Chapter 14 - Assessing

While assessing an older adult client's upper back, the nurse notes round, raised red spots along the client's back. The client's daughter says, "Oh, that is just cupping." What action should the nurse take?

Ask about the practice of cupping

A nurse is conducting an ethnographic interview with a client. Which step would the nurse do first?

Ask an open-ended, general question

When talking with a client, the nurse notes that the client keeps backing up. What would be the most appropriate response?

Ask the client about personal space preferences.

Which nursing action displays linguistic competence?

Learning pertinent words and phrases in the client's language

The nurse is preparing to administer prescribed medication to a client who is Native American/First Nations. The nurse enters the room and observes a shaman performing a healing ritual for the client. What action would be the most appropriate by the nurse?

Leave the room and return when the shaman is finished.

Initial Assessment

comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient's health status, ability to manage one's own health care, and need for nursing, and to plan individualized, holistic health care for the patient

Observation

conscious and deliberate use of the five senses to gather data

Stages of Culture Shock

1. confusion 2. small victories 3. honeymoon 4. irritation and anger 5. resolution

Which nursing intervention reflects culturally appropriate care when addressing a client?

"Good morning, Mr. Smith. I am your nurse, John."

primary source

an account of an event created by someone who took part in or witnessed the event

A nurse is conducting a cultural assessment of a client. Which person would the nurse identify as the expert?

client

The nurse is caring for a client who is postoperative 24 hours from an appendectomy. The client is hesitant to get out of bed. How should the nurse respond?

"Can you describe what you are feeling when you try to move?"

The nurse is caring for a client who is admitted for hypertension (HTN). The nurse notes that the client has not been eating the food provided, and family members have brought in homemade food. What would be the best response by the nurse?

"Can you tell me what foods you prefer to eat and what your family is bringing you?"

When teaching a group of unlicensed assistive personnel (UAP) about race, which statement by a UAP requires intervention by the nurse?

"People with common physical features share the same culture."

The nurse has just attended a seminar on concepts of cultural diversity. Which statement made by the nurse would require further education?

"Culture cannot be influenced, and you are born with your culture."

A client admitted to the hospital asks the nurse whether it would be acceptable for the client to bring food from home to eat that better meets the client's cultural preferences. What is the nurse's best response?

"Food from home is fine as long as it does not violate hospital policy or contradict the prescribed diet."

The nurse is teaching a black client about common health conditions. Which statement by the client most directly addresses a health problem with an increased incidence in this population group?

"It is important to monitor my blood pressure."

A nurse is demonstrating ethnocentrism. Which statement would reflect this concept?

"My Russian heritage is superior to all others."

The nurse is collecting the health history of a client and notes the client is apprehensive in answering questions. The client states, "My spiritual healer will be here soon." What is the best response by the nurse?

"We can wait until your spiritual healer arrives and work together to answer these questions."

A nurse is admitting a client to the unit. Which cultural question is most appropriate?

"What are your dietary needs and preferences?"

The unlicensed assistive personnel reports to the nurse that the client is refusing to eat the food on the meal tray. The nurse observes the client eating the food brought in by family members. How should the nurse respond?

"What type of food did your family prepare for you, and does it have special meaning?"

A client is admitted to the health care facility with hypoglycemia. After the client is stable, the nurse discovers that the client has not had the prescribed medicines. The client believes that eating saffron will keep blood sugar under control. What is the most appropriate response by the nurse?

"Why don't you take the medicines, too, and benefit from both?"

A client has been admitted to the unit for chest pain. A nurse told the family that they could not be with the client. The family became very upset, and now the client wants to leave. What is the most culturally appropriate response by the charge nurse?

"Would you feel more comfortable with your family with you?"

The nurse is caring for a client who practices Catholicism and was newly diagnosed with cancer. The client states, "God is punishing me for my past sins." How should the nurse respond?

"You sound upset. Would like you to talk about it?"

When describing the concept of ethnicity, which statement would be most appropriate to use?

Ethnicity allows people to define themselves and others to define them.

A nurse caring for clients of different cultures in a hospital setting attempts to make eye contact with clients when performing the initial assessment. What assumption might the nurse make based on common cultural practices?

A Muslim-Arab woman refuses to make eye contact with her male nurse. Assumption: She is being modest.

inference

A conclusion reached on the basis of evidence and reasoning The judgement you reach about a cue

When providing culturally competent care to clients, a nurse understands that cultural competence involves which characteristics? Select all that apply.

A process that requires life-long learning A commitment to promoting health equity Knowledge of influences on the clients' beliefs Awareness of one's own influences on responses

Which behavior by the nurse demonstrates cultural blindness?

Administering antibiotics to a child whose parents do not believe in Western medicine

The nurse admits a client to the critical care unit to rule out a myocardial infarction. The client has several family members in the waiting room. Which nursing action is most appropriate?

Assess the client's beliefs about family support during hospitalization.

