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NUR 443

Examination 3 Study Guide

Class 10: International Health (9) Chapter 15
~Recall the elements of a travel health preparedness plan.
-Travel Warnings
*issued by state department
Smart Traveler
*recommendation to postpone travel RT:
widespread civil unrest; dangerous conditions; terrorist
activity; no US diplomatic relations w/in country---difficult
-department of state
to assist US citizens in distress
-updates on safety &
-Travel Alerts
-easy contact by
*issued by US embassies & consulates
embassy/consulate in
*quick info about terrorist threats/ other relatively short-term OR
case of emergency
transnational conditions that could post significant risks to you or
-NOTE: keep info UTD
affect travel plans
(especially phone# &
-Required Documents/ Timelines (Visas etc.)
*passport: internationally recognized travel doc that verifies
identity & citizenship
~used overseas & to re-enter US
~only issued through US department of state
~most foreign countries require to enter & leave (some w/
just birth certificate or BC & drivers license)
~all people traveling by air must present a valid
passport to reenter US
~traveling by land or sea provide evidence of both US
citizenship & identity to reenter US (may use new passport
card instead of book for some locations)
~when does passport expire?
=some require validation for 6months+ beyond
dates of trip
>must contact embassy of foreign
destination for more info
*proof of relationship to children & evidence of consent from any
non-accompanying parent(s) instituted to limit child abductions
-Emergency Preparedness
*have contact info of nearest US Embassy or Consulate (available
24/7/7 for emergency assistance)
*family needs to reach you:
~Office of Overseas Citizens Services [Washington, DC]
1 (888) 407-4747 (during business hours)
1 (202) 647-5225 (after hours)
=state department will relay message to consulate
=consular officers locate you; relay message; report
back if you wish

-Pack Smart
*pack light able to move quickly & have free hand when need it
*minimal # of valuables & places to conceal them
*check bags, clothing, and/or vehicle to make sure not carrying
banned items or substances into destination country
~covered luggage tags to avoid casual observation of
*avoid packing IDs, tickets, & other vital documents in
backpacks/other locations you wont be able to see at all times
-Itinerary & Travel Documents
*make 2 copies of all travel documents in case of emergency or
if documents are lost/stolen
~leave 1 w/ friend or relative at home & someone know
exactly where you are staying and how to contact you
~carry other copy stored separate from originals
****What to copy?
~Passport ID Page
~Foreign Visa (if Applicable)
~Hotel Confirmation & Airline Ticket
~Drivers License
~Credit Cards Brought on Trip
~Travelers Check Serial Numbers
>SAFETY: (What to take with you; Actions to be taken on-route & during stay;
What should returning travelers consider)
*Check & understand the exchange rate before you go
*Before you leave, notify your back, credit card company, or other
financial institutions that you are going overseas
*Avoid carrying cash
~Consider travelers checks OR major credit cards (make
sure theyre accepted before departure)
*Change travelers checks only as you need them
*Dont flash large amounts of money when paying bill
-Local Laws & Customs
*subject to local laws & legal systems while abroad
~US Passport wont help avoid arrest/prosecution
~US Embassy cant get you out of jail
-Operating Motorized Vehicles
*International Driving Permit (IDP)
limited validity, will need
local license if overseas for extended period of time and/or
~most countries dont recognize US license---illegal to
drive w/o valid license & insurance (most places)
=contact embassy of travel
*Renewing US License abroad contact DMV in home state

-Medical Emergency
*consular officer from embassy/consulate can assist in locating
medical services and informing friends/family (may also assist in
transfer of funds from US)
=payment of hospital & other expenses is patients
=local info at website of embassy/consulate near person
-Health Insurance
*if covered. Carry BOTH insurance policy identity card (proof of
May require short
insurance) AND claim form
term travel
=many cover customary & reasonable costs; VERY FEW
cover medical evacuation back to US (costs 10,000+
depending on location & medical condition)
insurance to
=may still be required to pay for care when you receive it
cover cost of care
regardless of whether or not your insurance covers the cost
[NOTE: travel
& Medicaid do NOT cover care abroad---contact
insurance is for
*Enough to last trip (plus extra in case of delay)
*Carry in original labeled containers in carry-on (in case of lost or
delayed luggage)
*Ask pharmacy/physician for generic equivalent names in case
need to purchase additional medications abroad
*Letter from physician in case questioned about carry-on
medication---some countries have strict limitations w/o proper
medical documentation (on Rx & OTC)
-What vaccines & medicines are mandatory and/or recommended?
=International Certificate of Vaccination (aka Yellow Card)
or other proof of inoculations/medical tests before
=check Country Specific Information AND contact
embassy for current entry requirements
=through CDC/WHO (details on vaccinations & other
health precautions)
-What non-vaccine preventable diseases are listed?
-Warning: avoid non-essential travel?
-Alert: practice enhanced precautions
-Watch: practice usual precautions
>If yes, what are the risks?

~Apply Maslows Hierarchy of Needs to travel health & safety

>PHYSIOLOGICAL: oxygen; breathable/clean air; potable water; clean water &
sanitation; food; clothing; shelter (heat/cold/weather, sleep, etc.)
>SAFETY: safe & secure environment; protection from physical hazards and
emotional harm; security, stability, order
>SOCIAL: belonging; trust; communication; respect; autonomy; responsibility
~Recall the challenges encountered while making a difference as a community health
nursing in a developing (low income) country
>International Healthcare Delivery Systems
-Role Of Community Health Nurse:
*primary healthcare & education
*impact social determinants of health
-Service Learning: help those in greatest need
*confidentiality/privacy issues RT cost cutting
*limited supplies (must reuse)temporary solutions for longterm
*language barriers
*limited transportation
*high number of people in need of care
*vast array of major & minor issues---forced to use home
remedies as cures
*individuals age far faster
*doctors limited RT owning private practice where they make
more $; want to stay in cities for better living (cant get them to the
outskirts for primary care)---focus on emergency, tertiary care
*lack of personal hygiene items for good health prevention
~Describe how population growth impacts health
>population characteristics
-globalization: process of increasing social & economic dependence &
integration as capital, goods, persons, concepts, images, ideas & values
cross boundaries
-taxes natural resources (water, food)
-developed vs. developing nations
*quality of life & life expectancy dwindling for less developed
*must combat famine, international trade problems, war---poor feel
disproportionate amount of increase in morbidity & mortality
-shifts in demographic characteristics of countries have social & economic
*in essence dividing the countries by fast-growth/developed &
slow-growth (further dividing the rich/poor)

>environmental factors
-global burden of disease: environmental factors
*environmental stressor types
1) factors that directly assault human health: air
pollution/lead pollution
2) secondary damage to societys goods & services: air
3) quality of life: noise & liter
4) ecological balance: global warming
5) all aspects of life: natural disasters, terrorism, war
-sustainable development?
*as world becomes more urbanizedpeople living closer means
increased disease as sanitation and pollution (CO) build/become a
~Differentiate patterns of health and disease in developed (high income) vs. developing
(low income) countries
>neglected diseases
-AIDs, TB, (endemic) malaria, hep B, parasitic infections, dengue fever,
rheumatic heart disease
***immunization! Most cost-effective tool to combat
>tobacco, burning of solid fuels
>occupational & environmental safety & health hazards
>cycle of war, famine, disease
Primary Causes of Mortality
Developing Countries
Developed Countries
transition from having
Cardiovascular Disease (CVD)
infectious disease profile
to chronic disease
Respiratory Disease
(secondary to tobacco
(CVDs increasing)
use & air pollution)
more middle aged &
elderly instead of young
Traumatic Injury
~Recognize international agencies, government organizations and non-governmental
organizations that are actively involved in global health
>International Agencies and Organizations goal: health for all
-Who Health Organization (WHO)
*international health agency of UN
*directs & coordinates international health efforts, producing &
disseminating global health standards & guidelines, helping
countries address public health issues & supporting health research
-Pan American Health Organization (PAHO)
*international public health agency
*works to improve health & living standards of the Americas
*regional office of WHO
*part of UN system

-United Nations
*192 nations committed to world peace & security through
international cooperation
*resolves global conflicts & formulates policies that impact all
***all member nations have equal vote
*developed the Millennium Development Goals to coordinate &
strengthen global efforts to meet the needs of the poorest of the
1) Eradicate extreme hunger & poverty
2) Achieve universal primary education
3) Promote gender equality & empower women
4) Reduce child mortality
5) Combat maternal health
6) Combat HIV/AIDs, malaria, and other infectious disease
7) Ensure environmental sustainability
8) Develop global partnerships
>Non-governmental Organizations (NGOs)
help the UN
-Bill and Melinda Gates Foundation
*local, national, and global objectives
*global: reduce extreme poverty; improve health; increase public
library access
*Africa: increase anti-retroviral medications &
prevention/treatment for HIV/AIDS, malaria & TB
-Clinton Global Health Initiative (initiative of Clinton Foundation)
*convenes global leaders to create & implement innovative
solutions to the worlds most pressing challengesrather than
directly implementing project, CGI facilitates action by helping
members connect, collaborate, and make effective & measurable
commitments to action
=through: Inspiration, Networking, Knowledge Building, &
-UNICEF (UN Childrens Fund)
*needs of women & children across world
*implement community-based programs & establish/maintain
womens rights
-International Red Cross/Crescent
* an international humanitarian movement founded to protect
human life and health, to ensure respect for all human beings by
upholding human dignity especially during armed conflict & other
emergencies, and to prevent and alleviate human suffering
=consists of several distinct organizations that are legally
independent from each other, but united within the

movement through common basic principles, objectives,

symbols, statutes and governing organizations
=present in EVERY country & supported by volunteers
Chapter 15

By the middle of the 21st century, the world population is expected to do which of the
Reach 10 to 12 billion Correct

Reach 8 billion


Be largely unchanged from the 20th century


Show a slight decline

The world's population soared to 4 billion between 1960 and 1974 and then to 5 billion between
1974 and 1987. In 1999, the world population was 6 billion; in 2005, it was nearly 7 billion. The
population is projected to reach 8 billion by 2025 and 10 to 12 billion by midcentury.
REF: Page 273

Population overcrowding can result in which of the following?

Increased productivity

Improved education


Increased incidence of disease Correct


Decreased mortality

Overcrowding leads to pollution, stress, disease, and violence. Mortality rates are increased, and
quality of life decreases.
REF: Page 273

Which of the following environmental stressors directly assaults human health?

Global warming

Air pollution Correct





Air pollution and poisoning directly assault human health. Noise and litter affect quality of life.
Global warming affects the ecologic balance.
REF: Page 273


Through improved sanitation, developed countries have significantly reduced high

mortality rates from:
respiratory diseases.

cardiovascular diseases.




infectious diseases. Correct

Improved sanitation has led to reduced mortality rates from infectious diseases. Respiratory
disease, cancer, and cardiovascular diseases are the primary causes of death in developed
REF: Page 274
The life-threatening parasitic disease that causes at least one million deaths annually is:

malaria. Correct





Malaria is a life-threatening parasitic disease transmitted by mosquitoes. Malaria causes more

than 300 million acute illnesses and at least 1 million deaths annually. AIDS is a disease caused
by the HIV virus. Tuberculosis is an infectious disease caused by the tubercle bacillus. Hepatitis
is inflammation of the liver.
REF: Page 274

The concept of "health for all by the year 2000" was initially introduced by which of the
following international organizations?
World Health Organization (WHO) Correct

Centers for Disease Control (CDC)


United Nations International Children Emergency Fund (UNICEF)


National Institutes of Health (NIH) Healthy People 2000

The WHO introduced the goal of "health for all." The CDC strives to prevent and control
infectious and chronic diseases, injuries, workplace hazards, disabilities, and environmental
health threats. UNICEF focuses on child and women's health.
REF: Page 275

The global health organization that works for children's survival, development, and
protection is the


World Health Organization (WHO).


Centers for Disease Control (CDC).


United Nations International Children Emergency Fund (UNICEF). Correct


Pan American Health Organization (PAHO).

UNICEF works for children's survival, development, and protection by developing and
implementing community-based programs. UNICEF achievements are well documented in child
health, nutrition, education, water, sanitation, and progress for women. PAHO is an international
public health agency that works to improve the health and living standards of the Americas. The
WHO introduced the goal of "health for all." The CDC strives to prevent and control infectious
and chronic diseases, injuries, workplace hazards, disabilities, and environmental health threats.
REF: Page 277


The first nurse to establish international links and networks was:

Clara Barton.

Mary Breckenridge.


Dorothea Dix.


Florence Nightingale. Correct

Florence Nightingale's legacy serves as the foundation for community health nursing in the
global health care arena. She channeled her energy into all aspects of health from the care of
wounded soldiers at Scutari to the broad public policies that affected health in her time. The
other three women were instrumental primarily for their contributions in the United States
REF: Page 279

People who live in developing countries are at risk for a variety of health threats as a
result of all of the following factors except:
limited sanitation facilities.

increased chance of exposure to communicable diseases, including AIDS,

tuberculosis, and hepatitis B.

higher rates of tobacco use compared with most developed countries.


lack of interest in health issues and health care. Correct

In developing countries, people are more likely to be exposed to communicable diseases as a

result of a number of factors, including high population density, lack of accessible health care
and treatment, and poor or limited sanitation. In addition, although tobacco use is decreasing in
most developed countries, it is increasing in many underdeveloped ones. Although people in
developed countries often lack resources and information, they are nonetheless interested in
health promotion, disease prevention, and many aspects of health care delivery.
REF: Page 274

After the implementation of various policies to reduce tobacco use, the tobacco industry
has begun targeting: (Select all that apply.)
elderly people.



youths and young adults. Correct


African Americans.


international markets. Correct

The tobacco industry has now started targeting youths and dramatically increased international
exports. Tobacco sales among American adults is down.
REF: Page 274
Class 11: Vulnerable Populations (35) Chapters 22, 23, 27
Based on
~Discuss the role of the public health/community health nurse who is providing
healthcare for vulnerable populations
>***the nurse breaks down barriers between RN and homeless by treating the health
person with respect, compassion, and concern
>OUTREACH: nursing approach to making health care more readily available toon wheel
vulnerable populations by implementing education, counseling, and support
services where people congregate
Downstream: surveillance; disease
***Upstream: collaboration;
investigation; outreach; screening; case
coalition building; community
**Social justice: all people
equally entitled to key ends
finding referral & follow-up; case
organizing; advocacy; social
(i.e access to health care &
management; delegated functions; health
marketing; policy development &
minimum income); all
teaching; counseling; consultation
members of society must
accept collective burdens for a
Soup kitchens
Change the system ! (economics,
fair distribution
inequality, discrimination)
Market justice: people are
entitled to valued ends (i.e
status, income, happiness)
according to own individual
Clothing drives
Food drives
Drug & ETOH problems
Runaway youth

~Define homeless
>European conceptual definition of homeless: [developed by researchers]
*broken down by (3) domains of home
Any individual lacking a
-physical: having adequate dwelling for which a person/family has
fixed, regular, &
exclusive possession
-social: able to maintain privacy & enjoy relations
adequate nighttime
-legal: exclusive possession, security of occupation, and legal title
to occupation
temporary is still
*broken down into (4) classes subdivided for policies/ interventions
(rooflessness; houselessness; insecure housing; inadequate housing
Individuals with no
mailing address or
place to sleep; people
who sleep outdoors on
streets or in parks, train
stations, subways,
underground, in cars
and people on the

Healthy People 2020:

create social & physical
environments that promote
good health for all by
targeting the social
determinants of health
[circumstances, in which
people are born, grow up,
live, work &age, and
systems put in place to
deal with illness. In turn
shaped by economics,
policies, and politics]
-access to mass media
-residential segregation
-exposure to crime,
violence, and social
-socioeconomic conditions
(concentrated poverty)

