Exam 2 PrepU Quizzes

Choose the nursing statement that would best reflect the final component of the "Ask-Tell-Ask-Close" technique of communication and demonstration. ○ "Is this a good time for me to show you how to irrigate your colostomy?" ○ "Here are the written directions for changing your dressings." ○ "Do you understand how to take your blood pressure?" ○ "Can you repeat for me the information I just reviewed about weighing food portions?"

"Can you repeat for me the information I just reviewed about weighing food portions?" Explanation: The last component to the "Ask-Tell-Ask-Close" communication technique is "Close the Loop." This component recommends asking the patient to restate the information as the patient understands it.

The mother of two young children has been diagnosed with HIV and expresses fear of dying. How should the nurse best respond to the client? ○ "Would you like me to have the chaplain come speak with you?" ○ "You'll learn much about the promise of a cure for HIV." ○ "Can you tell me what concerns you most about dying?" ○ "You need to maintain hope because you may live for several years."

"Can you tell me what concerns you most about dying?" Explanation: The nurse can help the client verbalize feelings and identify resources for support. The nurse should respond with an open-ended question to help the client to identify fears about being diagnosed with a life-threatening chronic illness. Immediate deferral to spiritual care is not a substitute for engaging with the patient. The nurse should attempt to foster hope, but not in a way that downplays the client's expressed fears.

Which statement by the client indicates the client's experiential readiness to learn? ○ "Do you have a video about my disease? I don't like to read." ○ "Can we take a minute to pray before learning about my treatment plan?" ○ "Now that I am more comfortable, I am ready to learn about pain management techniques." ○ "I understand that I have diabetes and will need to learn how to administer my daily insulin injections."

"Do you have a video about my disease? I don't like to read." Explanation: Experiential readiness refers to past experiences that influence a client's ability to learn. Emotional readiness refers to the client's acceptance of an existing illness or the threat of an illness and its influence on the ability to learn. Physical readiness refers to the client's ability to cope with physical problems and focus attention on learning.

A client and his spouse are in the client's hospital room. The spouse says to the nurse, "I looked up one of the new drugs on the Internet, gabapentin. It said it is for seizures. My husband has never had a seizure." Which would be a therapeutic response by the nurse? ○ "Gabapentin can also be used for leg pain associated with diabetes." ○ "I will get you a current drug handbook; you can look it up." ○ "I cannot discuss the drugs the physician has ordered. You need to call her to ask that question." ○ "Why are you asking? Your husband's physician has probably told him the reason."

"Gabapentin can also be used for leg pain associated with diabetes." Explanation: The therapeutic response by the nurse is to provide education related to the spouse's question. By providing education the nurse is facilitating informed decision making on part of the client and the family. Teaching is an independent function of the nurse. It is certainly within the responsibility of the nurse to discuss the method of action of the client's medications with the spouse. This is part of patient teaching and if the client is aware, it is not a HIPAA violation.

The nurse determines that a client would benefit from changing a lifestyle factor that adversely affects health. Which statement indicates to the nurse that the client takes responsibility for the health problem created by the lifestyle factor? ○ "My health was predetermined by my parents through genetics." ○ "No one in my family developed lung cancer from smoking, so why should I?" ○ "Having a cocktail every night after work has contributed to my liver disease." ○ "I get enough exercise by taking care of the house and cooking my family dinner."

"Having a cocktail every night after work has contributed to my liver disease." Explanation: Taking responsibility for oneself is the key to successful health promotion. The concept of self-responsibility, personal accountability for one's actions or behavior, is based on the understanding that the individual controls his or her life. Each person alone must make the choices that determine whether he or she lives a healthy lifestyle. Stating that drinking alcohol every night contributed to the development of liver disease demonstrates self-responsibility for the health problem. Stating that health was predetermined through genetics indicates a lack of responsibility for health. Stating that no one in the family developed lung cancer from smoking indicates a lack of responsibility for health. Stating that enough exercise is obtained through completing household chores indicates a lack of understanding about exercise and does not demonstrate taking personal responsibility for ensuring adequate physical activity guidelines are met.

The nurse is caring for a client who is newly diagnosed with diabetes. Which statement indicates to the nurse that the client is ready to learn about the disease process and treatment? ○ "I watched my parent check blood sugar levels several times." ○ "This is not a bad disease like cancer, so I will eventually get over it." ○ "There must be some mistake because I cannot believe I have this disease." ○ "I see the television commercials for diabetes medication, so I know I will be all right."

"I watched my parent check blood sugar levels several times." Explanation: One of the most significant factors influencing learning is a person's learning readiness or the optimum time for learning to occur, which usually corresponds to the learner's perceived need and desire to obtain specific knowledge. The client is demonstrating experiential readiness because of having observed a family member perform a skill that was used to manage the illness. The statement that the illness is not like cancer does not indicate readiness to learn about the health problem. Stating that there must be a mistake in the diagnosis is an indication of denial and does not indicate readiness to learn. The statement about seeing television commercials for diabetes medication could indicate that the client needs additional information, because the content of the commercial might not be the treatment prescribed for the client. The commercial may have caused the client to decide that additional learning is not required.

Which statements made by the nurse demonstrates that the nurse is providing spiritually sensitive care? ○ "A key component of hospice care is following your family for up to a year after your death." ○ "Denial, sadness, anger, fear, and anxiety are normal grief reactions." ○ "Mourning may be demonstrated by emotional feelings of sadness, anger, guilt, and numbness." ○ "Tell me who or what gives you strength."

"Tell me who or what gives you strength." Explanation: Spirituality is a personal belief system that focuses on a search for meaning and purpose of life. Assessment of people or things that provide strength to a terminally ill client is one way the nurse provides spiritually sensitive patient care. Grief is defined as the personal feelings that accompany an anticipated or actual loss. Bereavement is a period during which mourning for a loss take place. Mourning is an expression of grief and associated behaviors.