When completing a transcultural assessment of communication, which assessment by the nurse is most appropriate?

Assessment of eye contact, personal space, and social taboos

A new resident in a long-term care facility who was having difficulty adapting to the routine has begun participating in activities on a daily basis. Which stage of culture shock is this resident displaying?

Beginning resolution

time-lapsed assessment

an assessment that is scheduled to compare a patient's current status to baseline data obtained earlier

A nurse interviews a client to determine the client's health beliefs and behaviors. The nurse uses this information for which aspects of care? Select all that apply.

Conducting an assessment Developing client outcomes Providing client education

A staff nurse meets with the charge nurse and is reporting that all the new nurses are leaving messes on the unit. The staff nurse states, "These youngsters think they can waltz in here and get our jobs." What is this nurse demonstrating?

Cultural conflict

The client is admitted to the hospital with a ruptured ovarian cyst. The client has expressed that it is very important that the spouse be present to receive all medical information. Using the concepts of culturally competent care, which is the best response?

Document the client's request in the nursing care plan.

When an American client states, "I only want an American doctor," the client is expressing:

ethnocentrism

What is the most critical factor in the very first assessment by the nurse?

First impressions

Which area is typically included in a cultural assessment?

Food preferences

What does cluster analysis do?

Identifies patterns and points to specific problems

Madeline Leininger's transcultural nursing theory

Incorporating the client's request for complementary treatment therapy

Which teaching statement best exemplifies cultural competence in relation to time for the American culture?

It is important to be on time for your health care appointment.

A nurse is providing care to a client and has enlisted the help of a trained interpreter to assist in communicating with the client. Which action would the nurse do first?

Meet with the interpreter alone before a combined meeting with the client.

Inferences may be validated in multiple ways:

Physical examination clarifying statement sharing your inferences with a team member checking your finding with research reports comparing cues to your knowledge based on normal findings checking cue consistency

Which stereotypical ideas about older adult clients does the nurse associate with the concept of ageism?

Physically impaired Burdensome to family Uninterested in intimacy

Which statement best conveys the relationship between race and ethnicity?

Race denotes physical characteristics, while ethnicity is rooted in a common heritage.

In addition to understanding the culture of the client, what other actions are required to provide culturally competent nursing care? Select all that apply.

Recognizing one's own culture and biases Recognizing the culture of the healthcare system

The nurse overhears a colleague state, "All people from that client's country are rude." What is the appropriate nursing response?

Respond by saying, "Stereotypes keep us from accepting others as unique individuals."

A client has recently immigrated and is exhibiting symptoms of culture shock. The client reports feeling unaccepted in the new culture. The client states, "I can't do anything right here." What is the priority nursing diagnosis?

Situational low self-esteem related to culture shock and feelings of fear and incompetence

Which statement by the nurse demonstrates ethnocentrism?

That client needs to learn that pain is best managed with traditional medications like morphine."

The community health nurse is developing a workshop for a group of Native American/First Nation clients. Which topic should the nurse teach?

alcohol use disorder

database

all the pertinent patient information that enables a comprehensive and effective plan of care to be designed and implemented

A nurse convinces a client who is a Jehovah's Witness that receiving blood products is more important than the legalistic components of religion. What client reaction may be expected following this mandated change?

The client states, "I feel like I abandoned my religion."

A client is seeking care at the local clinic. The nurse is completing a cultural assessment. Which scenario would demonstrate cultural assimilation?

The client's child learned the dominant lanuguage as a second language.

ANA Standards of Practice: Standard 1 Assessment

The registered nurse collects comprehensive data pertinent to the patient's health or the situation.

Which nursing actions are appropriate when collecting a health history for a client whose primary language differs from the dominant language? Select all that apply.

Use the facility telephonic interpreting system. Have a bilingual nurse assist with the health history. Request assistance from a certified interpreter.

minimum data set

a standard established by health care institutions that specifies the information that must be collected from every patient

Sources of Data

a) Primary = the CLIENT b) Secondary = all other sources which does NOT COME FROM THE client (family, patient record, assessment technology, health care professionals, literature)

What is the priority assessment for the nurse when developing a plan of care for a client living in poverty?

access to care

validation

act of confirming or verifying

PCAM is an ___________ oriented tool

action

What does the entire nursing process rest upon?

assessment and ongoing assessment

focused assessment

assessment conducted to assess a specific problem; focuses on pertinent history and body regions

nursing history

assessment of the patient by interview to identify the patient's health status, strengths, health problems, health risks, and need for nursing care

A parent informs the nurse that immunizations are against the parent's cultural and religious beliefs and the parent does not want the child to receive immunizations. The nurse proceeds to inform the parent that the child will be consistently ill and will not be allowed to start school unless immunized. The nurse also informs the parent that the nurse had all of the nurse's own children vaccinated. The nurse's behavior an example of:

cultural imposition

A client who immigrated from another coutnry informs the nurse of dietary requests. The nurse responds to the special dietary needs by stating, "You are now living here, and you should try to start eating those foods common to our diet." This inappropriate response is an example of:

cultural imposition.