>Canadian conceptual definition categories: further subdivided for government

agents, service providers, researchers [developed by researchers]
-unsheltered: living on streets or places not intended for humans
-emergency sheltered: staying in overnight shelters designed for
people who are homeless
-provisionally accommodated: people who are homeless whose
accommodation is temporary or lacks security of tenure, including
interim (or transitional) housing, people living temporarily with
others (couch surfing), or living in institutional contexts (hospital,
prison) without permanent housing arrangements
-at risk for homelessness: people who are NOT homeless, but
whose current economic and/or housing situation is precarious or
doesnt meet public health and safety standards
>US Legal Approaches to defining homelessness [developed by federal legislative
& administrative actions]
*provide statutory & regulatory basis for homeless service providers
including program direction, funding, and eligibility

*implemented & managed by (7) departments within executive branch

1) Housing and Urban Development (HUD)
=Homeless Assistance Grants
Category 1: [literally homeless] individuals &
families who lack a fixed, regular, & adequate
HUD and ED are the
nighttime resides; those in emergency
primary federal
shelters/location not meant for human habitation;
agencies with
those exiting institution previously resided
responsibility for
Category 2: [Imminent risk of homelessness]
reporting US
Category 3: [Homeless under other federal statutes]
Category 4: [Fleeing/Attempting to Flee Domestic
Violence (or other threatening situations)]
2) Education (ED)
=Education for Homeless Children & Youth
=meant to direct state & local educational services to
ensure all children receive free, public education includes
~sharing housing of other persons (doubling up)
~abandoned in hospitals
~awaiting foster care placement
3) Health and Human Resources (HHS)
=uses (2) definitions to determine eligibility for services
~runaway youth: person under 18 who absents from
1)shortage of affordable
home/legal residence w/o permission
housing (<30% or monthly
~homeless youth: person under 18 in need of
services w/o a shelter to receive supervision & care
2) insufficient income to
definition for who is eligible for services
meet basic needs (median
through the Healthcare for the Homeless (HCH)
income declining; $ not going
as far; forced to pay more for
rent, less on
4) Veterans Affairs (VA)
5) Homeland Security (DHS)
3)inadequate and scarce
6) Justice (DOJ)
support services (particularly
7) Labor (DOL)
~List contributing factors to homelessness (NOT causation)
>childhood experiences
>foster care, physical and sexual abuse, and parental substance abuse
>group home placement, running away from home/throwaways
*run away: child chooses to leave (safety)
*throwaway: asked to leave
>Micro: individual pathologies (physical/psychological)---downstream factors
>Macro: capitalism; industrialism; poverty; individualism; lack of housing,
education, jobs; lack of affordable health care---upstream factors
~Describe the prevalence of homelessness and poverty in the United States
>HUDs Efforts to Count the Homeless
*continuum of care (CoC) concept:

-homeless service providers in each local community submit 1

CoC application to HUD for funding
=provide housing & related services (includes emergency
& preventative responses)
=must also implement & manage HMIS at local level
-whats included for funding?
=point-in-time (PIT) count: count of sheltered homeless on
single night in late January every year submitted via HMIS
~every 2 years (at least) must include sheltered
AND unsheltered
*Homeless Information Management System (HMIS):
-computerized database designed to facilitate collection of clientlevel data used to plan for service needs of homeless
-used to compile Annual Homeless Assessment Report sent to
Congress reflects individuals, families, chronically homeless,
veterans (all but children & youth in public schools)
>EDs Efforts to Count the Homeless
*Education for Homeless Children & Youth (ECHY) program: for those
not included in the HUD definition
-info collected from all state education agencies (SEAs) and local
education agencies (LEAs) of children enrolled during school year
=submitted in annual Consolidated State Performance
Record (CSPR)

~Recall the stages of homelessness

>Episodic homelessness: in & out of homelessness
>Temporary homelessness: displaced by disaster ranging from fire to eviction
>Chronic homelessness: live on streets for years (must be on street for 1 year
w/o any periods of housing); most likely have mental illness or drug problem
~Identify homeless populations using demographics
US Conference
*rise over the past 20-25 years
of Mayors
-shortage of affordable rental housing
-increase in poverty (direct relationship to homelessness)
Hunger and
*large proportion have disabilities
Survey: urban*most homeless adults 31-61; 22.1% under age 18
local perspective
based in cities
*single homeless adults most likely to be male largest population
reported every
>Families [at least 1 adult & 1 child]
year (NOT a
*# of families increasing significantly (ppt indicates higher in rural areas)
national report as
*homeless tend to be younger than the poor households w/ large numbers
the HUD and ED
of minorities and disabled (with most being single mothers)
reports are as
cities reporting

>Ethnicity (most to least)

*African American; White; Hispanic; Native American; Asian
>Victims of Violence
*battered women forced to choose between abusive relationships &
*less veterans than in general population; however, most are older 51-61
and the number is on the rise
*more likely to be in poverty & have a disability
>(Severe) Mental Illness
*26% of sheltered homeless
*deinstitutionalization: the policy of moving severely mentally ill people
out of large state institutions and then closing part or all of those
institutions; it has been a major contributing factor to the mental illness
>Addiction Disorders (alcohol & drugs)
*declining wages has put housing out of reach---forced to do shadow
work (underground work like washing windows or playing music)
*(3) main causes of hunger poverty, unemployment, high housing cost

~Outline those health problems that contribute to homelessness

>trauma: environmental effects of street life, assault, temperature
>infectious disease: HIV/AIDs, TB, STDs, URI
>substance abuse/addiction: crack cocaine use
>chronic illnesses: HTN; malnutrition; anemia; DM; mental illness
>children have increased risk for:
*premature birth, LBW, death
*chronic illness
*traumatic death & injuries
*nutritional deficiencies: iron, blood lead levels
~Outline those health problems that occur consequently to being homeless
Trauma &
>Nutrition deficits
>Mental Illness
>Tobacco, ETOH, elicit drugs
every day
>lack of steady jobs
>poor quality of life
>increased health

>Skin infestations
~Describe the challenges of caring for homeless populations (healthcare
for the homeless)
>resources lacking in food, shelter, safety
-foods primary fats & grains75% never eat fruit/veggies
>healthcare is tertiary in nature
>ER utilization rate is high
>barriers to care: transportation, phone, address, health insurance
-lack of access
-may not have regular family practitioner
-may be discouraged from obtaining services OR turned away from
private clinics
~ patient dumping/ cogomer phenomenon----statutorily
imposed liability that occurs when a hospital capable of providing
the necessary medical care transfers a patient to another facility or
simply turns the patient away because of the patient's inability to
pay for services.
-lack of systematic communication with health care professionals
-lack of social & family support
-psychological depression; hard-to-reach
-lack of motivation to seek health care
>attitudes of health providers to the poor: normal rubbish dirty work
Chapter 22

Based on the Department of Housing and Urban Development (HUD) definitions of

homelessness, which one of the following individuals would be considered homeless?
An individual whose residence lacks access to public water and electricity

An individual who has a permanent nighttime residence in the housing for

mentally ill people
An individual imprisoned or detained under an act of Congress or state law
An individual who spends most nights at public or private places not

designed for regular sleeping accommodations Correct

HUD defines homelessness in four categories: (1) literally homeless, (2) imminent risk of
homelessness, (3) homeless under other federal statutes, and (4) fleeing/attempting to flee
domestic violence. An individual who spends most nights at public or private places not designed
for regular sleeping accommodations is considered literally homeless. Literally homeless is
defined as individuals and families who lack a fixed, regular, and adequate nighttime residence
and includes a subset for an individual who resided in an emergency shelter or a place not meant

for human habitation and who is exiting an institution where he or she temporarily resided. An
individual whose residence lacks access to public water and electricity, an individual who has a
permanent nighttime residence in the housing for mentally ill people, and an individual
imprisoned or detained under an act of Congress or state law are not considered homeless under
the HUD definition.
REF: Page 431

The Brown family is being evicted from their home and will be moving into a homeless
shelter in 3 days. Under the Department of Housing and Urban Development (HUD) definition,
the Brown family is:
literally homeless.

in imminent risk of homelessness. Correct


homeless under other federal statutes.


fleeing or attempting to flee domestic violence.

Imminent risk of homelessness defines those who will imminently lose their primary nighttime
residence. The literally homeless have no fixed, regular, or adequate nighttime residence.
Unaccompanied youth and families with children who are defined as homeless under other
federal statues but do not fit into the other HUD defined categories of homeless may be defined
as homeless under this HUD definition. Finally, individuals and families who are fleeing or
attempting to flee domestic violence or other life-threatening conditions that relate to violence
against the individual or family are defined as homeless.
REF: Page 431


What is the purpose of the Homeless Information Management System (HIMS)?

Provides means to feed homeless people

Obtains national data on homeless individuals Correct


Serves as a screening tool to obtain any history of criminal activity


Provides homeless individuals with educational materials

The intent of the HIMS is to obtain national data, including the number of and demographic
information on the homeless population. Providing means to feed homeless people, serving as a
screening tool to obtain any history of criminal activity, and providing homeless individuals with
educational materials are not functions of the HIMS.
REF: Page 432


Which of these statements is true regarding income insufficiency in the United States?
The poverty rate increased between 2007 and 2010. Correct

People who make minimum wage would not be categorized as impoverished.


Alcoholism is the major reason for lack of employment.


The median household income in 2011 was around $40,000.

The poverty rate increased from 2007 to 2010. median income in 2011 was greater than $50,000.
The economy and related issues are the most common reasons for unemployment. Working at
minimum wage places a person below the poverty line. REF: Page 435

What official national organization provides financial housing assistance to low-income

World Health Organization (WHO)

Federation of National Organizations Working with the Homeless

Robert Wood Johnson Foundation
Department of Housing and Urban Development (HUD) Correct

HUD, in cooperation with state and local governments and nonprofit housing organizations,
operates programs that provide financial housing assistance to low-income families. The WHO is
an organization that is concerned with international public health. FEANTSA is a European
organization that works to prevent and alleviate poverty and homelessness in Europe. The Robert
Wood Johnson Foundation provides funding for nursing education.
REF: Page 431

What group of homeless individuals is known for their involvement in survival sex?
Young adult gay men

Middle-aged women


Adolescents Correct

Runaway or homeless adolescents make up a large percentage of all youth involved in

prostitution. Many become involved because they need money to meet subsistence needs, hence
the term survival sex.
REF: Pages 438-439

Which model supports upstream thinking with the purpose to improve homelessness
through reduction of structural conditions contributing to homelessness?
Social justice Correct


Market justice


Physical justice


Mental justice

The social justice model seeks to reduce the structural conditions contributing to homelessness
through collective action, thus supporting upstream thinking.
REF: Pages 439-440

According to the vulnerability index, the individual at highest risk for death is:
a 46-year-old person who has been homeless for 2 months and has HIV.

a 22-year-old person who lives in a homeless shelter and is addicted to



a 65-year-old person who is being evicted from his home after living there for
25 years.


a 60-year-old person who has been homeless for 9 months. Correct

Those at high risk for death are individuals who have been homeless for 6 months or more with
one or more of the following conditions:
? More than three hospitalizations or emergency department (ED) visits in 1 year
? More than 3 ED visits in the previous 3 months
? 60 years or older
? Cirrhosis of the liver
? End-stage renal disease
? History of frostbite, immersion foot, or hypothermia
? Co-occurring psychiatric, substance abuse, and chronic medical condition
REF: Page 439

The U.S. Department of Education defines a homeless child as:

a child abandoned in a hospital. Correct

a child in foster care.


a child in a group home.


a child living with a grandparent.

The definition of a homeless child according to the U.S. Department of Education includes
children and youth who are:
? Sharing the housing of other persons because of loss of or inadequate housing
? Abandoned in hospitals

? Awaiting foster care placement

REF: Page 432


Public health policy in the United States is influenced by two types of justice, market
justice and social justice. Examples of market justice include which of the following? (Select all
that apply.)
All people are entitled to the status they create for themselves. Correct

All people are entitled to a livable minimum wage.


All people are entitled to happiness if they put forth enough effort. Correct


All people are entitled to the income they work for. Correct


All people are entitled to access to health care.

Market justice has been the dominant model in the United States and purports that people are
entitled to valued ends (i.e., status, income, and happiness) according to their own individual
efforts. Moreover, this model stresses individual responsibility, minimal collective action, and
freedom from collective obligations other than respect for another person's fundamental rights. In
contrast, under a social justice model, all people are equally entitled to key ends (i.e., access to
health care and minimum standards of income).
REF: Page 439

~Identify the migrant worker population using demographics

>Migrant Farm Worker Definitions
*# of rural
-NAWs definition: an individual who travels 75 miles or greater to obtain
residents on the
a job in US agriculture
-Office of Migrant Health: a person whose principal employment is in
*agriculture: food
agriculture on a seasonal basis, who has been so employed in the last 24
& fiber system;
months and who establishes for the purpose of such employment, a
encompasses all
temporary abode
aspects of
-seasonal farm workers work cyclically without migrating
agriculture from
of the Migrant Farm Worker
core material
sectors (farm, food
-native born: displaced former slaves and sharecroppers
-dustbowl years: farmers who lost their farms
textiles, other
-Bracero program 1943 (WWII): import farm workers from Mexico
manufacturing) to
(guest worker program)
officially terminated in 1964
wholesale & retail
***majority of farm worker labor force now foreign born
(primarily from Mexico)
>Snapshots of the US Migrant Farmworker Population
Rural US
-over 3 million in the US
Economic Base
*poverty continues
-80% male, 20% female
to be greater in rural
-81% foreign born (Mexico; Latin America; Asia; Other)
areas compared to
>Language and Education
-84% Spanish Speaking; 12% English speaking; 4% other
Age Composition
-15% report completion of the 12th grade
*more older (60+),
-20% report <3years education
isolated people w/
-median level of education: 6th-7th grade
diminished access to
care as the young
move to urban
*hourly: 77% (5.64/hour)
*piece rate: 20%
*influx of retirees &
*combination: 2%
others who conduct
-75% earn less than 10,000/year
business through
-3 out of 5 earn less than federal poverty level
& travel
-No workers compensation, disability compensation, health insurance, or
retirement benefits
*older w/ less
>Utilization of Assistance Programs
education; live in
-17% utilize assistance
poverty; lack health
-13% Medicaid
insurance; lack of
providers & access
to care
*more acute
problems resulting in
lost work days &
issues RT to

-10% food stamps

-1% AFDC (aide to families w/ dependent children)/GA (general
assistance)/Public Housing
>Working Hours
-56% [31-50hours/week] 15% [>50hours/week]
-14% work for employer year round
-83% work on a seasonal basis
-6month/year agricultural work; 8 weeks non-agricultural; 8 weeks
traveling; 8 weeks unemployed
>How do Migrant Farm Workers Travel?
-(3) streams of travel
*California, Oregon, Washington
*Texas/Arizona moving through Mississippi River valley and into
*eastern stream: Florida/Georgia, Carolinas, Maryland, Delaware,
NJ, NY, and New England
=ethnically heterogeneous
=Jamaicans; Haitians; Puerto Ricans; Mexicans; Mexican
Americans; African Americans
~mainly in Mass and CT, then RI
=New England + Migrant Farmworkers (doesnt
compute---invisible, silent population working on:)
~field crops, landscape nurseries, shade tobacco
(mass, CT), orchard crops
>Are Streams a Thing of the Past?
-less pronounced, fewer follow the crop migrants
-fading streams may be RT increases in specialty farming vs. multiple
-advent of some mechanical harvestors may interrupt the sequence of
the stream
-work is dependent on weather, status of the crops, first come, first
employed, go where the work is!
~Summarize the work conditions of migrant farm workers and the importance of doing
as a measure of health--being able to work used as a key indicator of health/when to seek help
>Environmental Stressors
-hard physical work
-long hours
-unhealthy living conditions
-unhealthy working conditions
-social isolation
-geographic isolation
>Other Factors Impacting Health
-transient nature of the population
-fatalistic attitude towards illness