The nurse is administering a new medication to an elderly male client and begins instruction about the medication. The client states, "Tell my wife. She takes care of all this kind of stuff." The nurse replies ○ "It is necessary that you learn about this medication." ○ "When your wife comes in to visit, I will return and provide the information to both of you." ○ "I will print the information about this medication and leave it with you to give to her." ○ "I will have to return when she arrives."

"When your wife comes in to visit, I will return and provide the information to both of you." Explanation: Family members should be involved in teaching sessions when possible and appropriate. The client is giving permission with his statement to include his spouse. The nurse telling the client that it is necessary to learn about the medication and the nurse telling the client that they will print the information and leave it with the client are both nontherapeutic responses. The nurse only saying that they will return does not inform the client that the nurse will make sure learning about the new medication will occur.

Place the following nursing actions in sequence in the nursing process. ○ Identifying alterations that need to be made to the teaching plan ○ Identifying learning needs and etiology ○ Determining what the patient wants to learn ○ Putting the teaching plan into action ○ Establishing expected outcomes

1) Determining what the patient wants to learn 2) Identifying learning needs and etiology 3) Establishing expected outcomes 4) Putting the teaching plan into action 5) Identifying alterations that need to be made to the teaching plan Explanation: The steps of the teaching/nursing process are assessment, diagnosis, planning, implementation, and evaluation. Assessment in the teaching-learning process is directed toward the systematic collection of data about the person and family's learning needs and readiness to learn. A nursing diagnosis that relates specifically to a patient's and family's learning needs serves as a guide in the development of the teaching plan. The expected outcomes, which identify the desired behavioral responses of the learner, are completed during the planning phase of the nursing process. The implementation phase of the teaching-learning process, the patient, the family, and other members of the nursing and health care team carry out the activities outlined in the teaching plan. The evaluation phase of the teaching-learning process is used to determine what was effective and what needs to be changed.

Which patient age group makes up the fastest-growing segment of the population? ○ 85 years of age and older ○ 65 to 70 years of age ○ 71 to 75 years of age ○ 76 to 80 years of age

85 years of age and older Explanation: People aged 85 and older constitute the fastest-growing segment of the population. The health care needs of older adults are often chronic in nature with intermittent exacerbations or acute episodes.

How can the nurse best provide culturally sensitive care? ○ Become familiar with physical differences among ethnic groups. ○ Provide the proper food for nourishment. ○ Accept each client as a unique individual. ○ Facilitate rituals that bring comfort to the client.

Accept each client as a unique individual. Explanation: Becoming familiar with physical differences, providing food that is customary to the culture, and facilitating rituals are all recommendations for enhancing transcultural sensitivity, but accepting each client as an individual is a characteristic that is found in the provision of culturally competent care.

A recommended approach to planning health teaching is applying the trans-theoretical model, which considers the stages of behavioral change. The stage in which the patient engages in calorie counting to reduce weight is called: ○ Contemplation ○ Preparation ○ Action ○ Maintenance

Action Explanation: Individuals in the action stage of the trans-theoretical model would be expected to endorse the need for change and engage in specific behaviors that lead to change in the problem behavior. Engagement in educational activities would be expected at this stage.

Which is a physician-initiated intervention? ○ Teach the client how to transfer from bed to chair and chair to bed. ○ Administer oxygen at 4 L/min per nasal cannula. ○ Assist the client with coughing and deep breathing every hour. ○ Monitor intake and output every 2 hours.

Administer oxygen at 4 L/min per nasal cannula. Explanation: A physician-initiated intervention is an intervention initiated by a physician in response to a medical diagnosis but carried out by a nurse in response to a physician's order. A physician's order is required for the nurse to administer drugs, such as oxygen. A nurse-initiated intervention is an autonomous action based on scientific rationale that a nurse executes to benefit the client in a predictable way related to the nursing diagnosis and expected outcomes. Nursing-initiated interventions, such as teaching a client how to transfer, assisting with coughing and deep breathing, and monitoring intake and output, do not require a physician's order.

A home care nurse educator is providing training to staff nurses on the importance of compliance to medication regimens. What demographic variables may lead to the decrease in compliance of medication regimens? Select all that apply. ○ Age ○ Gender ○ Race ○ Socioeconomic status ○ Severity of illness

Age Gender Race Socioeconomic status Explanation: Compliance and adherence to medication regimens may be influenced by various demographic variables such as age, gender, race, socioeconomic status, and education level. Severity of illness is a variable that leads to the decrease in compliance of medication regimens; however, this is not a demographic variable.

How can a nurse improve his or her transcultural sensitivity and demonstrate culturally competent nursing care? ○ The nurse can learn to speak a second language. ○ The nurse can become familiar with physical differences among ethnic groups. ○ The nurse can perform a cultural and health beliefs assessment and plan care accordingly. ○ All of the responses are correct.

All of the responses are correct. Explanation: Culturally sensitive nursing care is evidenced by examining your personal beliefs, communication habits, and healthcare practices.

Personal space and distance are culturally dependent and can impact nurse-client interactions significantly. What is the best way for the nurse to interact with a client who has a different cultural perspective on space and distance? ○ Allow the client to adopt a position that is comfortable for them. ○ Realize that sitting close to the client is an indication of warmth and caring. ○ Stand or sit 10 to 12 ft from the client to accommodate the most common cultural preferences. ○ Remember not to intrude into the personal space of the elderly.