A nurse is caring for a 79-year-old client who is new to a long-term care facility. Previously, the client lived in a rural community in a household consisting of the client and an adult child. The child is no longer able to care for the client. The client appears disoriented and reports being bothered by the "bright lights and constant activity." The nurse appropriately documents what condition in the chart?

culture shock

The emergency department nurse is caring for a client injured in a motor vehicle collision. The client recently immigrated to the country. The nurse should implement interventions aimed at addressing which issue?

culture shock

When reviewing the chart of an older adult client, the nurse notes that the client identifies as Asian. The nurse realizes the client is referring to which ancestral and cultural factor?

ethnicity

The use of one's culture as a cultural standard is known as:

ethnocentrism

Data

information

subjective data

information perceived only by the affected person

objective data

information that is seen, heard, felt, or smelled by an observer; signs

cue

significant information that is helpful in making decisions

A newly hired young nurse overheard the charge nurse talking with an older nurse on the unit. The charge nurse said, "All these young nurses think they can come in late and leave early." What cultural factor can the new nurse assess from this conversation?

stereotyping

A preconceived and untested belief about an individual or group of individuals is:

stereotyping

Physical Assessment

systematic examination of the patient for objective data to better define the patient's condition and to help the nurse in planning care, usually performed in a head-to-toe format; a collection of objective data about changes in the patient's body systems

What should a nurse do if there is any data discrepancy or conflict?

the nurse must investigate further, gathering focused information to support, confirm, or negate the suspicions.

patient-centered assessment

tool for assessing patient complexity using the social determinants of health that often explain why patients with the same or similar health conditions differ in their ability to manage their health and in their outcomes

emergency assessment

type of rapid focused assessment conducted when addressing a life-threatening or unstable situation

Preparing for data collection

- Establish Assessment priorities - don't ask same questions again - Health Orientation - identify potential health risks - Developmental Stage - Culture - Need for nursing

To promote sound clinical reasoning, your nursing assessments should be

- Purposeful - Prioritized - Complete - Systematic - Factual and accurate - Relevant - Recorded in a standard manner

Methods of Data Collection

1) Observation 2) Interviews 3) Comprehensive or focused physical examination 4) Diagnostic and laboratory reports 5) Collaboration

A nurse is providing care to a client from a culture different from the nurse's own. The nurse is having difficulty relating to the client. What intervention by the nurse is most appropriate?

Ask the client how the client wants to be treated based on the client's values and beliefs.

The nurse is caring for a terminally ill client who immigrated from Mexico. Which nursing intervention regarding spiritual care is appropriate?

Ask the client if a spiritual leader is desired.

What cultural considerations might the nurse expect of those living in poverty? Select all that apply.

Large numbers in the culture need government assistance. Living conditions are often crowded, with several families living together. Low levels of self-respect and feelings of worthlessness are common. Family structures are often unstable and abusive.

Variable that can negatively influence an interview

anxiety pain language previous negative experiences unrealistic expectations

The nurse is caring for a client who perceives time differently. What action should the nurse take for this client?

maintain flexibility in the schedule

Review of Systems (ROS)

physical examination of all body systems in a systematic manner as part of the nursing assessment

interview

planned communication for a specific purpose (e.g., data collection)

A client refuses to allow any healthcare worker of Asian descent to provide care. This client is demonstrating what practice?

racism

A nurse is working with a culturally diverse group of clients. The nurse understands that cultural norms:

require an individualized approach by the nurse.

nursing assessments focus on the patients________ to health problems

response

Types of Nursing Assessments

1. Initial Assessment. 2. Focused Assessment. 3. Emergency Assessment. 4. Time-lapsed Assessment.

The nurse is assessing an older adult who immigrated at the age of 3 years. The client speaks the dominant language and lives in a neighborhood with many households from the country of origin. Which action by the nurse is most appropriate?

Ask the client about special cultural beliefs or practices.

Which scenario is an example of cultural competence in nursing?

Attending a conference for cultural diversity

A client tells the nurse that the only thing that helps the client sleep is a glass of warm milk. The nurse caring for the client insists that this cultural practice is a myth and tries to convince the client that reading a book would be better. What is the nurse demonstrating?

ethnocentrism

A nurse is caring for a postoperative client after knee arthroplasty. The nurse plans to help the client ambulate but is aware that the client may feel threatened by physical closeness because the client is from a culture that tends to prefer more personal space when interacting with others. What would be the most appropriate nursing action?

Explain the purpose and need for assistance during ambulation.

HELP (structuring of assessment)

H = Help: Observe the first signs patient may need help. Look for signs of distress (pallor, pain, labored breathing). E = Environmental equipment: Look for safety hazards; ensure that all equipment is working (IVs, oxygen, catheter). L = Look: Examine patient thoroughly. P = People: Who are the people in the room? What are they doing?