-mistrust of health system and/or providers of the dominant culture

-definitions of health/illness

~Describe the prevalence of injury & illness among migrant farm workers
>Health Issues Experienced by Migrant Farm Workers
~highest rate of toxic chemical injury/illness
~higher rates of HIV/TB/CA/HTN/DM
~13% occupational fatality rate
~exposure to carcinogenic agents (pesticides, sun, chemicals,
~respiratory illnesses
~parasitic infections
~urinary tract infections: not going to bathroom; dehydration
~musculoskeletal d/o
~traumatic injuries
~eye trauma
~mental health
~substance abuse
~occupational illness and injuries
~reproductive issues
~prenatal care
~domestic violence
~sexual abuse
~mental health
~pesticide related illnesses
~respiratory illnesses; lead exposure
~musculoskeletal injuries
~over/under immunized
~dental caries
~difficulty completing their education
~List key barriers to healthcare resources experienced among migrant farm workers
-expectations of patient/provider relationship
-beliefs about health/wellness/illness

-folk/home remedies
-community elder/healer
-structure of social group/family roles
-mobility required to secure employment
-continuity of care/health history
-rural location of most farms
-hours of work vs. hours of clinic operations
-lack of transportation
-low wages/ variations in earnings or employment
-disincentives to miss work
-lack of health insurance
-eligible/not eligible for benefits
~cannot maintain PCP
~benefits may be linked to residence in a particular state
~fears of deportation
~Discuss the ethical principles of providing healthcare to migrant workers
>How Does the Migrant Farm Worker Impact the Health System?
-ER use only
-critically ill
-no follow up
-no prevention/health maintenance
-increase costs for care RT severity of illness/injuries
-treatable illnesses vs. death/disability
>***Nurse-Client Relationship
-Respecto (respect the individual)
-Personalismo (relate to the individual)
-Dignidad (dignity)
-Simpatia (polite, non-aggressive)
-cultural humility
-linguistic capability
~Conduct a health assessment of a migrant worker
>Occupational History
-type of job
-did S&S start after you began working on the farm?
-S&S worse at the end of the workday and better at night or on
-co-workers with similar S&S?
-patients opinion of cause of S&S?
>Dermatitis (contact/allergic and heat rash)
-skin have contact w/ plant material?
-contact with pesticides, fertilizer, other chemicals?
-is rash worse where you have had contact?
-wet work?
-facilities for hand/clothes washing and/or showering

-excessive heat & humidity

-new soaps/detergents/lotions
>Musculoskeletal D/O
-pain in muscles/joints and in what positions?
-lifting awkward loads
-repetitive work
-hand tool use
-standing long hours doing your job
-did you fall/hurt self on the job
>Respiratory Symptoms
-work with chemicals that irritate nose, throat, and/or lungs & make you
-outdoor pollen, mold, dust irritate throat/nose and/or lungs and/or make
you cough?
>Heart Related Illnesses
-able to get used to heat before starting to work?
-able to drink a lot of water during the workday
-able to alternate work with rest in a cool area
-perform heavy work during the hotter periods of the workday
>Green Tobacco Sickness (GTSAcute Nicotine Poisoning)
-S&S: HA (headache) or vertigo AND N/V AND worked in tobacco that
day or previous day
~have you been handling wet tobacco?
~have you been working in wet clothes while handling tobacco?
~Nursing Interventions as we Move Upstream
>political activism
>awareness of the unique health issues associated with the occupation
>development of working relationships with providers
>education of providers

Chapter 23

Rural residents in the United States compose more than _____% of the nation's poor.
50 Correct






More than 50% of the nation's poor live in rural areas; 35% live in the South. Current census
estimates are that 20% of the nation's children younger than age 18 years live in rural areas, as do
15% of the nation's elderly.
REF: Page 445

Which of the following statements best describes the demographics of rural


Despite the shrinking number of family farms and full-time farmers,

agriculture continues to be an important part of the rural and U.S. economy. Correct
There has been a shift in the economic base of rural America as more

communities are dependent on income generated from mining and construction.

There has been a decline in diversity in rural America, with more

Hispanics and youth moving to urban areas rather than rural communities and small
There are more positive health behaviors (e.g., less smoking, obesity,
and drug use) among residents of rural America when compared with urban America.
Despite the shrinking number of family farms and full-time farmers, agriculture continues to be
an important part of the rural and U.S. economy. Changes in rural demographics include a shift
in the economic base from agriculture to industry, as well as more diversity as the number of
rural Hispanics increases. Additionally, there has been a rise in negative health outcomes for
rural residents; obesity, smoking, and drug use are more prevalent in rural America than in urban
REF: Page 445


The number one health concern identified by the majority of rural health care
leaders is:

lack of health insurance. Correct


limited access to health care.


increase in communicable diseases.


social isolation of rural dwellers.

Rural health leaders identified ten priorities for health care in rural America, with access and
affordability to care topping the list. Surveys have found rural uninsured people are more likely
to have a usual source of care compared with their urban counterparts. An increase in
communicable diseases and social isolation of rural dwellers were not listed as a priority health
concern identified by rural health leaders.
REF: Pages 448-449

Agricultural workers are at high risk for occupational injuries and illnesses. To
reduce the most common cause of fatalities among youth on farms, which of the following is the
most important strategy for the community nurse to implement?
Planning a community media campaign advocating the use of helmets

Partnering with the county extension agent to offer tractor safety

classes Correct


Working with local health care providers to encourage use of personal

protective equipment, such as hearing and respiratory protection
Offering a class for local health care providers addressing the signs

and symptoms of pesticide toxicity

Tractor-related accidents, especially rollovers, are the most frequent cause of farm accidents and
account for more than one-fourth of farm fatalities. Encouraging the use of helmets is important,
but the most important measure would be to offer tractor safety education. Working with local
health care providers to encourage use of personal protective equipment, such as hearing and
respiratory protection and offering a class for local health care providers addressing the signs and
symptoms of pesticide toxicity are less important measures.
REF: Page 456

Based on the common illnesses and risky health behaviors among farmers, the
community health nurse should implement which of the following health promotion activities?
Partner with the local health department to offer smoking cessation
classes for farmers and their spouses.


Collaborate with health care providers and provide support and

education for farmers with respiratory conditions and their families. Correct
Collaborate with health care providers to conduct skin assessments at

a meeting of local farmers.

Work with mental health consultations to outline a community-based
program to address the high rate of suicide and depression among farmers.
Plan, implement, and evaluate an outreach program designed to
improve the cardiovascular status of farmers and their families.
Several types of farming activities are associated with higher than expected occurrences of acute
and chronic respiratory conditions. The role of the nurse is to refer patients to appropriate health
care providers and provide support and education for affected people and their families. Farmers
have a lower rate of cardiovascular disease, use of mental health services, and tobacco use than
their urban cohorts.
REF: Page 456


Migrant and seasonal farm workers constitute a high-risk population due to their
low income and migratory status. These workers lack adequate access to preventive services. The
most important role of the rural community health nurse in meeting the health care needs of this
vulnerable population is to:
address the multiple communicable diseases of these farm workers.

serve as an advocate working to gain health care access for these farm

workers. Correct
participate in political activities with an emphasis on changing

immigration laws.
learn to speak Spanish to improve communication with this specific

One of the greatest needs of the migrant and seasonal farm workers is the lack of access to health
care. The community health nurse is in a strategic position to advocate for change to restructure
health services and thus reduce this rural health disparity. Providing direct care for
communicable diseases is important but does not meet the overarching goal of getting adequate
health care access to migrant farm workers. C&D do not address the healthcare needs of migrant
farm workers. REF: Page 457


In contrast to people who live in urban areas, rural residents frequently describe
their health by their ability to:
avoid hospitalizations.

maintain social connections.


perform activities of daily living.


work and be productive. Correct

Rural residents generally describe themselves as healthy if they can do their usual work and
remain productive. Performing activities of daily living may be one part of being productive.
Avoiding hospitalizations and maintaining social connections are the most frequent descriptions
of health by rural residents. REF: Page 458

The greatest promise for improving health outcomes for rural residents is:
the increase in health care providers migrating to rural areas.


the expansion in Medicare services to rural hospitals and clinics.


the increase in distribution of technology, providing more education

and health services. Correct

the expansion of public transportation, allowing rural residents to
travel to tertiary care hospitals for specialty services.
Rural patients are able to access specialty services such as radiologic or dermatologic
examinations through telemedicine (internet). Expansion and increased distribution of tech in
rural areas has increased access to health care services and education through distance programs
for rural residents. Health care providers remain scarce. Rural hospitals and clinics generally
have Medicare services. There is still inadequate public transportation from most rural areas to
tertiary hospitals.
REF: Page 463

Which statement regarding the impact of managed care on rural public health
departments is true?
Managed care has expanded the safety-net role of many local health
departments by funding primary care services.
Medicaid's importance for rural areas is likely to decrease.

The role of rural public health departments may increasingly narrow

into areas that are currently without any type of reimbursement. Correct


Medicaid programs will continue to serve the rural communities on a

fee-for-service basis.
The evolution of managed care into rural environments has limited the safety-net role of some
local health departments to provide primary care by preventing fee-for-service reimbursement
and contracting care to networks of providers or organizations. This is especially true for
Medicaid managed care, which serves that same population of people that are traditionally
served with primary care services through local public health departments. Medicaid's
importance for rural areas is likely to grow as broader health care developments, such as
declining inpatient use of rural hospitals and reductions in Medicare reimbursement, provoke
more interest in using the Medicaid system to support threatened rural infrastructure.
Consequently, the administration of the Medicaid program will increasingly seek the cost savings
promised by managed care, and the role of rural public health departments may increasingly
narrow into areas that are currently without any type of reimbursement.
REF: Page 465

A community health nurse is concerned about reducing the fatal injuries to

America's rural children. To address this problem, the nurse organizes a community of solution
(see Chapter 1). For this group, it would be important to have representatives from all of the
following groups or organizations: (Select all that apply.)
the Department of Public Highway and Safety. Correct

emergency department staff (both doctors and nurses) from local

hospitals. Correct
teachers and coaches from area schools. Correct


area employers.


city or county government. Correct

Limited resources are available in rural areas, and more can be accomplished when resources are
pooled. Also, to ensure a more successful outcome, all players with a vested interest in the
problem should have a voice in the problem-solving approach. This would include public
personnel (city and county government, police, teachers) and private groups (RNs and MDs).
Less important for looking at children's issues, however, would be private employers.
REF: Page 461

~List the factors that contribute to violence/intentional injury to self and/or others Table
27-3 Page 551
>violence: the intentional use of physical force or power, threatened or actual
against oneself, another person, or against a group or community, which results in

or has a high likelihood of resulting in injury, death, psychological harm,

maldevelopment, or deprivation---injuries as result are intentional injuries
>factors that contribute:
~poverty, unemployment, economic dependency
~substance abuse
~dysfunctional family and/or social environment and lack of emotional
~mental illness
~media influence
~access to firearms
~political and/or religious ideology
~intolerance and ignorance
~Define interpersonal violence and its connection to power and control
>formerly known as domestic violence: pattern of coercive behaviors
perpetrated by someone who is or was in an intimate relationship with the victim,
such as a (ex)spouse, (ex) boy/girlfriend, or date
~behaviors may include: battering (resulting in physical injury);
psychological abuse; sexual assault (contributing to progressive social
isolation & intimidation)
>often repetitive & escalates in frequency & severity
~Discuss the responsibilities of a nurse in assessing, reporting, and referring suspected
and/or confirmed cases of violence/abuse
>Box 27-1 page 545 & page 546; Table 27-1 Pg 548; Table 27-2 Pg 550; Box
27-4 Pg 553; Table 27-4 Pg 554
~Define a gang, gang member, and gang-related crimes
>Federal Definition of Gangs
-an ongoing group, club, organization or association of 5+ persons
a) that has as one of its primary purposes the commission of one or
more of the criminal offenses described in subsection c
~any federal or state felony offense that by its nature
involves a substantial risk that physical force against
the person of another may be used in the course of
committing the offense
b) the members by which engage, or have engaged within the past
5 years, in a continuing series of offenses described in subsection c
Nature of crimes in
c) the activities of which affect interstate or foreign commerce
general is
>State Definition of Gangs
violent; involved in
Gangs increasingly
-40 states & Washington, D.C. have legislation that defines a gang
also occurs while
gang activity
-32 states define gangs as consisting of 3+ persons
alien smuggling, human
Also include:
& theft,
prostitution) as -25 states include a common name and identifying sign/symbol as
as white-collar
crime (i.e identifiers of gangs in their definition
kills , robberies identity theft,
& Definition of Gang Member (a person who)
mortgage fraud)high
1) participates in criminal street gang w/ knowledge that its members
profitability & much lower
engage in or have engaged in a continuing series of offenses described
visibility/risk of detection &
in subsection c
punishment as compared to
drug & weapons trafficking
-encourage members,
associates & relatives to obtain
law enforcement, judiciary &
legal employment to gather
info in rival gangs & law
enforcement operations) & also

2) intends to promote or further the felonious activities of the criminal

street gang or maintain or increase his or her position in the gang
3) has been convicted within the past 5 years for:
a) an offense described in subsection c
b) a state offense:
i) involving a controlled substance (as defined in section
102 of the Controlled Substance Act) for which the
maximum penalty is 5 years in prison
ii) that is a felony crime of violence that has an element of
the use or attempted use of physical force against another
c) any federal or state felony offense that by its nature involves a
substantial risk that physical force against another may be used in
the course of committing the offense
d) a conspiracy to commit an offense described in a-c
~Recall signs and behaviors that may identify gang members
>Identification of Gang Members
~admission by self, family, reliable informant, untested informant
(corroborated by independent information), other members, other law
enforcement agency of gang membership
~tattoos depicting gang affiliation
~style of dress consistent with gang membership
~possession of gang graffiti on personal property or clothing
~use of hand signs or symbols associated with gangs
~associates or prior arrests with known gang members
~attendance at gang function or known gang hangouts
>Types of Gangs
~Black [Bloods: Drugs, Crips: drive-bys & robberies)
~Asian [RT social, economic, and racial issues; not turf oriented;
~White a.k.a skin heads or neo-nazis
~Prison [security threat group STG; do more than offer protection; all
drugs inside prison through them]
~Motorcycle [use membership as conduit for criminal enterprise colors
are SACRED & patches indicate level of membership/crimes committed]
~lips on neck (mexican mafia)
~3 dots (mi vida loca)
~1% (OMG motorcycle)
~Lightening Bolt (Aryan brotherhood)
~Devils pitchfork (MS 13)
~little scratches
~communicate 4 things