Allow the client to adopt a position that is comfortable for them. Explanation: If the client appears to position himself or herself too close or too far away, the nurse should consider cultural preferences for space and distance. Ideally, the client should be permitted to assume a position that is comfortable to him or her in terms of personal space and distance. Older adults do not share a common perspective on personal space. A distance of 10 to 12 ft is far and is not normally necessary. Close proximity can be interpreting as being invasive by some individuals.

The nurse has just taken report on a newly admitted client who is a 15-year-old girl who is a recent immigrant. When planning interventions for this client, the nurse knows the interventions must be which of the following? Select all that apply. ○ Appropriate to the nurse's preferences ○ Appropriate to the client's age ○ Ethical ○ Appropriate to the client's culture ○ Applicable to others with the same diagnosis

Appropriate to the client's age Ethical Appropriate to the client's culture Explanation: Planned interventions should be ethical and appropriate to the client's culture, age, and gender. Planned interventions do not have to be in alignment with the nurse's preferences nor do they have to be shared by everyone with the same diagnosis.

The nurse is providing discharge instructions to an elderly client. The nurse hands the client a paper about a new medication. The client cannot read. Learning does not occur. In this situation the nurse has failed to assess the ○ Physical readiness of the client ○ Appropriateness of teaching techniques ○ Client's social and cultural patterns ○ Past experiences of the client

Appropriateness of teaching techniques Explanation: Teaching techniques and aids enhance learning if they are appropriate to the needs of the client. A client who cannot read will not be able to use a written report about a medication. Insufficient data are in the stem for the student to select the client's physical readiness, social and cultural patterns, and past experiences.

The nurse performs discharge teaching for a client. How would the nurse best evaluate the effectiveness of the discharge teaching? ○ Review it to see if all health care provider prescriptions were covered. ○ Ask the client to repeat back to the nurse how care will be conducted at home. ○ Determine if critical pathways were completed. ○ Ask if the client understands the teaching.

Ask the client to repeat back to the nurse how care will be conducted at home. Explanation: Evaluation is defined as the judgment of the effectiveness of nursing care to meet client goals based on the client's behavioral responses. This phase involves a thorough, systematic review of the effectiveness of nursing interventions and a determination of client goal achievement. The best way to evaluate the effectiveness of discharge teaching is to have the client repeat back to the nurse how care will be conducted at home. The nurse does not evaluate whether health care provider prescriptions or critical pathways have been completed during discharge teaching. Asking if the client understands the teaching does not allow the nurse to fully evaluate if the teaching was indeed successful.

The yin and yang theory of illness proposes that the seat of energy in the body is within a specific area. Which of the following is the correct area of the body? ○ Autonomic nervous system ○ Cardiac system ○ Pulmonary system ○ Reproductive system

Autonomic nervous system Explanation: The yin/yang theory proposes that all organisms and objects in the universe consist of yin and yang energy. The seat of the energy forces is within the autonomic nervous system, where balance between the opposing forces is maintained during health.

The future of transcultural nursing care lies in finding ways to promote cultural competence in nursing students. How can this goal be best accomplished? ○ By offering multicultural health studies in nursing curricula ○ By enhancing the content of community nursing classes ○ By requiring students to care primarily for clients from other ethnic groups ○ By screening applicants according to their cultural competence

By offering multicultural health studies in nursing curricula Explanation: Nursing programs are exploring creative ways to promote cultural competence and humanistic care in nursing students, including offering multicultural health studies in their curricula. Enhancing the content of community nursing classes would not necessarily achieve this goal. Matching students to clients from other cultures is often impractical and applicants are not screened by their cultural competence.

The nurse is providing education to an English-speaking client who immigrated to the United States 2 years ago. The nurse determines that further education may be needed when the client does which action? ○ Changes the subject ○ Laughs appropriately ○ Makes eye contact ○ Asks several questions

Changes the subject Explanation: Changing the subject may be a sign that the listener does not understand what is being said. Laughing appropriately, making eye contact, and asking questions are not indications that the client is in need of further education.

The nurse is caring for the client with pneumonia. An expected client outcome is, "The client will maintain adequate oxygenation by discharge." Which outcome criterion indicates the goal is met? ○ Client drinks at least 2 to 3 liters of water each day. ○ Client completes coughing and deep breathing exercises hourly. ○ Client does not demonstrate signs of orthostatic hypotension when ambulating. ○ Client no longer requires supplemental oxygen.

Client no longer requires supplemental oxygen. Explanation: The client who is maintaining adequate oxygenation would not require oxygen. Completing required deep breathing exercises is an intervention to achieve the outcome. Drinking adequate amounts of water is not an outcome criteria for achieving adequate oxygenation. Likewise, orthostatic hypotension is not particular to oxygenation outcomes.

The nurse is caring for a client who is a recent immigrant. Which of the following variables should the nurse prioritize when performing an assessment of the client's cultural beliefs? ○ Client's previous medical history ○ Client's marital status ○ Client's age ○ Client's communication style

Client's communication style Explanation: Assessment of a client's culture should include the client's country of origin, language (communication style), food preferences or restrictions, health maintenance practices, and religious preferences and practices. This aspect of assessment does not explicitly include the client's support systems, marital status, or age, though each of these parameters would be assessed at different points.

Which parties are essential for the nurse to include in the implementation of a client's plan of care? ○ Client, family, and physician ○ Client, physician, and hospital director ○ Client, physical therapist, and nursing staff ○ Client, surgeon, and physician

Client, family, and physician Explanation: To ensure the success of the care plan, the nurse must involve all necessary parties. It is essential that the client be involved in the client's own health care decisions. The client's family provides needed support, and the physician is essential to provide medical interventions. The hospital director is not necessary for the implementation of the plan of care. A physical therapist and a surgeon are not necessarily involved in every client's care.

