teacher for support.
d. The wife tells her husband’s boss that her husband is sick when he is actually
inebriated.

Answer 26

ANS: D
Enabling is the act of shielding or preventing the addict from experiencing the consequences
of his or her addiction.

Question 27

Which statement made by a parent indicates a need for more education about child abuse?
a. “I have stopped slapping my child, and I am learning to count to 10 before
reacting.”
b. “I never spank or hit my children; I yell at them to stop being stupid, and if they
don’t, I tell them that the boogeyman will steal them away at night if they don’t
obey.”
“I use ‘time out’ 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 try to focus his attention on other
things. If he throws a tantrum, I just pick him up and leave the store or show or
wherever we may be.”

Answer 27

ANS: B
Emotional abuse involves extreme debasement of feelings and may result in the child feeling
inadequate, inept, uncared for, and worthless. A parent is emotionally abusing the children by
yelling at them (“to stop being stupid”) and frightening them (“boogeyman will steal them
away at night”).

Question 28

During a group counselling session for perpetrators of intimate partner violence, which client
statement indicates a lack of insight into his violent behaviour?
a. “I have been taking out my frustrations about 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 I am
getting angry.”
d. “When I drink alcohol, I become more abusive toward my girlfriend.”

Answer 28

ANS: B
Violence is defined as those nonaccidental acts that result in physical or psychological injury.
Although the client may now be feeling remorse, at the time that the violent act was
committed against the girlfriend, his intent was to inflict harm.

Question 29

A mother confides to the CHN that her live-in boyfriend pushed her 2-year-old child because
he was crying too much. She begs the CHN not to tell anyone because her boyfriend has
agreed to take anger management classes. What should the CHN do?
a. Abide by the mother’s wishes because this information was provided in
confidence.
b. Arrange for the earliest available counselling for the boyfriend.
c. Advise the mother to take the child away from the boyfriend and find alternative
housing right away.
d. Report the incident to the child protection agency.

Answer 29

ANS: D
All individuals in Canada who suspect child abuse are required to report it to the proper child
protection agencies as mandated by law. First Nations peoples also have access to specific
child protection agencies. All of the other options put the child’s welfare at risk.

Question 30

Which characteristics observed in a teenage boy should always alert the CHN to the
possibility of suicide?
a. Age between 15 and 19 years
b. Questioning sexual orientation and history of depression
c. Threatening to cause harm to peers
d. A history of torturing and abusing animals

Answer 30

ANS: B
Depression, homosexuality, and questioning gender identity are among the leading risk factors
for adolescent suicide. Those who threaten peers or torture and abuse animals are more likely
to cause harm to others than to themselves.