-crimes committed
>Gang Hand Signs
~represent themselves
~identify themselves to other members
~ throwing up (putting up your gang sign)
~ situations where other identifiers may not be possible or appropriate
~Describe how youth gang members are considered a vulnerable population
>Who are gang youth?
~80% are African American or Latino
~relatively deprived socioeconomic background
~high rates of welfare dependency
~families with poor parenting skills
~family members who are in a gang
~communities with long histories of drug sales, crime, and gang activity
~perform poorly in school, negatively labeled by teachers & have friends
involved in crime, drug use and/or gang activity
>More likely to engage in risky behaviors
~alcohol use
~illicit drug use (50-90% more than nongang peers)
~sexual behaviors
-sex initiation at very early age
-multiple partners
-unprotected sex
-homosexual relationships in correctional facilities
~victimized by violence
-60* more likely to be killed than rest of population
>Mental Health disorders
~44% were possible psychopaths (w/ S&S of moderate psychopathy)
~4% were psychopaths (w/ S&S of high psychopathy)
~psychopath: person characterized by reduced fear, lack of empathy, coldheartedness, egocentricity, superficial charm, manipulativeness,
irresponsibility, impulsivity, criminality, antisocial behavior, lack of
remorse, and a parasitic lifestyle
~List appropriate precautions for a nurse to stay safe while providing healthcare to a
suspected or known gang member
>OMG (outlaw motorcycle gang) Vests: Dont Cut!!
~many gang members carry weapons: guns, knives, shivs/shanks
>Rival Gangs
~separate gang members as far away as possible
~notify police
~watch the waiting room

~Discuss how social media promotes gang behaviors

>local gangs are turning to social media to taunt their rivals
-messages from various Providence gangs showing up on Youtube----gang
members specifically target their rivals, threatening extreme violence
>videos being utilized to recruit kids into gang life (EX Gandy Kaydeayoung
aspiring rapper strangled & lit on fire in gang retaliation)
*****Providence polices gang unit does monitor these videos & in some cases
use them to identify the gang members
~Describe the terminology and concepts related to LGBT populations
>lesbian & gay: people who have (or desire to have) an intimate relationship
with individuals of the same gender; primarily or exclusively RT the same gender
>bisexual: people who have (or desire to have) an intimate relationship with
individuals of the same OR different gender; attraction may be stronger to one
than the other
NOTE: may still identify as gay, heterosexual, etc. OR no label
>sexual orientation: the emotional & sexual attraction one feels for others;
heterosexual (diff sex), homosexual (same sex)
~ umbrella term for (3) categories: [that are fluid (can change over time)
AND based on individuals developmental stage & cultural environment
shapes individual awareness & acceptance of sexuality; leads to
covering living as hetero in identity & behavior, but have secret
how a person self-defines or labels their the gender(s) of a persons
gender(s) a person is attracted to
sexuality; physical & emotional
sexual & romantic partners
-attraction usually (but NOT)
attraction to others ****identities can
-identity isnt always linked to
always aligns with behavior and
behavior (EX saying you are
identity; however, some dont
-a persons sense of their own gender;
hetero, but are a woman and
act on these feelings or find them
do I feel I am male or female?
sleep with women)
until later in life
-EX: queer, gay, lesbian, bi, straight,
-need to learn the specific
polysexual, etc.
sexual behaviors engaged in
-independent of the gender of the
persons current partner (DONT
ASSUME); woman/man can know only
label regardless of who theyre dating
Sexual identity & sexual
-people have own reasons for use of
orientation are separate concepts !
identities EX: recently divorced woman
EX: a transgender person might
may use bi to give recognition to
consider themselves straight, gay,
previous marriage when shes indeed
lesbian, bi, neither, etc. This can evolve
over time
-gender/gender role: traditional behavioral differences between men and
women as defined by a culture in which they live

-sex: biology and anatomy that determine if a person is male, female, or

-gender expression: how one expresses themselves through their
mannerisms, speech patterns, dress, hairstyles, etc (more less
>LGBT Labels
-more often used in mainstream western culture; particularly by those that
are younger as a means to reclaim/ self-empower
-ethnic/racial minorities & youth may not use these terms:
*Indian/Latino cultures: more narrow definition of homosexualityfear of discrimination
*Two-Spirit/Native American: traditional role embodying
male/female spirit; current usage encompasses LGB and T
* On the Down Low/ same-gender loving: different identities
in different cultural circles; tend to be African Americans who
dont want to be part of the gay white culture
>transgender: people who identify and/or express their gender as the opposite of
their biologic birth sex; transsexuals
-no 1 accepted definition----umbrella term for anyone who doesnt
conform to traditional gender roles
***Gender identity
-gender queer/queer: people who define themselves as a gender
terms vary by
outside the either/or construct of male/femalei.e having no gender, or
individual & change
having elements of multiple genders
over time
-cisgender: people who arent transgender; when the identity given at
birth matches what the person feels is their gender (ex: female is a
***always ask the
patient how they would
-How do transgender present themselves to the world?
*some medically/surgically alter their body to affirm their gender
themselves !
identity (may not want to take hormones/go through surgery; may
not have financial resources)
**being transgender
*some change hairstyle & dress
refers to a persons
*some make no changes to their appearance
gender identity &
*most, but not all, will change their given name
expression NOT to the
-gender affirmation (transition): the process by which individuals are
affirmed in their gender identity
>Intersex/Variations of Sexual Development: spectrum of conditions involving
anomalies of sex chromosomes, gonads, reproductive ducts & genitalia (can be
internal, external, or both); people with ambiguous genitalia
-medical community refers this as disorders of sexual development RT
the stigma & confusion of the term intersex
-may only become apparent later on (during puberty) when unexpected
secondary characteristics arise
-sometimes considered to be a gender minority OR transgender person
-unique ethical, medical, and surgical concerns
-infants assigned gender identity at birth eventually designation doesnt

*sometimes genital surgery performed on infants controversial

[many people it should be up to the intersex individual when they
are old enough to make an informed decision]
>Sexual & Gender Minorities
-being increasingly used
-why minority?
*research/epidemiology: important to define population groups
experiencing health disparities (as well as for funding & advocacy)
*policy change: minority group membership important for
achieving protections against discrimination (legal or policy
-LGBT opinion:
*some HATE the term as they believe it further marginalizes rather
than normalizes sexual or gender identities
~ LGBT demographics
-impossible to know actual #s/%s RT stigma (causes underreporting) & exclusion
from government and/or large population-based studies
- [Laumann Study The Social Organization of Sexuality] 1992
=identify as homosexual or bisexual
>women: 1.4% men: 2.8%
Results vary
considerably by
=behavior: same-sex behavior since puberty
>women: 4.3% men: 9.1%
education level
>women: 7.5%
men: 7.7%
Huge diversity in
=higher education; live in urban area; white (men)
>higher identification as LGB
=Hispanic & Asian 2x more likely to report same-sex
desire/attraction compared to black/white men
-2002 National Survey of Family Growth (ages 18-44): done by National Center
for Health Statistics; compiled in-person interview data from nationally
representative sample of males & females
=identify as gay (male) or lesbian (female)
>women: 1.3% men: 2.3%
=identify as bisexual
>women: 2.8% men: 1.8%
=behavior: same sexual contact in the last year
>women (15-44): 4%
men (15-44): 3%
=behavior: had both male and female partners
>women: 3%
men: 1%

-Census Information
*census started to identify same-sex partnerships in 1990

*census 2000 collected information on unmarried same-sex partners

=estimate 600-770,000 same-sex couples living together; about
even between M/F
=same sex households in 93% of all counties; nearly every county
in the country; huge populations along the coasts
=45% live in cities; 40% in suburbs; 13% in non-metro areas
>doesnt include single individuals who are LGBT/ live
with a partner
>non-disclosure by some respondents
>doesnt include self-identified bisexuals who are in
opposite sex relationships
*no reliable data on number of transgender people (in US OR abroad)
*existing estimates on prevalence of transexualism
=1:500-1:2000 MTF (based on individuals who attended a clinic
for medical or surgical attention)
=1 in 11,900 MTF; 1 in 20,400 FTM hormonally and surgically
treated only
=prevalence of transgender people (including those who dont seek
medical intervention) is thought to be much larger [influenced
heavily by definition of transgendered]
~Explain cross-cultural care of LGBT clients
-Construct for Caring: Providing Cross-Cultural Care
*Respect: of what you might hear
*Curiosity: about beliefs, practices, fears & customs (patients usually
happy that youre interested)
*Empathy: put yourself in their position & try to think about why they
are acting in a certain way; dont just dismiss things that are different from
what you like or would expect to hear
Dont Assume:
-Enhancing Cross-Cultural Care
-all patients are
*reflect on your attitudes about sexuality and gender roles
*learn more about the contexts in which LGBT people live & define
-all patients use
traditional labels
*learn more about unique health concerns of LGBT people
-sexual orientation
*becomes comfortable communicating with sexual and gender minorities
based on
through study and practice (role-playing, shadowing)
-sexual identity
based on behavior
(or partners
-sexual behavior
based on sexual
havent changed
since last visit
-bisexual identity is
only a phase
patients to be gay,
bisexual, or lesbian

-Attitudes in Medicine/ Effects of Stigma on Health

*daily stressors caused by stigma & discrimination lead to adverse mental

& physical outcomes
*internalized stigma can cause self-harm & unhealthy risk behaviors
*fearing discrimination by health care providers impacts access to care
****homosexuality removed as mental disorder from DSM in 1973
= gender identity disorder a.k.a gender dysphoria is still as
DSM diagnosis/pathology [transgender]
*there used to be a large percentage of physicians that would discontinue
referrals to a gay pediatrician & those who were uncomfortable with gay
patients leads to non-affirming care
-Communication with Patients
*follow your patients lead (how do they describe themselves/their
*if in doubt, ask patients what terms they prefer. Be curious without
worrying about offending patients
*if you slip up apologize and ask the patient what they prefer. Patients
will appreciate your sincerity and good intentions!
*get to know your patients as a person (jobs, kids, house)
*use inclusive & neutral language EX: do you have a partner? Are you in a
relationship? What do you call your partner?
*appearance alone cannot determine a persons sexual or gender identity!
Only the patients can supply that information
*be open, honest, non-judgmental & ensure patient confidentiality !
*ask about comfort with gender (may be struggling with their identity)
~List strategies for creating a safe and welcoming environment for LGBT clients
-patients assess office for signs of affirmation (will I be accepted here? Does the
staff see other people like me?)posters, reading materials, office images, etc.
***want to signal acceptance, respect, and safety !
Remember the
-NOTE: LGBT at risk for avoiding routine care because theyre unsure if theyll
be accepted OR have been discriminated against
experiences begins
Enhancing Healthcare= Enhancing Human Rights
as soon as the
(treating all patients with care, dignity, and understanding)
phone call is made
-Staff Training
to the office for an
*ensure that staff are comfortable communicating with LGBT patients
apt & continues
(offer short trainings, educational sessions)
*distribute referral list to staff of LGBT-friendly community resources &
*create intake forms that include the full range of sexual & gender identity
and expression
always state info is asked of all patients & used to
ensure comprehensive care; ensure patients can skip questions
*ensure confidentiality on forms
*train staff to use patients preferred names & pronouns (may be different
than what appears on the health insurance forms)
-Patient Relations

*post a patient non-discrimination policy that includes sexual orientation

and gender identity
*provide educational brochures on LGBT health topics
*offer unisex bathrooms
*provide procedures for patients to file & resolve complaints alleging
violations of anti-discrimination policies
*conduct patient outreach & marketing in LGBT venues, websites, and
*promote your practice of LGBT friendliness widely to reach LGBT
clients who do not access LGBT targeted media
*consider listing your practice in the Gay and Lesbian Medical
Associations web-based provider directory (
-Pro-Diversity Workplace Policies
*prohibit discrimination & harassment of LGBT employees
*provide LGBT employees with the same benefits and compensation for
themselves & their families as all other employees
*advertise & recruit for staff positions in LGBT media and organizations
*consider participating in the Health Equality Index an indicator of how
well various healthcare organizations serve LGBT people (currently only
available at
-Building Your Skills
*Knowledge, Attitudes, and Skills !
~Recall approaches to taking a sensitive and thorough sexual history
-to get a comprehensive Hx we need to know sexual behavior, identity, and
attraction and any complexity surrounding these issues
-what is important to know?
*lesbians out to their PCP were more likely to: seek health & preventative
care, ever have a pap test, be a non-smoker, be comfortable discussing
difficult issues
-unique clinical issues to consider
*medical: targeted risk reduction & STI counseling
*emotional: more sensitive physical evaluations, treatments & referrals
~Describe strategies of providing relevant sexual risk reduction counseling
-Risk-Reduction Counseling/Behavioral Change
*patient-centered approaches are best
*assess the patients stage of change
-how ready they are to make change/have they already started
-based on the transtheoretical model of change
=precontemplation (not ready): no intention in 6
mo/unaware of need to change; TEACH
=contemplation (getting ready): start in 6mo; pros=cons
try to limit/reduce cons
=preparation (ready): action in 1mo; seek support & tell
people of plan to change
=action : changed behavior in last 6mo; teach techniques to
keep commitment going

=maintenance: 6mo+; increase awareness of triggers to

unhealthy behavior
*tailor the therapeutic relationship and treatment intervention to the stage
*motivational interviewing: directive, client-centered counseling style
for eliciting behavior change by helping clients to explore and resolve
-Prevention Interventions
*Guide to Community Preventative Services
-provides systematic reviews of interventions for tobacco, alcohol,
cancer, obesity, sexual risk behavior, violence, and more
*Put Prevention Into Practice (PRIP)
-recommends formal systems to implement clinical preventative
*Diffusion of Effective Behavioral Interventions (DEBI)
-provides interventions, training, and technical assistance on
evidence based HIV/STI/Viral Hepatitis prevention programs
(particularly with MSM male have sex with male populations)
*National Cancer Institute Research-Tested Intervention Programs
-provides access to cancer intervention programs and products
~Recall the challenges and limitations in LGBT research
-clinical and public health studies on LGBT health are rare:
*historically, small convenience-samples; limits generalizability of the
*more recently, larger, population-based studies
*lack of funding a major challenge
-some study designs overestimate pathology (i.e studies of alcohol use that recruit
from bars)
-inclusion of sexual orientation measures in government surveys is very recent,
non-routine, and limited in scope
-transgender and bi-sexual specific research is still extremely limited
*bi even more rare as they are often categorized as lesbian or gay
*transsexuals studies mainly based on small convenience samples RT HIV
risk among MtoF who work in sex industry
~List and describe LGBT health disparities
-most systems dont support the collection of sexual orientation & gender identity
in electronic health records
-most focus on gay mens health RT HIV/AIDSstill focused on STIs (need
more comprehensive sexual history, risk reduction, and talks on sexual health)

NOTE: remember
up until the 90s
LGBT health
revolved around
prevention and
treatment of
HIV/AIDs and men

-Healthy People 2020 Disparities:

*LGBT youth are:

=2-3x more likely to attempt suicide

=more likely to be homeless (20-40%)
=higher HIV & STDs
=smoke tobacco or other drugs, drink ETOH
-Institute of Medicine (1999): Lesbian Health: Current Assessment and
Directions for the Future; raised concern about women
=growing evidence that lesbians at higher risk for some health
=lesbians experience financial and cultural barriers to accessing
optimal health
Health promotion
=more research and population-based data needed to better
understand the health and health status of lesbians (of all sexual
goes beyond
and gender minority populations)
knowing the risks
-Major goal of HP2010: to eliminate health disparities among LGBT populations
& how to screen
*eliminate health disparities experienced by different demographic
for themneed
groups including differences that occur by race, income, gender,
good environment
geographic region, disability, and sexual orientation
***sexual orientation included in 29 health objectives; disparities finally
recognized by the federal government
n: multidisciplinary
LGBT Companion Document: makes recommendations for improving
approach for
health outcomes & creating federal policies to reduce disparities
teaching &
*written year after 2010 report
learning centered
*coalition of health professionals & educators led by the Gay & Lesbian
on primary care,
Medical Association---funded by the Health Resources and Services
public health AND
Administration (HRSA)
~Discuss key clinical approaches to health promotion screening to reduce LGBT health
-LGBT Health Concerns [found at the population level]
*cigarette smoking
~LGB have significantly higher smoking rates compared to
heterosexuals (not enough information on the transgender
~LGB adult men and women 2x as likely to smoke as
~38-59% LGB youth smoke vs. 28-35% hetero youth
~bisexual-identified people report equal or higher rates of
smoking than gays and lesbians
~30,000 (estimate) LGB people die each year from
tobacco-related diseases

=why are smoking rates higher?