The nurse is caring for a vegetarian who has iron deficiency anemia. The standardized nutritional plan for a client with anemia calls for the client to increase consumption of animal protein. How should the nurse plan to meet this client's nutritional needs? ○ Collaborate with the nutritionist to modify the nutritional plan. ○ Instruct the client that consumption of animal protein is necessary to cure the anemia. ○ Meet with the client's family to emphasize the importance of nutritional modification. ○ Arrange for animal protein to be disguised in the client's meal.

Collaborate with the nutritionist to modify the nutritional plan. Explanation: A vegetarian does not consume animal proteins. Although animal proteins are an important source of iron, plant proteins are available. To honor the preferences of the client, the nurse would collaborate with the nutritionist to include these plant sources of protein in the client's diet (instead of the animal protein). It is not true that the client has to consume animal protein to cure the anemia. Meeting with the client's family would be inappropriate because this would violate the wishes of the client. Arranging for animal protein to be disguised in the client's meal would violate the client's trust and would also not be effective in the long term after the client has been discharged.

It is important for the nurse to acknowledge cultural differences that may influence the delivery of health care. In order to do this, the nurse must do which of the following? ○ Be clear with the client about the nurse's own cultural perspective. ○ Confront the nurse's own bias and influence of his or her culture. ○ Talk to the client about the nurse's own cultural heritage. ○ Be aware that ethnic culture does not change.

Confront the nurse's own bias and influence of his or her culture. Explanation: To truly acknowledge the cultural differences that may influence health care delivery, the nurse must confront bias and recognize the influence of his or her own culture and cultural heritage.

A nurse is planning teaching for a client who has stated a desire for health change. Using the AMSO (Awareness, Motivation, Skills and Opportunity) model, what will the nurse recognize as optimal health? ○ Self-efficacy of viewing one's health status as balanced ○ Creating and maintaining a balance among four determinants ○ Motivating factors for achieving and maintaining balance ○ Creating and maintaining a balance among five dimensions

Creating and maintaining a balance among five dimensions Explanation: According to the Awareness, Motivation, Skills, and Opportunity (AMSO) model, optimum health is a dynamic process of creating and maintaining a balance among five dimensions—physical, emotional, social, intellectual, and spiritual. The model with four determinants of health is the Achieving Health for All initiative. Perceived self-control and self-efficacy of one's own health status is the Resource Model of Preventative Health Behavior.

Which action by the nurse can negatively affect the patient's ability to learn? ○ Feedback in the form of constructive encouragement when a person has been unsuccessful in the learning process ○ Criticism when the patient is unsuccessful so that inappropriate behavior patterns will not be learned ○ The creation of a positive atmosphere in which the patient is encouraged to express anxiety ○ The establishment of realistic learning goals based on individual needs

Criticism when the patient is unsuccessful so that inappropriate behavior patterns will not be learned Explanation: A well-designed learning contract is realistic and positive. In a typical learning contract, a series of measurable goals is established, beginning with small, easily attainable objectives and progressing to more advanced goals. Frequent, positive reinforcement is provided as the person moves from one goal to the next. For example, incremental goals such as weight loss of 1 to 2 pounds (0.45 to 0.9 kg) per week are more appropriate in a weight reduction program than a general goal such as a 30-pound (13.6 kg) weight loss.

The inability to recognize the values, beliefs, and practices of others because of strong ethnocentric preferences is which of the following? ○ Acculturation ○ Cultural imposition ○ Cultural blindness ○ Cultural taboos

Cultural blindness Explanation: Cultural blindness is an inability to recognize the values, beliefs, and practices of others because of strong ethnocentric preferences. Cultural taboos are activities governed by rules of behavior that a particular cultural group avoids, forbids, or prohibits. Acculturation involves adapting to or taking on the behaviors of another group. Cultural imposition is an inclination to impose one's cultural beliefs, values, and patterns of behavior on people from a different culture.

Which of the following terms refers to Leininger's description of the person's inability to recognize his or her own values, beliefs, and practices and those of others? ○ Culture ○ Minority ○ Cultural blindness ○ Subculture

Cultural blindness Explanation: Leininger's description of cultural blindness is the person's inability to recognize his or her own values, beliefs, and practices and those of others because of strong ethnocentric tendencies. Leininger was the founder of the specialty called transcultural nursing and advocated culturally competent nursing care. Minority refers to a group of people whose physical or cultural characteristics differ from the majority of people in a society. Subculture refers to a group that functions within a culture.

A nurse is caring for a client who suffered a fall while on vacation. He is from another state and has no visitors except his spouse, who seems lonely without any friends or family nearby. The nurse invites the spouse to attend services with her at the nurse's church, which is a denomination different from the spouse's. This could be construed as which of the following? ○ Cultural blindness ○ Acculturation ○ Cultural taboo ○ Cultural imposition

Cultural imposition Explanation: A cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture.

The nurse is orienting a new nursing graduate to the medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should the nurse refer the colleague to obtain appropriate dietary recommendations for this client? ○ Evidence-based websites with multicultural content ○ Evidence-based written resources on nutritional assessment ○ Culturally sensitive materials, such as the Mediterranean Pyramid ○ A Greek cookbook that contains academic references

Culturally sensitive materials, such as the Mediterranean Pyramid Explanation: Culturally sensitive materials, such as the Mediterranean Pyramid, are available for making appropriate dietary recommendations. Nursing resource books do not usually have culturally sensitive dietary specific material and websites may not be available or relevant. A Greek cookbook would not be an appropriate clinical resource because it is unlikely to be based on the principles of nutrition.