~coping with stress, discrimination

~among youthseeking social acceptance while coping

with social isolation, loneliness
~bars, clubs have historically been primary social outlets
for LGBT (drinking & smoking) common
~targeted advertising by tobacco industry (Virginia slims &
American spirit---centered on freedom)
=tobacco screening & counseling
~ behavioral approach to tobacco cessation; briefprovider initiated screening and counseling is effective
(Rating: A)
There exists a doseThe 5 As
response relationship
1.) Ask if the patient smokes: do you smoke? How
many cigarettes do you smoke a day? Have you
between the intensity of
ever tried quitting
intervention &
2.) Advise patient to quit
effectiveness HOWEVER
3.) Assess readiness to quit
communication helps
4.) Assist patient in quitting (if ready)
5.) Arrange follow-up visit
=LGBT-specific interventions:;
*alcohol and recreational drug use and abuse
=lesbian and bisexual women: [#s influenced by samples-bars]
~more-alcohol related problems
~heavier alcohol use
~greater lifetime rates of weed, coke, and other drug use
(especially in combo with sex)
=gay & bisexual men
~greater lifetime use of coke, weed, MDMA (ectasy),
methamphetamine, poppers---more extreme recreational
~alcohol use similar to hetero men
=transgender women (MTF)
~HIV risk behaviors study indicate higher IV/injection drug
~IDU rates (12%)
~other illicit drugs (27%)
>not as much info/specific info
=influencing factors
~to cope with stress from victimization; homophobic
attitudes; coming out
~to escape feelings of loneliness, depression
~to help build courage to approach potential partners
~environment: marginalization of LGBT people encourages
socializing at bars & clubs (limited social outlets)
Concurrent use of
=sexual risk behavior
ED drugs & poppers
(various types of
alkyl nitrites
(inhaled)) risk of

******sex UTI of drugs & alcohol is one of most

commonly cited risk factors for HIV---leads to unsafe sex
~increased risk due to:
>disinhibitory effects of some substances
>prolongation of sexual encounters
>decreased pain thresholds= increased mucosal
>possible immunosuppressive effects of drugs
>increased rates of condom failure when on drugs
=subpopulation considerations
~gay and Bi men:
>party/club drugs: MDMA (ectasy), Ketamine,
GHB, poppers, crystal meth
-view as recreational & harmless
-***potentiate risky sex !!!
>circuit parties, raves: high levels of substance
abuse, combining substances (long multi-day
>anabolic steroid use
~lesbian and bi women:
>substance use may not dec with age as much as in
general population
>African-american lesbians more may be more
likely to be heavy drinkers & have drinking
~transgender individuals:
>high rates of injection drug use
>injection hormones from black market
-high risk of HIV and/or hepatitis from
infected needles & health complications
from unregulated products
>sex work linked to substance abuse (MTF)
-drugs for stamina & coping; young trans
women at most risk, more research needed
on FTM
=screening & treatment
~many 12 step fellowship program (AA, NA) have GL or T
groups (B&T groups in Boston K Street)
~some residential and outpatient programs focus on LGBT

*excess weight and obesity (lesbian women)

=lesbians have 2x the odds of being overweight or obese

=eating habits among lesbians may be less healthy some research
suggests that lesbians are less concerned about their physical
=USPSTF recommends that clinicians screen all adult patients for
obesity and offer intensive counseling and behavioral interventions
to promote sustained weight loss for obese adults
*eating disorders/Body image disorders (gay men)
=GB men have higher prevalence rates of eating disorders
SCOFF questionnaire
compared to hetero; higher body dissatisfaction
tested on women for
~same beauty standards as women to attract men
eating disordersno
=younger men (18-29) at higher risk
equivalent tool exists for
=data on LB women is mixed
~same risk as hetero women
~lower risk for lesbians
~higher risk for bisexual women
=no official recommendations for screening or counseling
=when caring for GB men, be aware of possible eating disorders,
know clinical manifestations
*cardiovascular disease
=GB mens risk factors:
~cigarette smoking
~use of club drugs, anabolic steroids (linked to HTN)
~HIV infected individuals use of HAART (RT increased
incidence of dyslipidemia, insulin resistance, DM II)
=LB womens risk factors:
~obesity/being overweight
=Transgender peoples risk factors:
~use of estrogen or testosterone may increase risk but
evidence is indeterminate
=Hypothesized increase in risk for CVD
~stress from concealing sexual orientation or transgender
identity (linked to HTN)
~ experience of discrimination (elevates BP)
=Screening Recommendations
~screen for all relevant risk factors
~follow health promotion guidelines for general population
-screen for BP 18+ years (Rating: A)
-screen for lipid disorders 35+ men and 45+ women
(Rating: A)
-treat abnormal lipids in people at increased risk of
CVD (Rating: A)

-anal cancer: HIV related cancers (gay/bisexual men)

=incidence estimated to be 80x higher in gay men than
=men who have receptive anal intercourse & multiple
partners at highest risk
=HIV-infected GB men at increased risk
=unknown incidence of anal cancer in women who report
anal sex
=recommendation by SOME specialists (none by USPSTF
or CDC due to low rate of anal cancer in general
~anal pap smears every 1-3years in MSM (annually
for HIV+) looking for anal dysplasia & HPV
-risk factors for breast & reproductive cancers (lesbian/bisexual
=cervical cancer
~lesbians get pap tests less frequently than hetero
~lesbians ARE at risk for cervical cancer (hpv can
spread from woman to woman)
~recommendation: follow cervical cancer screening
(Rating: A) and HPV vaccination guidelines;
encourage all patients with under under 65 to be
~NOTE: transgender with cervix should also be
screened routinely (SENSITIVITY)
=breast cancer
~LB 4x less likely to undergo mammography
~LB more risk factors for breast cancer [obesity,
alcohol use, smoking, lower rates of parity]
~cross-gender hormone therapy used by MTF may
increase risk
~transgender FTM with intact breast tissue require
~recommendation: counsel all patients with breasts
to undergo screening mammography (Rating: B)
*violence & trauma
-hate crimes
=definition: an incident perpetrated specifically because of
Although the statistics are
a persons race, ethnicity, religion, gender, disability status,
or sexual orientation
high, they are thought to
=trauma can be physical/emotional and lead to
be underestimated RT fear
psychological or behavioral problems (i.e substance abuse
of being outed; belief
& suicidal behavior)
authorities wont be
=sensitive & effective recognition, intervention, and
sensitive/discriminate; fear
prevention are key!
of retribution from
=common reactions to victimization by hate crimes:

~feeling personally targeted

~crisis of identity
~self blame: internalized homo/bi/transphobia
~loss of trust (including in medical providers)
~feelings of vulnerability
~depression, stress, anxiety
~community members may have trauma responses
even if not directly targeted
=evaluation and management
~victims usually present in ER w/ physical injuries
~evaluate & treat according to trauma protocols
Violence & Trauma: Assessment
~attend to possible sexual victimization
& Management
~patient may fear further victimization and
-during Hx: ask routine screening
humiliation by perpetrator, providers, and/or family
At any time has anyone hit, kicked,
~familiarize self with local statutes/mandatory
choked, threatened, forced
reporting, and resources/referrals
him/herself on you, or touched you
-domestic violence
in a way that was unwanted, hurt, or
=same rate as in heterosexual couples
scared you?
=manifest as: physical, sexual, or psychological abuse (in
-always ask in private !
the form of: economic control, social isolation, threats)
-assure pt they are believed,
=characterized by: abusive partner attempts to exert power
respected, and not to blame for the
and controlincreasingly violent over time
=in same sex-relationship can also include:
-help pt assess risk of future
~threats of outing partner
~persuading victim that leaving relationship is akin
-initiate discussion of safety
to admitting same sex relationship are deviant
~asserting women cannot be violent (denying
*IF ANY YES< follow-up w/
additional assessment to guide
management of situation
~asserting men are violent & therefore domestic
Steps for Recognizing & Treating
violence is expected
Victims of Trauma (use your
=male victims may feel ashamed of fearing partner
R: remember to ask routinely about
~there may not be physical evidence at time of
violence & victimization in own
clinician visit
~chronic pain, sleep disorders, anxiety,
A: ask directly about violence,
depression---all possible effects of domestic
interview in private always
D: document information about
~recommendation: routine injury about current and
past domestic violence for all patients
-sexual assault
=findings vary, more information needed
=lifetime victimization 2-3x higher than non LGB
=LB women have higher rates of childhood sexual abuse
=3-10.5% men experience rape/assault (may be higher)
=GB male victims may underreport RT shame and/or
uncertainty due to belief it only happens to women

=MTF sex workers at increased risk

=Victim Concerns:
~Lesbian and Bi women
>(by man): pregnancy, STIs
>(by woman) law enforcement & health
You dont
providers may not believe woman could
need a
vagina to
Bi Men
be raped!
>additional shame because men arent
typically victims
>lack of resources specific to men
kits can
~Sex Workers
still be
>***fear of legal consequences (prostitution
is illegal)
>concern of not being recognized as
sexually assaulted RT nature of sex work
>fear of discrimination when disclose
gender of perpetrator or own gender
>lack of response by law enforcement
*sexually transmitted infections & HIV, viral hepatitis
-Sexual health & function:
=ask about sexual health in an open-minded way (free of
judgments & assumptions)
Remember, most STIs are
=sexuality, desire, and intimacy should be approached on
the patients terms using patient vocabulary (i.e sexual
asymptomatic; patients
activity, desire, function, satisfaction)
are tested based on their
risk behaviors &
=At risk For:
~syphilis; HIV/AIDS; Gonorrhea; Chlamydia/LGV
(rare strain); viral hepatitis (A & B); Herpes
Simplex; HPV (urethral, anal); MRSA
=CDC Recommendations
~routinely ask sexually active MSM about STI
symptoms, maintain a low threshold for diagnostic
testing of symptomatic patients
~regardless of symptoms or condom use, sexually
Counseling: The 5
active MSM should be tested at least annually for:
>HIV; syphilis; hep B; urethral
Partnerswho? How
gonorrhea/chlamydia if had insertive
intercourse in past year; rectal
Prevention of Prgnancy
gonorrhea/chlamydia if receptive anal
Protection from STDs
intercourse; pharyngeal gonorrhea if had
Practiceskind of sex?
receptive oral
Condom use?
-consider HSV-2 if infection status
Past Hx of STDs

~more frequent STI screening (3-6months) if

multiple or anonymous partners and/or drug use
~vaccination for hep A & B recommended
~HPV vaccine in men being evaluated
~NOTE: USPSTF takes a more conservative view
of STI screening compared to CDC---I rating for
symptomatic chlamydia & gonorrhea, A for
-STIs among WSW
=research limited
=can transmit:
~**bacterial vaginosis; chlamydia; HSV-1; HPV;
=things to keep in mind:
~large #s of WSW have Hx of/ have sex with men
>these women more at risk
=take a thorough sexual history & screen accordingly
=perform pap tests on all women
-STIs: Transgender findings
=research limited
~HIV infection is high (particularly among MTF
African Americans)averaged prevalence 1/3, AAs
at 56%
~many dont know they are infected
~FTM studies very rare
-Routine HIV testing: New CDC Guidelines
=NOTE: many states still dont allow testing without
counseling and specific informed consent
~routine HIV testing for all patients (13-64),
regardless of risk
~patient notified testing will occur (pt can opt-out)
~separate written testing should not be required,
general informed consent is sufficient
~pre-test prevention counseling should not be
~persons at high risk for HIV should be screened
AT LEAST annually

*mental health disorders [depression, anxiety, suicide]

-Research Findings
=homosexuality is NOT a mental illness ( normal variant
of human behavior)
=LGB people at increased risk for: [most likely to seek
mental health care]
~anxiety & panic attacks
~suicidal behavior (particularly adolescents)
~eating & body image disorders (men)
=transgender MTF at high risk for:
~suicidal thoughts, attempts
-Why a higher prevalence?
=possibly associated w/ stigma, negative societal attitudes
(minority stress theory)
~stigma increases barriers to social supports &
other supports that help people to cope with stress,
depression, and anxiety [social isolation/lack of
social supports]
=internalized homophobia, social learning to reject ones
basic personal preferencesassociated w/ eating disorders,
high-risk sexual activity, substance abuse, suicide
=42% of Americans believe homosexuality SHOULD NOT
be accepted by society
=heterosexuals view bisexuals highly unfavorably (right
above IV drug users)
~T & B feel isolated from G & L community
=constant concealment of true identity covering
=victimization by (or fear of) verbal or physical attack
=problems with self acceptance
-Assessment: [in primary care setting]
=ask patient about most pressing mental health concerns
=assess patients degree of comfort with sexual orientation
and gender identity [key factor of mental health]
=Social Factors
~social isolation
~social supports (friends, family, mentors)
~current & historic trauma (i.e victimization by hate
crimes, discriminatory acts)---vulnerable to abuse
=Coping Styles
~how do you deal with your problems?
>do you talk about them?
>are you able to do something to
yourself during times of

>are you able to confront the factors that

cause you stress?
-Comorbidities & Cofactors
=Gay and bisexual men
~methamphetamine and/or anabolic steroid use
(associated w/ depression, mania, psychosis)
~depression could lead to unsafe sex (counsel!)
~depression/anxiety affect HIV med adherence
****Ask about recreational drug use!!!
=Lesbian and Bisexual women
~as with hetero: premenstrual dysmorphic disorder
~mood disorders RT pregnancy, fertility meds
=Biologic/somatic treatment: same as general population
NOTE: the effects
=psychotherapeutic treatment
~refer to APA Guidelines for Psychotherapy with
of psychotropic
LGB clients
drugs on
~Gay-affirmative therapy: affirms rather than
pathologies LGB identity; addresses internalized
people on
homophobia; can use in combination with other
hormones has
-recognized LGB sexual orientation as
normal variant of human condition
-*****widely accepted
~conversion or reparative therapy:
contraindicated; no evidence of efficacy; medical
association advise STRONGLY AGAINST
-view LGB as a pathology to be fixed
=community supports
~referrals to LGBT sensitive therapists or focused
~support groups for LGBT (online/in person)
NOTE: for B&T: when possible refer to
specific support groups
-The Multiple Influences on Health
*health is not just about the individual (genes and behavior)
Social-ecologic theory *health is influenced by many external, environmental factors
of health: suggests that
-interpersonal relationships
individual behavior &
-institutional/organizational factors: can marry, cant get health
genes arent the only
factors that determine a
-community factors: stigmashame & secrecyanxiety &
persons health status
-public policies: doctor visits
EX: community norms;
*as w/ any person, health status & access to appropriate healthcare can be
institutional & public
affected by socioeconomic status, stress, early life experiences, social
policies; interpersonal
exclusion, field of work, social support, addiction, nutrition, etc.

-A Patient-Centered Approach
*LGBT people have same health concerns as general population, as well
as some additional risk factors
*important to treat the whole person, not a collection of risk factors
*important to understand that LGBT life issues are similar, but also can
present unique challenges:
-coming out as LGBT
-relationships: marriage/long-term partnership
-children: reproduction, adoption
-parenting and families
-legal rights as parents and partners
-Guidelines for Health Promotion
*guidelines developed by many sources, including government sources,
professional specialty societies
*sources not always consistent with each other
*In the US, the most rigorous evidence-based analyses, which rate
interventions, are published regularly by the US Preventative Services
Task Force (USPSTF) of HHS
-Evidence Ratings: recommendation ratings based on the strength
of evidence & magnitude of net benefit (benefits minus harms)
A: strongly recommends that clinicians provide (the
service) to eligible patients
B: recommends that clinicians provide (the service) to
eligible patients
C: makes no recommendation for or against routine
provision of (the services)
D: recommends against routinely providing (the service) to
asymptomatic patients
I: concludes that the evidence is insufficient to recommend
for or against routinely providing (the services)

Chapter 27

As a school nurse, you know the leading reason cited as the cause of school violence is:
use of violence to handle disputes. Correct

an unhappy home life.


overly protective parental situations.


poor communication with authority figures.

Adolescents and children increasingly use violence to settle disputes. Children are often not
taught peaceful ways of resolving differences and learn by what they observe at home, on
television, and in movies. Consequently, schools have become a common site for violence. The
reasons for violence are complicated and multilayered, but the most common reason cited is use
of violence to handle disputes.
REF: Page 553

Chronic stress characterizes the lives of people living with domestic violence. As the
community health nurse, you recognize which of the following as a long-term effect of violence?
Spontaneous disclosure of abuse to health care provider

Not complaining of physical symptoms


Having disturbed eating patterns, but sleeping well


Suffering chronic fatigue and tension Correct

When subject to repeated abuse, the victim experiences a variety of responses, including shock,
denial, confusion, withdrawal, psychological numbing, and fear. He or she lives in anticipatory
terror and experiences chronic fatigue and tension, disturbed sleeping and eating patterns, and
vague gastrointestinal and genitourinary complaints. The other options are not symptoms of
chronic violence.
REF: Page 549

Child maltreatment cases are most frequently attributed to:

sexual abuse.

physical abuse.


psychological abuse.


neglect. Correct

Seventy-one percent of all child maltreatment cases are classified as neglect. Approximately 9%
of child abuse cases are sexual abuse. Physical abuse accounts for 16% of all child maltreatment
cases. Emotional abuse accounts for 7% of child maltreatment cases.
REF: Page 550


Which of the following clients is at highest risk for elder abuse?

A 75-year-old nursing home client who is alert and has osteoporosis

A 70-year-old client being with dementia cared for at home Correct


A 65-year-old client who has just had a hip replacement


A 72-year-old client on a rehabilitation unit with bilateral above-the-knee

The most likely victims of elder abuse are individuals 70 years of age and older who are in poor
physical or mental health and dependent on others for physical or financial support; these clients
are often confused and depressed. REF: Page 552

As a visiting community health nurse, you must take precautions to avoid unsafe
situations. To avoid putting yourself in danger, you would do which of the following?
If you enter a house where a violent act is occurring, call 911 and wait inside
for the police to arrive.
Expect the client to control angry family members.

Repeat the reason for your visit and stay and continue your task.


Do not enter a home if you hear sounds of fighting. Correct

When approaching a home, as a community health nurse, you should notice the environment,
animals, fences, activities, possible indicators of crime, and places you could go for assistance if
necessary. Walk with confidence and maintain a professional attitude. Listen for signs of fighting
before knocking. If you hear sounds of fighting, leave. Do not enter a home if you suspect an
unsafe situation. REF: Page 556

Which of the following statements about homicide in the United States is false?
Most homicides are caused by stabbings. Correct

Homicide is the third leading cause of death for 1- to 4-year-old children.


Blacks are more likely to be the victims of homicide than whites.


Over 50% of homicide victims are killed by someone they knew.

Most homicides are caused by firearms. The other statements are true. REF: Page 547

Nurses, including public health nurses, are at increased risk for workplace violence. Risk
factors for violence in the workplace include all of the following except:
working in pairs. Correct

access to medications.


increased number of mentally ill patients.


inadequate security.

Risk factors for violence in the workplace include increasing number of acute and chronically
mentally ill patients, working alone, availability of drugs at worksite, low staffing levels, poorly
lit parking areas and corridors, long waits for service, inadequate security, increasing number of
substance abusers, and access to firearms.
REF: Page 553

Which of the following individuals should be evaluated for intimate partner violence
(IPV)? (Select all that apply.)
The 24-year-old white woman with low self-esteem Correct

The 33 year-old black divorced single mother


The 18-year-old Hispanic gay man with multiple sexual partners Correct


The 50-year-old Asian man who is addicted to methamphetamine Correct


The 48-year-old black woman who was recently hospitalized for

depression Correct
IPV crosses all ethnic, racial, socioeconomic, and educational lines. Risk factors for victims of
IPV include low self-esteem, poverty, risky sexual behavior, eating disorders or depression,
substance abuse, and trust and relationship issues.
REF: Page 547

Which of the following assessment findings by the community health nurse would
suggest that an elderly client may be the survivor of physical abuse by a caregiver? (Select all
that apply.)
The client has a laceration on her forehead that was sutured. Correct

The client has a flat affect.


The client has bruises on her forearms in various stages of healing. Correct


The client withdraws from soft touch.


The client is not sexually active but has a diagnosis of Chlamydia. Correct

Signs of physical abuse include bruises, lacerations, fractures, dislocations, untreated injuries in
various stages of healing, and STDs in sexually inactive clients. The other options are not
indications of physical abuse.
REF: Page 553

The school nurse is interviewing a student who has been assaulted by another student.
Both students proclaim to be gang members. The nurse understands the reasons most youth give
for joining a gang include the following: (Select all that apply.)
financial gain.

sense of belonging. Correct


peer pressure. Correct


relative is in a gang.


need for respect. Correct

Reasons that young people give for joining gangs include the belief that gangs will protect them,
peer pressure, the need for respect, and a sense of belonging.
REF: Page 554

Class 12: Population Settings (31) Chapters 29,30,31

~Define forensic nursing and its subspecialties, including SANE and correctional nursing
>forensic nursing: application of nursing process to public or legal proceedings
and the application of forensic healthcare in the scientific investigation of trauma
and/or death related to abuse, violence, criminal activity, liability, or accidents
Advanced practice
-screening/ assessment & collection of evidence (includes evidence
forensic nurse: assist
dispersement sheet/catalog)
in developing &
-documentation and expert witness testimony (for victims AND
implementing protocols
& systems to help
-may also be involved with: paternity disputes, work-place injuries,
victims OR
malpractice, vehicle accidents, food/drug tampering, medical
perpetrators of violent
occurrences, aid in
-Sexual Assault Nurse Examiner (SANE): certified
research & policy
changes, Develop &
supervise systems of

~conduct thorough examination AFTER physician assesses

& stabilizes victim (if patient deemed unstable prior)
~crisis intervention referral, health risks & interventions
-Death Investigator: manner of death [conditions in which the
cause of death occurred] and cause of death [events that initiated
Evaluates death
the progression of events ending in death]
scene from
~Nurse Coroner: responsible for ensuring that appropriate
holistic nursing
measures are taken to perform death investigations &
certify death certificates
>in areas where coroner is elected
-Legal Nurse Consultants & Nurse Attorneys [specialize nursing
knowledge and expertise respect to interaction of law & health]
~evaluate, analyze, and render informed opinions on the
delivery of health care & its outcomes
~hired by attorneys & insurers to review medical records as
well as testify
-(Clinical) Forensic Nurse Examiner
1) Emergency & Critical care: living OR dead patients
somehow involved with the legal system; find tangible &
transient evidence
2) Organ/Tissue Donation & Transplantation: federal law
dictates next of kin must be notified; investigations may
occur; work directly with the harvesting companies
3) Care of Vulnerable Populations (children, elders,
disabled) **most vulnerable to abuse & neglect***
4) Forensic Psychiatric Nurse: testimony with respect to
mental health issue or personality disorder (competency
evaluation, violence potential, capacity to formulate intent,
probation, racial/cultural factors in crime, jury selection,
sexual predator screening, expert witness testimony)
~must determine intent and/or diminished capacity
5) Correctional Nursing:
~Be Safe. Follow Protocol: must constantly
negotiate safety (personal) w/ adequate care
~Outline the major health issues found among prison populations
>chronic and communicable disease: screen for HIV; Hep (A, B, C); TB
(including strain-resistant---RT overcrowding, poor ventilation, and rapid inmate
movement in & out of jail)
>women (including pregnant & women with children): victims of IPV [rape or in
relationships]; substance abuse
=not enough care RT the extent of the abuse these women endure
-need regular GYNO exams
-counseling for parenting
-need substance abuse treatment
=Health Care of Pregnant Women in State Prisons

-women of childbearing age are the fastest growing segment of US

incarcerated population
-6-9% women pregnant when they enter correctional facilities
-continued use of shackles & restraints w/ pregnant women in
prisons; FBI ended shackling in 2008
>pregnant women in many state prisons receive
substandard care
>advocacy is needed on the state level to promote
legislation regarding restraints and shackles
>impact on policy:
~legislation in RI
~contact w/ all State Nurses Associations to
Advocate for Legislation in their states
~position papers
~amnesty international
>adolescents who are increasingly incarcerated as adult: [unique developmental
needs arent being met]
-5x more likely to be sexually assaulted in prison
-3x more likely to be beaten by prison guards
-50% more likely to be assaulted with a weapon
-8x more likely than juveniles imprisoned to commit suicide
>criminalization of the mentally ill: schizophrenia, bipolar affective disorder,
major depressive disorder, personality disorder
=access to mental health treatment including psych med is a RIGHT for
prison inmates including paroled and released prisoners
-correctional facility provides meds until community support
established; state assists
-many dangerous/violent acts by people w/ severe mental illness
are the result of inappropriate/inadequate care!
>constitutional right to refusal medications/treatment: legal & ethical issues RT
individual rights, states interest and value of treatment; obliged to care even if
inmate refuses treatment or doesnt adhere to treatment process
=court decision by judicial hearing is required to forcibly treat a
nondangerous, incompetent offender to render competence at trial
=they can refuse treatment, but you still have to treat the consequences
EX: refuse retrovirals for HIVhave to treat decline in health status

Chapter 31

Forensic nursing is best defined as which of the following?

A field of legal nursing in which the nurse works with or for lawyers

A field of correctional nursing in which the nurse works with inmates


Investigational nursing in which the nurse works with law



A link among the health care system, the investigative process, and

courts of law Correct

Although the other options are somewhat correct, the correct choice includes all three areas in
which forensic nursing is involved: (1) health care, (2) investigation, and (3) the court system.
REF: Pages 619-620


A 16-year-old young woman arrives at the local emergency department (ED) early
Sunday morning and states, "I was on a date last night, and the last thing I remember was eating
dinner with my boyfriend." She comments that she woke up in her bed with her clothes "messed
up" and states, "I just don't feel right down there" as she points to her genital area. She appears
medically stable. Which of the following health care providers would be most appropriate to
conduct the physical examination?
An experienced obstetrical nurse because the patient could be

A SANE (sexual assault nurse examiner) Correct


The physician on call in the ED department


An emergency nurse

Although all of the health care providers listed are able to complete a physical examination on
this patient, the SANE would be most appropriate because of the clues that a date rape may have
occurred. The SANE is trained specifically to collect evidence in such a case, which is why the
emergency nurse would not be most appropriate. The stem includes a statement that the patient is
medically stable; therefore, the SANE should be chosen over the physician.
REF: Page 620

A 71-year-old man is brought to the emergency department by his daughter and

states that he has fallen and appears to have a broken arm. He is alert and oriented and walks
alone without difficulty. Which nursing intervention is most appropriate after he is seen and
treated by the physician?
Talk with the daughter about nursing home placement for the patient.

Discuss the dietary needs and regimen with patient and family.


Review the patient's current medications.


Talk with the patient alone and question the possibility of elder

abuse. Correct
Elder abuse is underdiagnosed and underreported. The nurse must assess the possibility of elder
abuse occurring. The other interventions are not indicated based on the information provided.
REF: Page 624

It is vital that the forensic psychiatric nurse be knowledgeable about mental

illnesses and personality disorders because:
the nurse will be diagnosing many of the illnesses.

the nurse will work in psychiatric facilities.


the nurse may be an expert witness in court. Correct


the nurse will be identifying new cases.

The nurse will not be diagnosing or identifying illnesses; that is a physician's role. Although the
nurse may be working in a psychiatric facility, the best reason for being knowledgeable about
these illnesses is because the forensic psychiatric nurse may be called to be an expert witness in
REF: Page 625

Which of the following nursing interventions is the most appropriate as an initial

intervention for a prison inmate?
Manage a chronic illness through needed education.

Administer the routine medication ordered.


Complete the medical history and physical assessment. Correct


Test for HIV and tuberculosis.

Although all of the interventions are important, the most appropriate initial intervention is to
complete the history and assessment. The nursing process is followed by using assessment first,
and it is also at this time when medical issues are found for the inmate.
REF: Page 626

Joanne, a 37-year-old incarcerated woman, is reluctant to seek medical attention

for a routine Pap smear. The correctional nurse knows which of the following?
This is usual; women do not seek health services as much as men in
this setting.

Other factors may be influencing Joanne's hesitancy in seeking

medical attention. Correct

Joanne is delaying the visit because she probably has a sexually
transmitted disease or HIV.
Because she is not sexually active, Joanne is not in need of a Pap
smear at this time.
Other factors, such as having experienced trauma or victimization, may cause female inmates to
delay or never seek medical attention regarding female services. The other statements are
REF: Page 627


Which of the following is true of adolescents who have been convicted and
incarcerated in adult facilities rather than in a juvenile facility?
They are less likely to be sexually assaulted.

They are usually not attacked by other inmates.


They are more likely to commit suicide. Correct


They are less likely to be diagnosed with a mental illness.

Adolescents in an adult correctional facility are more likely to be sexually assaulted, attacked by
other inmates, or to threaten suicide than adolescents in a juvenile facility. REF: Page 627

Joe is released from the correctional facility to return to the community. The
facility is required to do which of the following?
Help with job placement.

Provide his psychotropic medications until he sees his

physician. Correct
Assist in finding housing.
Provide health care for the first year out of prison.

The correctional facility is only required to provide the psychotropic medications when returning
to the community until they are under care of their physician. REF: Page 628

Which of the following actions is inappropriate for a correctional nurse when

testifying in court?
Looking the jurors in the eye when answering questions

Asking the attorney to repeat a question when not understood


Practicing saying difficult medical terms before the court date


Interrupting when necessary to verbalize correct medical

information Correct
The correctional nurse should never interrupt when testifying in court. The other actions are
appropriate. REF: Page 623

All of the following factors contribute to the infection spread rate in a correctional
setting: (Select all that apply.)
overcrowding. Correct


poor ventilation. Correct


rapid movement of inmates in and out of jail. Correct


the number of minorities in the setting.


an increase in undocumented immigrants in the correctional system.