A community health nurse is preparing learning materials for an upcoming public seminar for adults. What factors will the nurse consider, based on applying concepts of adult learning readiness? Select all that apply. ○ Culture ○ Personal values ○ Physical status ○ Emotional status ○ Teaching style

Culture Personal values Physical status Emotional status Explanation: One of the most significant factors of an adult's ability to learn is the individual's learning readiness. Learning readiness is based on the individual's culture, personal values, physical and emotional status, and previous experiences in learning. Teaching style is important in the learning process; however, it is not what learning readiness is based on.

The nurse working in a predominantly Amish community realizes that one reason the Amish do not obtain mammograms is because of transportation issues. The nurse obtains a grant to fund a dedicated van to provide transportation for members of the community to obtain mammograms. According to Leininger, this nurse is providing culturally congruent nursing care through which of the following? ○ Culture care accommodation ○ Culture care restructuring ○ Cultural imposition ○ Cultural blindness

Culture care accommodation Explanation: The nurse is using culture care accommodation by overcoming the transportation issues to help the clients achieve a beneficial health outcome. Culture care restructuring refers to actions that help clients change their lifestyle toward more beneficial patterns. Cultural imposition is the imposition of one's culture on a person from a different culture. Cultural blindness is the inability of people to recognize their own values and beliefs and/or those of others.

Select the nursing action that is least likely to motivate a person to learn. ○ Constructive encouragement when a person has been unsuccessful in the learning process ○ Emphasis on negative outcomes as a method to prevent learning incorrect practices ○ The creation of an atmosphere in which the patient is encouraged to express anxiety ○ The establishment of learning goals based on individual needs

Emphasis on negative outcomes as a method to prevent learning incorrect practices Explanation: Successful learning is associated with positive encouragement and feedback, a comfortable learning environment, and realistic learning outcomes that an individual can understand and embrace.

Which of the following teaching strategies may be used with a patient diagnosed with a developmental disability? Select all that apply. ○ Encourage active participation. ○ Use nonverbal cues as needed. ○ Use simple explanations. ○ Demonstrate information followed by return demonstration. ○ Base information on chronologic age.

Encourage active participation. Use nonverbal cues as needed. Use simple explanations. Demonstrate information followed by return demonstration. Explanation: Those with a developmental disability would benefit from active participation, use of nonverbal cues as needed, simple explanations, and a demonstration of information followed by return demonstration. Information and teaching should be based on developmental age, not chronologic age.

Which step of the nursing process determines whether the client understands the health teaching that is provided? ○ Evaluation ○ Assessment ○ Planning ○ Implementation

Evaluation Explanation: Evaluation includes observing the client, asking questions, and then comparing the client's behavioral responses with the expected outcomes. Assessment includes determining the client's readiness regarding learning. Planning includes identification of teaching strategies and writing the teaching plan. Implementation is the step during which the teaching plan is put into action.

The yin/yang theory of harmony and illness is rooted in which paradigm of health and illness? ○ Biomedical ○ Holistic ○ Religious ○ Scientific

Holistic Explanation: One example of a naturalistic or holistic belief, held by many Asian groups, is the yin/yang theory, in which health is believed to exist when all aspects of a person are in perfect balance or harmony.

A patient who is Asian practices the yin/yang theory of harmony and illness. What paradigm of health and illness is this practice rooted in? ○ Biomedical ○ Holistic ○ Religious ○ Scientific

Holistic Explanation: The naturalistic or holistic perspective is another viewpoint that explains the cause of illness and is commonly embraced by many Native Americans, Asians, and others. According to this view, the forces of nature must be kept in natural balance or harmony. One example of a naturalistic belief, held by many Asian groups, is the yin/yang theory, in which health is believed to exist when all aspects of a person are in perfect balance or harmony. Rooted in the ancient Chinese philosophy of Taoism (which translates as "The Way"), the yin/yang theory proposes that all organisms and objects in the universe consist of yin and yang energy.

There are many goals for health teaching. Which of the following is the primary goal of family and patient education? ○ Increase knowledge ○ Motivate people to learn ○ Improve patient outcomes ○ Establish trust

Improve patient outcomes Explanation: The primary goal of patient and family education is to achieve, improve, or alter behaviors that directly or indirectly change and improve patient outcomes.

Which of the following is the goal of patient and family education? ○ Improvement of patient outcomes ○ Assumption of responsibility for care ○ Lessen financial burden ○ Decrease amount of healthcare services

Improvement of patient outcomes Explanation: The goal of patient and family education is to improve patient outcomes. Teaching is an integral tool that all nurses use to assist patients and families in developing effective health behaviors and in altering lifestyle patterns that predispose people to health risks.

A nurse administers a medication for pain but forgets to document it in the client's health care record. Legally, what does this mean? ○ Nothing, the nurse's honesty will not be questioned. ○ The nurse can add the documentation after the client goes home. ○ The health care provider will verify that the nurse carried out the order. ○ In the eyes of the law, if it is not documented, it was not done.

In the eyes of the law, if it is not documented, it was not done. Explanation: Nurses must carefully document each intervention. The legal truth is if it wasn't documented, it wasn't done. The health care provider cannot verify the nurse's action. If the medication causes an adverse effect, then the nurse's action will be held accountable. The nurse is not to add entries into the health record after the client has been treated and released.

Nonadherence to therapeutic regimens is a significant problem, especially in the elderly population. Nonadherence can lead to which outcome? ○ Increased cost of treatment ○ Decreased morbidity ○ Decreased chronic illness ○ Increased compliance with medical regimen

Increased cost of treatment Explanation: Nonadherence to therapeutic regimens is a significant problem for elderly people, leading to increased morbidity, mortality, and cost of treatment. There is an increasing rate of nonadherence among persons with chronic illness. Elderly people may also have problems that affect adherence to therapeutic regimens, such as the side effects of medications and financial constraints.