Correct Feedback:
Overcrowding, poor ventilation, and rapid movement of inmates in and out of jail contribute to
the rates of an infection spreading. The number of minorities or undocumented immigrants in a
correctional setting has not been reported as a factor in infection spread rates. REF: Page 626

~Identify and discuss (8) components of a comprehensive school health program

>link between academic success & health (physical, mental, developmental)
-lack of regular medical care (rely on ER or clinics); poverty;
absenteeism/ presenteeism
-general student population, mainstreamed special education
students, severely chronically ill or developmentally delayed
>school health services: coordinated system that ensures a continuum of care
from school to home to community.
=CDC Youth Risk Behavior System--purposes
-every 2 years from selected high school students in US
-monitors progress towards 2020 goals & other program indicators
-determine prevalence of health risk behaviors
-assess whether behaviors inc, dec, or stay same
-examine co-occurrence of health risk behaviors
-provide comparable data among sub-populations of youth
(national, state, territorial, tribal, & local)
=Healthy People 2020 (Targeted Areas of edu. to middle/high schoolers)
-health education: alcohol & drug use; injury & violence; tobacco
use; nutrition (obesity & eating disorders); physical activity; sexual
behaviors; tattoos/body piercings; dental health; mental illness
1) comprehend concepts RT health promotion & disease
prevention to enhance health
2) analyze influence of family, peers, culture, media,
technology, and other factors on health behaviors
3) demonstrate ability to access valid information, products
& services to enhance health
4) demonstrate the ability to use interpersonal
communication skills to enhance health and avoid/reduce
health risks

5) demonstrate the ability to use decision-making skills to

enhance health
6) demonstrate the ability to use goal-setting skills to
enhance health
7) demonstrate the ability to practice health-enhancing
behaviors to avoid or reduce health risks
8) demonstrate the ability to advocate for personal, family,
and community health

~*****Recognize common health concerns of school-age children and associated health

>health services (preventative !)
*urban areas at increased risk RT increased risk of disease
outbreak RT non-immunized
~limiting vaccine preventable deaths (VPDs)
~all states require proof before entrance into school (some
religion/philosophical beliefs against are accepted)
=health screenings
~vision & hearing; before school entrance & at least once in
elementary, middle, and high school (set by district)
>snellen chart
>done to prevent amblyopia which can lead to
blindness--allowed to make referrals prn
>girls: 10 & 12, boys: 13 OR 14
-BP: periodic !
~Early & Periodic Screening, Diagnostic, and Treatment Service
(EPSDT): for those ineligible for Medicaid, but cant afford
insurance under 21yo
-include health education & screening
>screening: comprehensive health & developmental
Hx; physical; immunizations & lab tests; lead tox
-usually performed by public health offices, but also
community centers (clinics) and schools
=emergency care
~ emergency care plan for school staff to facilitate quickly
=Care of the Ill Child: acute & chronic illnesses

=medication administration
**only meds considered necessary are administered; requires
consent to talk to PCP & proper container/storage---ADHD meds
most common
~legal for kids to self-carry asthma meds (with permission slip)
=children with special health needs
~Public Law 99-142: gives ALL students the right to public
education in the least restrictive environment possible regardless of
mental or physical disabilities
-requires school nurses to screen/identify children in need
of special education & related services & develop an
interdisciplinary IEP for educational goals & services
-Individualized health care plan: for those in need of
continuous nursing management while at school
~Individuals w/ Disabilities Education (IDEA) act of 1990:
enhanced opportunities for children previously served in acute care
& long-term care settings to have access to public education
=student records: FERPA, HIPAA
~ Family Educational Rights & Privacy Act: protects student
education & health records
=delegation of tasks
~***responsibility for assessment, diagnosis, goal setting, &
evaluation may NEVER be delegated
~nurse gives education, written procedures & ongoing
supervision/evaluation of caregivers if delegated
=nutrition: eating disorders; obesity; hunger/malnutrition
~nurse must: identify nutritional problems; counsel; make referrals
~female athlete traid: amenorrhea, eating disorder, osteoporosis
>counseling, psychological & social services [maltreatment, abuse, neglect, etc]
>healthy school environment: security, safety, and environmental health
>school staff & educators: occupational health & safety
=exercise & nutrition workshops; BP screenings; wt management
>family and community involvement
=families at risk index [those w/ 4+ of those below considered high risk]
~child not living with 2 parents
~household head is school dropout
~family income is below poverty line
~child is living w/ parent(s) w/o steady, full-time income
~family receiving welfare
~child is w/o health insurance
~Recall standards of school nursing practice
>definition: specialized practice of professional nursing that advances the wellbeing, academic success, and lifelong achievement & health of students
~facilitate positive student responses to normal development

~promote health and safety (including healthy environment)

~intervene w/ actual & potential health problems
~provide case management services
~actively collaborate w/ others to build student & family capacity for
adaptation, self-management, self-advocacy, and learning
>school-based health centers: work in collaboration with the school nurse;
prevents fragmented & duplicated care
-nutrition education; social work
-general & sports physicals; injury treatment; immunizations
-prescriptions & med dispensing; management of chronic illness
-lab services; pregnancy testing; OBGYN
>examples at each level of prevention (table 29-3)
>ethics: confidentiality & obligation to report
Chapter 29

Healthy People 2020 addresses all of the following goals for children and adolescents
physical activity.

sex education and HIV prevention.


smoking prevention.


cardiovascular accidents, stroke, and diabetes. Correct

Healthy People 2020 does not address cardiovascular accidents, stroke, or diabetes in its
objectives for children and adolescents. The other options are addressed. REF: Page 586

A comprehensive school health program should include all of the following except:
health promotion for staff and health education.

health services and health education.


physical examinations and comprehensive health history. Correct


nutrition services and counseling.

The eight components of a comprehensive school health program are health education, physical
education, health services, nutrition services, counseling, psychological and social services,
healthy school environment, health promotion for staff and family, and community involvement.
Physical examinations and comprehensive health history are not included. REF: Page 586

A week before finals, a school nurse assesses a 15-year-old girl complaining of vague
symptoms. All of the following symptoms or behaviors should result in an immediate request for
parent or guardian conference and referral to a physician for further evaluation except:


problems eating or sleeping.


problems making decisions.


frequent requests for a visit to the school nurse. Correct


inability to concentrate.

Problems eating or sleeping, use of alcohol or other substances, problems making decisions,
persistent angry or hostile feelings, inability to concentrate, increased boredom, frequent
headaches or ailments, and inconsistent school attendance are all warning signs of stress. The
nurse should be aware that these symptoms can negatively affect an adolescent's mental and
physical health, and the student should be screened for depression and suicide REF: Page 594


A priority health education topic for school-age children is which of the following?
Schoolyard safety Correct

Motor vehicle safety


Sports safety


Immunization schedules

Schoolyard injury accounts for 200,000 injuries yearly and is one of the greatest health concerns
for elementary children. Motor vehicle safety should be included in programs for adolescents
who are beginning to drive. Sports safety is particularly important among adolescents as
participation in sports continues to grow, especially among girls. Immunization schedules are an
important topic of education for parents of younger children and babies.
REF: Page 587

A 6-year-old child fails a routine vision screening on a Snellen chart at a school-based

health center. The appropriate action by the nurse is to do which of the following?
Rescreen the child in the following year.

Refer the child to an eye specialist. Correct


Use a Rosenbaum chart instead of a Snellen chart.


Do an internal ophthalmologic examination.

The role of the nurse in a school-based health center includes vision, hearing, and scoliosis
screening and first-aid and medication administration, but the nurse should refer the individual to
an appropriate specialist for diagnosis and treatment.
REF: Page 586

A school nurse knows that under the Family Educational Rights and Privacy Act, a
student's health record can be released:
if the student is not a minor.

in an emergency. Correct


to educators not involved in the student's education.


without the student's or guardian's permission.

School health records are confidential, and without permission, releasing them is unethical and
improper unless in an emergency.
REF: Page 592


A 10-year-old boy visits the nurse complaining of a headache and nausea. The nurse
recognizes the boy from an earlier conference with a teacher about the boy's declining school
performance. The nurse has been concerned because the boy's father and mother are recently
divorced, and his mother works nights. An appropriate nursing intervention would be to
investigate the boy's eligibility for which of the following?
The Nutritional Education and Training Program (NET)

Youth Risk Behavior Surveillance System


Adult and Child Protective Services


Federally funded breakfast and lunch program Correct

The school nurse has several federal resources available to assist children in need. The nurse
must be able to recognize children and families that may be eligible for assistance. Options A, B,

and C are not appropriate referrals for a child in the specified situation. NET focuses on healthy
nutritional choices and health promotion and disease prevention topics in school and child care
settings. The Youth Risk Behavior Surveillance System identifies and trends youth risk behavior.
Adult and Child Protective Services assesses and protects children from abuse. REF: Page 593

A school nurse evaluates the implementation of health promotion in a high school staff.
Which of the following indicates a need for more education?
flyer advertising an ice cream and pizza party for the student awards
program Correct
Condoms being provided in all restrooms of the school

A decrease in missed days at school


The discontinuation of the availability of soft drinks and candy in vending

machines during school instructional hours

School nurses facilitate positive student responses to normal development; promote health and
safety, including a healthy environment; intervene with actual and potential health problems;
provide case management services; and actively collaborate with others to build student and
family capacity for adaptation, self-management, self-advocacy, and learning. REF: Page 596

While verifying compliance with immunization requirements, a school nurse notices that
three students from the same family have not completed their immunizations. How should the
nurse address this problem?
Discuss with the principal the lack of immunizations

Expel the children from school.


Contact the parents and educate them about the immunization


requirements. Correct
Pull the students from class and immunize them.

All states require proof of current immunization status or evidence of immunity unless there is an
exception (religious, moral belief, or medical contraindication). It is the nurse's responsibility to
assess the situation and educate the family. The nurse's responsibility is not to expel the students
or immunize them herself.
REF: Pages 589-590

A goal set by Healthy People 2020 includes education to middle, junior, and senior high
school students in priority areas. These areas include: (Select all that apply.)
lack of physical activity. Correct

poor nutrition. Correct


alcohol and drug use. Correct


poor organizational skills.


injury and violence. Correct

An objective of Healthy People 2020 sets a goal that middle, junior, and senior high schools
provide health education courses in priority areas. Centers for Disease Control and Prevention
(CDC) (2012a) identified six high-risk behaviors that need to be targeted in health education
courses. The six behaviors identified by the CDC include: (1) alcohol and drug use, (2) injury
and violence (including suicide), (3) tobacco use, (4) poor nutrition, (5) lack of physical activity,
and (6) sexual behavior that results in sexually transmitted diseases or unwanted pregnancies.
REF: Page 586

~Describe the role & responsibilities of the occupational health nurse in a

corporate/workplace setting

>occupational health nursing: specialty practice that focuses on prevention of

adverse health effects from occupational & environmental hazards through health
& safety programs/services to workers, worker populations, & community groups
-promotion and restoration of health
-prevention of illness & injury
BS; Work experience
=protection of work-related and environmental hazards
community health,
~roles & responsibilities:
critical care,
-INDEPENDENT PRACTICE (standard protocols)
emergency nursing
-case management
Advanced Practice:
-counseling & crisis intervention
-health promotion & risk reduction
Board certification
-legal & regulatory compliance
-worker and workplace hazard detection
1.) Clinical Practice
Based on (3)
2.) Case Management
3.) Work force, workplace, and the environment
4.) Regulatory/legislative compliance
proficient, expert
5.) Management, business, and leadership
6.) Health promotion & disease prevention
7.) Research
8.) Professionalism
~Recognize the dynamics of todays workforce
>key points:
~each occupation & job title is unique (w/ own unique risks of hazards)
~***key to safe workplace, healthy employees, and clean environment:
eliminate or minimize exposure of people to hazards in the environment
=young workers at increased risk of work-related injury RT limited
job knowledge, training, and skills; inexperience/imperceptions of
danger may lead to risk-taking behaviors
=older workers at increase risk RT performance of work above
physical capacity & delayed manifestation of negative sequelae
from past exposures; healing also takes longer
= RN workforce age averages on the rise
=increasing amount of women in workforce, many also
parents/caregivers of elders
=women at increased risk for musculoskeletal injury RT stature &
physiology (strength)
=women make up large % of lower-paying service sector
occupations, as well as 94% of the RNs
=work related reproductive issues:

-pregnancy (birth defects and/or delayed development)

-breast-feeding (toxins through milk)
-child overall health & normal development (work clothes
work in the home exposure children)
=minorities 28% of workforce (mainly Hispanic men, and AA
women); jobs are lower paying & high-risk
=minority populations on the rise
=occupationally-related health literacy: capacity to obtain, process,
& understand basic health info to stay safe and healthy on the job
-14% of US population below basic literacy (3rd-5th grade)
~****ever changing demographic characteristics of workforce (the
challenge of occupational health nursing)
=evolving nature of work
-organization of work
>quantity/quality work: longer workdays,
extended commute times & foreign locations; mandatory
overtime; 24/7 operations requiring shift work; endless
Effects of
wireless communications intruding on personal time; lean
Work on
manufacturing= more work, fewer people; flexible
scheduling; job sharing; telecommuting
>employment relationship: contractual (onsite,
day laborers, and/or outsourced)
>work schedules: shift work hours & # of
consecutive work days + method of paying for work;
constant light, dim light at night, or simulated chronic jet
lag (rotating shifts) is disruptive to circadian rhythms and
increases risks for tumor development (breast ca) & dec
melatonin production
~substantial increase in risk at night &
consecutive work days
~quotas and/or pay by the piece work also
drastically increases risk (people push
themselves & bypass safety protocols)

=dynamics of workplace
-cooperate culture [culture determines nature of work]

>ISO 14001 Certification: international
standards organization environmental
certification---voluntary program of
excellence to demonstrate a strong
commitment to continuous improvement
-(formal) hierarchy of company
*pyramidal (top-down decision making)
*flat/wide (distributed/de-centralized decisionmaking)
-informal/undocumented organizational structure
with pressure to advocate and/or abdicate safety,
health, and environmental (SHE)-based practices
~union presence alters decision making
-measurable SHE-related performance outcomes:
-historical record of OSHA inspections
-injury/illness rates
-worker compensation claims
-environmentally-related citations
-**most important SHE management system is
institutionally-based change management (i.e the processes
& procedures by which a companys managers and
employees make decisions, accept and implement change,
and incorporate the mantra of continuous improvement)
~Describe the influence of work on health and health on work
>healthy worker effect
~workers usually exhibit lower overall death rates than the general pop
because severely ill and disabled people are excluded from employment
~any illness or injury can temporarily or permanently impact an
individuals capacity to work, thus threatening a loss of economic security
& his/her way of life
>vulnerable populations
~(have a) disproportional burden: exposure & disease
susceptibility to
harm; more
fragile, less
=socioeconomic disadvantage
resilient and/or
less resourceful,
=fetus [most vulnerable], infants, children
the more
>Vocational Rehabilitation Act/Americans with Disabilities Act (ADA): grants
qualified employees the right to workplace accommodations for their permanent

~NOTE: vulnerable populationincreased risk for injury/illness or

exacerbation of existing conditions
~chronic health problems (people have, but still work): CVD & HTN;
DM; cancer; HIV; asthma; environmental allergies; mental illness (ex:
~1:12 workers are impaired
>US Equal Employment Opportunity Commission (EEOC): federal agency that
administers and enforces civil rights laws against workplace discrimination
~Family and Medical Leave Act (FMLA):
-granted up to 12 weeks unpaid, job-protected leave per year where
group health benefits are maintained
Reasons for leave:
=birth/care of newborn child (or pregnancy complications)
=adoption/foster care child placement
=care for immediate family member (spouse, child, parent)
with serious health condition
=medical leave when employee unable to work RT serious
>each work day 13
health condition
people die on the job
Who is eligible?
=applies to all public agencies; public & private elementary
and secondary schools; companies with 50+ employees
medical treatment,
(within 75 miles)
restricted duty, lost time
=**worked 12 months (1,250+ hours)
~Workers Compensation: state mandated, state funded; income
replacement & pay for health care services for workers who sustain a
work-related injury, temporary or permanent disability
~Identify potential workplace hazards
>workplace walkthrough: focuses on the interactive relationship of workplace,
work, and workpractices
~workplace assessment:
1.) Guided tour of physical layout and facilities for familiarization
Workplace: physical
of product & processes
structure/function; building
Review of hazardous materials, hazardous waste streams, and
systems; surrounding
safety data sheets (SDS)
Direct observations of workplace activities
Work: product; process:
4.) Review of work-related injury/illness logs and OSHA
materials, equipment
inspections, work compensation records, company policies and
Workpractices: job tasks;
operating procedures; work
habits; support systems
5.) Interviews with managers, supervisors, workers, SHE staff,
members of safety committee and emergency response teams
>categories of agents (hazards, stressors)
~Chemical: properties & behaviors [corrosive, flammable, etc]