A current trend in health education that significantly influences nursing practice is: ○ Increased emphasis on patient involvement in their own care. ○ Improved distribution of health information materials. ○ Increased numbers of health care providers. ○ Increased emphasis on the diversity of patient needs.

Increased emphasis on patient involvement in their own care. Explanation: Much of the core of health education today is focused on increasing patient involvement and accountability for their care and treatment plans. Health education programs are often designed as patient safety initiatives and are geared toward encouraging increased communication between patients and care providers.

Which nursing diagnosis has priority? ○ Ineffective Airway Clearance related to retention of secretions ○ Disturbed Sleep Pattern related to abdominal incisional pain ○ Self-care Deficit: Bathing related to joint inflammation ○ Constipation related to decreased fluid intake and decreased mobility

Ineffective Airway Clearance related to retention of secretions Explanation: High-priority nursing diagnoses, such as Ineffective Airway Clearance, pose the greatest threat to the client's well-being and should be addressed by the nurse first. The priority is to assess airway, breathing, and circulation before any of the other body systems. Disturbed sleep, self-care deficit, and constipation are not as serious as an obstructed airway.

Which of the following is a diagnosis related to health education? ○ Ineffective health maintenance ○ Ineffective airway clearance ○ Altered nutrition, less than body requirements ○ Self-esteem disturbance

Ineffective health maintenance Explanation: Diagnoses related to health education may include ineffective health maintenance, health-seeking behaviors, deficient knowledge, and readiness for enhanced knowledge. The other diagnoses are not related to health education.

Which action should the nurse take to ensure that an unlicensed assistive personnel (UAP) understands the instructions to perform a delegated task? ○ Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. ○ Request that the UAP place the steps of the task in the framework of the nursing process. ○ Inform the UAP of the importance of following each step listed in the procedure manual. ○ Ask another UAP to observe and assist the UAP in performing the task.

Instruct the UAP to repeat the instructions to be sure the nurse has communicated clearly. Explanation: Instruct the UAP to repeat the nurse's instructions to be sure the nurse has communicated them clearly. The UAP must be clear on the difference between nursing tasks and the nursing process, as the nursing process structures care delivered by the registered nurse. Although it is important for the UAP to follow procedure manuals, it is important that the registered nurse is clear on the UAP's understanding of the steps through direct observation or discussions. It is not correct to ask another UAP to observe and assist the UAP in performing the task.

The nurse is providing information to a client about the safe use of a newly prescribed medication. The first question the nurse should ask is ○ Is the client ready to learn? ○ What is the expected outcome? ○ What teaching aids do I need? ○ How do I evaluate client learning?

Is the client ready to learn? Explanation: The nurse follows the nursing process when teaching a client. Probably the most important and first factor to assess is the client's readiness to learn. The other options are also components of the nursing process. The question what is the expected outcome is the goal of the nursing process. The use of teaching aids is part of the implementation process. Evaluating learning is the evaluation component of the nursing process.

Which statement best explains why continuing data collection is important? ○ It is difficult to collect complete data in the initial assessment. ○ It is the most efficient use of the nurse's time. ○ It enables the nurse to revise the care plan appropriately. ○ It meets current standards of care.

It enables the nurse to revise the care plan appropriately. Explanation: Continuous data collection ensures that the nurse has the most current client data to evaluate, which allows for updating the care plan as needed. A complete assessment is performed on admission, but the client's condition is always changing. The purpose of continued data collection is to provide good client care; it does not relate directly to efficiency of nursing care. While continuous data collection meets standards of care, it is not the primary reason for ongoing assessments.

After the health history and admission assessment are completed, the nurse establishes a care plan for the client. What is the rationale for documenting and planning the client's care? ○ It helps deliver holistic, goal-oriented, individualized care. ○ It creates a teaching log for family. ○ It verifies staffing. ○ It provides the client with information about treatments.

It helps deliver holistic, goal-oriented, individualized care. Explanation: This record provides a means of communication among members of the health care team and facilitates delivering holistic, goal-oriented, individualized care. A care plan is not a teaching log. It does not verify staffing, and it is not intended to provide the client with information about treatments.

A nursing student who has just completed a chapter on transcultural nursing knows that all ethnic cultures share four basic characteristics. Choose the correct four from the following list. ○ It is learned from birth through language and socialization. ○ It is shared by all members of the same cultural group. ○ It is influenced by specific environmental and technical factors. ○ It is dynamic and ever-changing. ○ It is shared with the senior members of the group.

It is learned from birth through language and socialization. It is shared by all members of the same cultural group. It is influenced by specific environmental and technical factors. It is dynamic and ever-changing. Explanation: The four main characteristics of ethnic cultures are as follows: (1) It is learned from birth through language and socialization; (2) It is shared by all members of the same cultural group; (3) It is influenced by specific environmental and technical factors; (4) It is dynamic and ever-changing.

Of the following nurse theorists, which one is considered the founder of transcultural nursing? ○ Dorothea Orem ○ Madeline Leininger ○ Jean Watson ○ Patricia Benner

Madeline Leininger Explanation: Madeleine Leininger is the founder of the specialty called transcultural nursing. Jean Watson founded the caring theory, Orem the self-care theory, and Benner the novice to expert model.

A patient with a visual impairment would benefit from which of the following teaching strategies? ○ Magnifying lenses ○ Sign language ○ Telecommunication devices ○ Captioned videos

Magnifying lenses Explanation: A visually impaired patient would benefit from the use of optical devices, such as a magnifying lens. A hearing-impaired patient would benefit from the use of sign language, telecommunication devices, and captioned videos.