~Physical: ionizing and non-ionizing radiation [electricity, sound/noise,

temp, pressure]
~Mechanical: movement; back injuries; ergonomic; chronic not trauma
~Emerging: nanoparticles
>New Products and Technologies
~Toxic Substances Control Act (TSCA)
-700 to 1,500 new chemicals and products annually
-emerging technologies [in vitro toxicity testing of nanoparticles]
=nanoparticles in commerce, pharmaceuticals, and
>The Alphabet Soup of Chemical Names
sodium chloride (NaCl)
~Similar, But Different dioxane vs. 1,4-dioxane
~Starts With Same Name, But Different
~Chemical Abstract Service Number (CAS) [ex: 123-91-1] similar to
chemicals social security number
>[Material] Safety Data Sheet (SDS) [MSDS]
~**possess SDS for each and every chemical per MANUFACTURER
even if same chemical; copies of SDS: in store room, remotely and with
fire marshal; available online electronically; up to date copy 3-5 years
Categories [What Sheet Covers]
1.) Product info: identifier (name), manufacturer & suppliers
names, addresses, and emergency #s
2.) Hazardous ingredients
3.) Physical data
4.) Fire/explosion hazard data
5.) Reactivity data: chemical (in)stability of product &
substances it may react with
6.) Toxicology properties: health effects
7.) Preventative measures
8.) First aid measures
9.) Preparation Information: who responsible for preparation &
date of MSDS

~Use SDS Information to Make Informed Decisions

=Specific Chemicals (%) TLV
-Physical Characteristics
-Health Effects
Static Control Mat Cleaner
Static Control Mat Cleaner

2-Butoxyethanol (7%) 20ppm
Ethanolamine (5%) 3ppm
Potassium Hydroxide (1%)


Isopropyl Alcohol (25%) 400ppm



Physical Characteristics


Health Effects
Acute: Irritant
Chronic: Toxic

Acute: Irritant
Chronic: None




-90% water
-2-Butoxyethanol: butyl cellosolve: glycol ether
-**skin notation
>Labels and Placards [Global Harmonization Standards; National Fire Protection
Agency (NFPA)]
~Hazard Ratings
4.) Extreme
3.) Serious
2.) Moderate
1.) Slight
0.) Minimal

~Not All Hazards are Observable, but They Are Measurable

Halving thickness:
amount of material to
block half the gamma
rays passing through
NOTE: any material
will block, you just
have to have enough

=Time [want to limit time exposed to the source; maximum time
to spend in presence of radiation a.k.a stay time]
=Distance [doubling distance away reduces exposure to
(inverse square law)]
=Shielding (1/2) [placement of an absorber between the person
and the radiation; interaction within the shield, not
=Dose Units
(Xray) 1 rad= 1 rem= 10mSv
(Neutron) 1 rad= 5-20rem= 50-200mSv
(Alpha) 1 rad= 20 rem= 200mSv
~Radiation Protection/Limiting Exposures [understanding the math]
-radiation usually specified as a rate (mrem/hour)
-dose: total amount of radiation absorbed relative to its
Radiation Absorbed dose
(Rad): absorbed dose;
biological effect
amount of energy absorbed
-dose rate: rate radiation is absorbed (mrem per hour or
into a material (any type &
mrad per hour)limiting time, limits radiation dose
any material) physical dose
-***dose= time x dose rate [radiation dose received]
Roentgen Equivalent Man
-time= dose/dose rate [time person can spend in a specific
(Rem): equivalent dose;
area without exceeding allowable dose limit]
relates absorbed dose in
human tissue to the effective
-reduction in dose depends on the type of radiation emitted
biological damage of radiation
and physical size of the source itself [larger particle,
[rad x quality factor
quicker reactivity, shorter distance it can travel]
(q)/weighting factor]
-line source: dose reduces directly with distance
Sievert (Sv):
R1 D1 =R2 D2 [inverse square law]
International unit
>R1 (initial rate/dose rate) R2 (new rate)
>D1 (initial distance) D2 (new distance)
-exposure reduction by distance factor
>(larger distance/smaller distance)^2
~multiply by the exposure rate if moving
toward source, divide if moving away
~Recognize the interactive relationship of agents, exposures, and health outcomes in the
context of worker, work, and workplace
>Workplace Standards

NOTE: not all radiation has

the same biological effect,
even for the same amount of
absorbed dose

~Occupational Safety & Health Administration (OSHA)

~Environmental Protection Agency (EPA)
Assure safe and
=U.S. federal government which was created for the purpose of
healthful working
protecting human health and the environment by writing and
conditions for
enforcing regulations based on laws passed by Congress.
working men and
~Department of Transportation (DOT)
women by setting
= ensuring a fast, safe, efficient, accessible and
and enforcing
convenient transportation system that meets our vital national
standards and by
interests and enhances the quality of life of the American people
providing training,
~Nuclear Regulatory Program (NRC)
=ensure the safe use of radioactive materials for beneficial civilian
purposes while protecting people and the environment
education and
=regulates commercial nuclear power plants and other uses of
nuclear materials, such as in nuclear medicine, through licensing,
inspection and enforcement of its requirements
~National Institute of Occupational Safety & Health (NIOSH)
>federal agency; conducts research & makes
recommendations for prevention of work injury and illness
=Registry of Toxic Effects of Chemical Substances (RTECs)
>database of toxicity information compiled from the open
scientific literature without reference to the validity or
usefulness of the studies reported
~US Dept. Health & Human Resources
=National Toxicity Program (NTP)
>inter-agency program run by the United States
Department of Health and Human Services to coordinate,
evaluate, and report on toxicology within public agencies
~International Agency for Research on Cancer (IARC)
>conduct and coordinate research into the causes of cancer
>collects and publishes surveillance data regarding the
occurrence of cancer worldwide
=IARC Monographs
>series on the carcinogenic risks to humans posed by a
variety of agents, mixtures and exposures
~American Conference of Governmental Industrial Hygienists (ACGIH)
> professional association of industrial hygienists and
practitioners of related professions
>establishes and recommends occupational exposure limits
for chemical substances and physical agents
> average exposure on the basis of a 8h/day, 40h/week
work schedule; level at which a worker can be exposed for
a working lifetime without adverse health effects
>Risk Characterization
~risk assessment: the process of identifying and evaluating adverse events
that could occur in defined scenarios, focusing on health impacts that

might result from being exposed to a particular agent or from working,

living, or visiting a particular environment
=based on probability theory & employs combo of empirical
evidence & specific assumptions
=characterize the probability & severity of risk to adverse
outcome(s) as a result of exposures to these hazards
-calculate overall probability & severity of risk; estimate
the response level required
-determining acceptable level of risk is combo of
scientific evidence & political responsibility
-there is overarching belief in ability to recover (humans &
the environment) if not immediately, then in future
>result: risks are small, they may be considered
insignificant and acceptable [or of low(er) priority]

>Sometimes the Boss Makes Getting the Work Done Safely Almost Impossible
~Systems Problems
~Corporate Safety Culture
>Ergonomic Hazards in Healthcare
~No Manual Lifting
~Paradigmatic Change in Corporate Safety Culture
~List the hierarchy of strategies used to eliminate and/or reduce occupational injuries &
>The Process
~plan intervention(s) by collaborating with stakeholders and utilizing
hierarchal based control strategies
~implement plan strategies with stakeholders participation
~evaluate effects of intervention strategies and modify plan accordingly
=evidence-based; leads to cost-effectiveness & safety
=metric benchmarks defined by OEHN [Occupational & Envir.
Health Network] in terms of levels & types of activities & program
successes, not merely absence of disease/ injury
=OEHN makes case for SHE [safety, health & environment] to
business management continuously

=SHE-related cost savings & cost avoidance impacts corporate

profitability directly
~change management
=OEHN repeats process periodically & when changes introduced
into work environment (i.e new products, technologies, processes,
and/or workpractices)
=***ideal scenario is culture of precaution within highest level
of company [board of directors, stakeholders, etc]
>Hierarchy of Control Strategies
=fundamental method of protecting workers
Easiest during
1.) Elimination
2.) Substitution
tal stage, or else
3.) Engineering Controls (Isolation, Ventilation)remove hazard from
may require MAJOR
source before contact with the worker
4.) Administrative Controls (Job Rotation, Workpractice Specification,
Education & Training)
5.) Personal Protective Equipment
Frequently used with
existing processes
where hazards are not
particularly well
controlled; costly to

~Recall examples of occupational health programs at each level of prevention

>primary: health promotion [environmental change & strive for optimal health] &
disease prevention [recognition of health risk, disease, or hazard]
~one-on-one interactions: assessment & treatment of episodic
illness/injury, health surveillance
~aggregate intervention strategies: ex: weight & cholesterol reduction,
ergonomics training, smoking cessation
~performing walk throughs & maintain communications

>secondary: early diagnosis, early treatment interventions, and attempts to limit

disability; focus: ID health needs, health problems, and employees at risk

~pre-placement eval: before employment at new company or new job

=baseline exam; medical Hx, occupational health hx, & physical
assessment that targets type of work employee will be performing
=medical tests to determine specific organ functions that may be
affected by exposure to existing agents in workplace [must comply
with ADA]
~periodic eval: regular intervals (annual, biannual)
~job transfer eval:
=based on specific protocols; careful documentation of health
changescomplies with OSHA regulations & NIOSH
>tertiary: rehabilitation & restoration to optimal level of functioning
=case management; negotiation of workplace accommodations;
counseling & support for chronic disease/disability

Chapter 30

Occupational health nursing is best described as a specialty practice that focuses on:


providing comprehensive health care service to workers and their



promoting, preventing, and restoring health within the context of a

safe and healthy environment. Correct

preventing adverse effects from occupational and environmental
hazards at the workplace.
planning, implementing, and evaluating safety programs for workers
at the workplace.
Occupational health nursing is a specialty practice that focuses on promoting, preventing, and
restoring health within the context of a safe and healthy environment. The other options limit the
scope of the practice role.
REF: Page 601

There was an increase in the number and voice of occupational health nurses
during the years of 1938 to 1943. All of the following occurrences explain the rationale for this
change except:
the U.S. Department of Health and Human Services mandated
occupational health nurses be hired for industrial settings that employed more than 350
people. Correct
a national association for the specialty of occupational health nursing
was created.

more women entered the workforce, changing the demographics of

the workplace.


the government demanded health services for defense contract

The focus of health care for employees changed as a result of the two world wars, which changed
the demographics of the workforce and increased the need for health services for employees, and
the birth of the first national association for this specialty. The federal government never required
companies to employ occupational health nurses.
REF: Page 603

Which of the following activities implemented by an occupational health nurse

would be considered primary prevention?
Annual blood pressure, cholesterol, and diabetes screenings

Negotiation with an employer for an onsite fitness program for all

employees Correct


Scheduling a mobile mammography van to see employees older than

age 40 and their wives
Overseeing a weight loss competition among workers who are

considered to be morbidly obese

Promoting physical activity is an example of health promotion activities at the primary
prevention level. Blood pressure, diabetes, and cholesterol screenings and mammograms are all
secondary prevention strategies aimed at early diagnosis and early treatment. Weight loss
programs for the severely obese would be considered tertiary prevention.
REF: Pages 607-608

Which of the following occupational health nursing interventions would be

appropriate secondary prevention strategies?
Arrange for the collection of baseline liver function tests if the

employee will be working with a chemical known to cause liver toxicity.

Provide vision, blood pressure, hearing, and cancer screenings on an
annual basis.


Coordinate periodic evaluations to ensure workers are placed in the

safest worksite setting.

All of the above Correct
Secondary prevention strategies are aimed at early diagnosis, early treatment interventions, and
attempts to prevent disability. All three choices focus on identification of health needs, health
problems, and employees at risk.
REF: Page 609

Which of the following occupational health nursing interventions is an

appropriate tertiary level strategy?
Negotiation of workplace accommodation for a worker with a
disability Correct
Work with an employer to build an onsite fitness center

Providing health-screening programs to detect conditions that could

aggravate the disability of worker

Get automated external defibrillators AEDs for the workplace and
train workers on how to use them
On a tertiary level, the occupational health nurse plays a key role in the rehabilitation of a worker
to the optimal level of functioning and includes such strategies as negotiation of workplace
accommodation and counseling and support for workers who will continue to be affected by

chronic disease. The other options are primary level strategies.

REF: Page 610

Which of the following actions of the occupational health nurse is NOT mandated
by state or federal regulations?
Maintaining confidentiality of medical records

Reporting accusations of sexual harassment to local police Correct


Recording and reporting occupational injuries and illnesses


Providing personal protective equipment training

Maintaining confidentiality of medical records, reporting occupational injuries and illnesses, and
providing personal protective equipment training are all mandated by law. Sexual harassment
allegations are routinely reported to administrative officials.
REF: Page 606


All of the following are challenges currently facing occupational health nursing
practice except:
a younger workforce. Correct

escalating health care cost.


increased number of women and minorities in the workforce.


influence of a competitive international marketplace.

Escalating health care cost, increased women and minorities in the workforce, and a competitive
international marketplace all contribute to the challenges of occupational health nursing practice.
In addition, an aging workforce also presents a challenge.
REF: Page 617

An essential strategy to deal with the complexities of the workplace and

workforce is for the occupational health nurse to do which of the following?
Recognize the need to work as a part of an interdisciplinary
team. Correct

Seek legal counsel to stay informed of the legislative mandates

influencing the workforce.


Engage in political action in order to have input into the revision of

the Healthy People 2020 document.
Participate in program planning to develop a model to ensure

advanced education for all workers.

As workplaces have continued to change over the past few decades, the role of the occupational
health nurse had become even more diversified and complex. It is essential that the occupational
health nurse functions as a part of an interdisciplinary team collaborating with workers,
employers, and other professionals to identify health needs, prioritize interventions, develop and
implement programs, and evaluate services delivered.
REF: Page 615

Legislation passed in the early 1970s that requires employers to provide a place of
employment free from recognized hazards to the employees is correctly referred to as the:
Americans with Disabilities Act.

Occupational Safety and Health Act. Correct


Workers' Compensation Act.


Occupational Health and Safety Administration.

The Occupational Safety and Health Act was enacted in 1970. The general clause of the Act
states that employers must "furnish a place of employment free from recognized hazards that are
causing or likely to cause death or serious physical harm to employees." The Act also identified
the role of various government agencies such as the Occupational Safety and Health
Administration under the jurisdiction of the Department of Labor.
REF: Page 613


Important historical events leading to the development of occupational health

nursing as a specialty practice include which of the following? (Select all that apply.)
Lillian Wald, the first public health nurse, established the Visiting

Nurse Service of New York.

Betty Moulder was employed by a group of companies to care for


coal miners and their families. Correct

Ada Mayo Stewart was hired by the Vermont Marble Company to


care for the company's workers. Correct

A nursing service was established for employees of the Frederick
Loeser department store in Brooklyn, New York. Correct


Anna B. Duncan was employed by the John Wanamaker Company to

visit sick employees at home. Correct

Occupational health nursing dates to the late 1800s with the employment of Betty Moulder by a
coal mining company and Ada Mayo Stewart by a marble company. After that, the Fredrick
Loeser department store hired a nursing service for employees and Anna B. Duncan was
employed by the John Wanamaker Company to visit sick employees at home. Lillian Wald was
instrumental in the development of public health nursing.
REF: Page 602