When a person works to prevent relapse and to sustain the gains made from actions taken, he or she is in which stage of the Transtheoretical Model of Change? ○ Maintenance ○ Action ○ Termination ○ Contemplative

Maintenance Explanation: A person is in the maintenance stage of the Transtheoretical Model of Change when there is work to prevent relapse and to sustain the gains made from the actions taken.

Which provides the best framework for prioritizing client problems? ○ Availability of hospital resources ○ Family member statements ○ Maslow's hierarchy of needs ○ Nursing skill

Maslow's hierarchy of needs Explanation: Maslow's hierarchy of needs provides a useful framework for prioritizing problems, with the first level given to meeting the physical needs of the client. The focus for the client assessment is on the client and not the availability of hospital resources, family member statements, and nursing skills; these do not provide an appropriate framework for prioritization of client problems. Family member statements can be included later, after the assessment of the client is performed.

Yin yang is an example which societal view of illness? ○ Biomedical perspective ○ Magico-religious perspective ○ Naturalistic perspective ○ Scientific perspective

Naturalistic perspective Explanation: The naturalistic view espouses that human beings are only one part of nature. The biomedical or scientific view embraces a cause-and-effect philosophy of human body functions. The magico-religious view believes that supernatural forces dominate.

Which of the following is accurate regarding wellness? Select all that apply. ○ One tries to maximize one's own health. ○ It requires a conscious commitment. ○ It is the result of adopting lifestyle behaviors for the attainment of one's highest potential. ○ It is a specific health status with the absence of disease. ○ Is the same for every person.

One tries to maximize one's own health. It requires a conscious commitment. It is the result of adopting lifestyle behaviors for the attainment of one's highest potential. Explanation: Wellness, as a reflection of health, involves a conscious and deliberate attempt to maximize one's health. Wellness requires planning and conscious commitment and is the result of adopting lifestyle behaviors for the purpose of attaining one's highest potential for well-being. Wellness is not the same for every person.

Which factor is a leading health indicator used to measure the health of the nation? ○ Overweight and obesity ○ Intelligence ○ Cultural awareness ○ Religion

Overweight and obesity Explanation: Leading health indicators used to measure the health of the nation include overweight and obesity, physical activity, and mental health. Intelligence, cultural awareness, and religion are not leading health indicators.

The nurse is developing a health-promotion program at a company in which many employees are women in their 20s and 30s. For this population, the nurse plans to include information about ○ Bone-density screening ○ Parenting issues ○ Mammography ○ Values training

Parenting issues Explanation: Young adults in their reproductive years want information about parenting issues. Values training is geared more for adolescents. Information about bone-density screening and mammography are for older women.

A nursing student observes the home care nurse provide education to a client with congestive heart failure (CHF). The nurse teaches the client how to read food labels and calculate sodium content. The nursing student recognizes that the home care nurse is aware of which basic principle of patient education? ○ Patient instruction related to self-care activities promotes patient independence ○ Patients are required to learn about their therapeutic nutritional regimen ○ The home care nurse has a physician order to teach a 2-g sodium diet ○ The home care nurse is providing hospital discharge instructions

Patient instruction related to self-care activities promotes patient independence Explanation: Teaching is a function of nursing to assist patients to alter lifestyle patterns that increase health risk. By teaching the client how to calculate sodium content of foods the nurse is facilitating independence in nutrition disease management. Patients have the right to decide whether or not to learn. Teaching is an independent function of nursing and does not require a physician's order. Teaching related to food labels in the patient home is an appropriate environment for this client. The nurse can use actual foods from the patient's kitchen.

A hospitalized client reports right lower quadrant abdominal pain at a level of 8 on a 0 to 10 scale. The client is scheduled for an appendectomy. The nurse is teaching the client about use of the incentive spirometer postoperatively verbally and by demonstration. The client is on his side, clutching his abdomen. Learning is not occurring. The nurse has primarily failed to consider the client's ○ Emotional readiness ○ Learning environment ○ Physical readiness ○ Experiential readiness

Physical readiness Explanation: Physical readiness for learning is when the client is physically capable of learning. A client in acute pain cannot concentrate on learning. Insufficient data are in the stem to select emotional readiness, learning environment, or experiential readiness.

A nurse developed a program of increased ambulation for a patient with an orthopedic disorder. This goal setting is a component of the nursing process known as: ○ Assessment ○ Planning ○ Implementation ○ Evaluation

Planning Explanation: Once assessment data are collected, the next step is to plan the teaching intervention, which begins with specifying immediate, intermediate, and long-term goals.

The nurse develops a program of increased ambulation for a patient with an orthopedic disorder. This is an example of what component of the nursing process? ○ Assessment ○ Planning ○ Implementation ○ Evaluation

Planning Explanation: The entire planning phase concludes with the formulation of the teaching plan.

The home health nurse reviews a medication administration calendar with an elderly patient. In order to consider sensory changes that occur with aging, how should the nurse proceed? ○ Print directions in large, bold type, preferably using black ink. ○ Highlight or shade important dates and times with contrasting colors. ○ Use several different colors to emphasize special dates. ○ Type out the information on the computer.

Print directions in large, bold type, preferably using black ink. Explanation: Older adults frequently have one or more chronic illnesses that are managed with numerous medications and complicated by periodic acute episodes. Older adults may also have other problems that affect adherence to therapeutic regimens, such as increased sensitivity to medications and their side effects, difficulty in adjusting to change and stress, financial constraints, forgetfulness, inadequate support systems, lifetime habits of self-treatment with over-the-counter medications, visual and hearing impairments, and mobility limitations. To promote adherence among older adults, all variables that may affect health behavior should be assessed (Fig. 4-1).

The practice of nursing care is multifaceted in its scope and delivery. Which of the following activities describe the role of nursing? Select all that apply. ○ Promoting health ○ Altering a medical plan of care ○ Preventing illness ○ Health education and maintenance ○ Changing prescribed treatment protocols

Promoting health Preventing illness Health education and maintenance Explanation: Nursing responsibilities are expanding continuously with increasing numbers of advanced practice nurses and changing state nurse practice acts. However, nurses cannot alter a medical plan of care or change health care provider prescribed treatment protocols.

The school nurse informs the mother of a second-grade student that lice were found in the child's hair. The mother explains to the nurse that she has another child to pick up and cannot stay to receive education related to the treatment of lice at this time. The mother reassures the nurse that she will "look up treatment options on the Internet and take care of the child." What would be the best action of the school nurse in this situation? ○ Provide the mother with a list of credible websites related to the treatment of lice ○ Instruct the mother to treat the other child for lice in the same manner as the second-grade child ○ Perform hand hygiene and notify the second-grade teacher to wash down the classroom ○ Notify the social worker of suspected child neglect and make a referral to child protective services

Provide the mother with a list of credible websites related to the treatment of lice Explanation: Providing the mother with a list of previewed websites related to treating lice gives the mother trustworthy, credible, and timely information related to treatment options. Although assessing and treating the other children in the home is indicated, it is more important to direct the mother to accurate information related to the treatment of lice. The nurse should perform routine hand hygiene; washing the classroom is not indicated. The presence of lice does not warrant a referral to the social worker or child protective services.

Since normal aging results in changes in cognition, how should the nurse teach an elderly patient to administer insulin? ○ Repeat the information frequently for reinforcement. ○ Present all the information at one time so that the patient is not confused by pieces of information. ○ Speed up the demonstration because the patient will tire easily. ○ The elderly patient is not capable of learning self-administration and someone else should be instructed.

Repeat the information frequently for reinforcement. Explanation: Nurses must also consider that cognitive impairment may be manifested by the older adult's inability to draw inferences, apply information, or understand the major teaching points. It is important to allow ample time to learn and provide reinforcement. Follow-up sessions are imperative to promote the learner's confidence in his or her abilities and to plan for additional teaching sessions.

A nurse is teaching a client taking digoxin about checking the pulse rate daily. The client counts her radial pulse as 64 beats/min. The nurse counts at the same time and assesses the rate as 58 beats/min. When evaluating response to treatment, the nurse would chart that the client ○ Requires another opportunity for practice ○ Demonstrates adequate knowledge of the skill ○ Cannot satisfactorily learn the skill ○ Needs a family member to perform this skill

Requires another opportunity for practice Explanation: The nurse needs to provide the client with ample opportunity for practice. Only one option represents this answer. The client did not demonstrate adequate knowledge in counting the radial pulse. She would have taken digoxin based on the pulse rate she counted. Insufficient data support that the client cannot learn the skill. Having a family member perform the skill does not ensure it will be done correctly.

The nurse is preparing to teach a client about a newly prescribed medication. The client lacks insurance. The medication costs approximately $100 per month. The client states, "I can't afford it." The nurse assesses a variable to successful education and health promotion for this client based on the Health Belief Model is ○ Demographic and disease factors ○ Barriers ○ Resources ○ Perceptual factors

Resources Explanation: The Health Belief Model is based on the premise that four variables influence health promotion behaviors. Resources address financial and social behaviors. Demographics and disease factors include client age, gender, education, employment, severity of illness or disability, and length of illness. Barriers are factors that lead to unavailability or difficulty in gaining access to a health promotion alternative. Perceptual factors are how a client views his health status, self-efficacy, and the perceived demands of the illness.

The nurse notes that a client who was instructed on how to do a prescribed treatment 1 week ago is unable to perform the task. Which action will the nurse take to improve this client's health literacy? ○ Report the client's nonadherence to the health care provider. ○ Review the material to determine that it is appropriate for the client. ○ Ask the client why the treatment is not being performed as instructed. ○ Determine if there is a family member who can provide the treatment.

Review the material to determine that it is appropriate for the client. Explanation: Health literacy skills are basic to understanding the body and how it functions, assessing lifestyle choices along with the variables that cause and perpetuate disease, as well as making health care decisions. If people have low health literacy, the consequence is poor overall health. To increase health literacy, accurate health information must be designed and ensured that the health materials are culturally appropriate for the client. The information also needs to be properly distributed. Reporting the client's nonadherence to the health care provider will not improve the client's health literacy. Asking the client why the treatment is not being performed as instructed is confrontational and may hinder the learning process. Determining if there is a family member who can provide the treatment will not help improve the client's health literacy.

A school nurse is developing a program about positive health practices for adolescents. The nurse includes information about ○ Blood pressure control ○ Chronic diseases ○ Self-esteem ○ Prenatal health

Self-esteem Explanation: Programs to promote good health habits for adolescents include issues about self-esteem. Programs relating to blood pressure control, chronic diseases, and prenatal health are more appropriate for other age groups.

Which is an example of a behavior that facilitates health? ○ Self-monitoring for signs and symptoms of illness ○ Noncompliance with a medication regimen ○ A sedentary lifestyle ○ Recreational drug use

Self-monitoring for signs and symptoms of illness Explanation: Common examples of behaviors facilitating health include self-monitoring for signs and symptoms of illness, increased daily activities and exercise, and taking prescribed medications.

The nurse is preparing a learning contract for a client to adhere to a prescribed activity schedule. Which content will the nurse include in the contract to motivate the client? ○ List of exercises to complete ○ Series of short, measurable goals ○ Time needed to complete the exercises ○ Actions to take if unable to perform an exercise

Series of short, measurable goals Explanation: Using a learning contract or agreement can be a motivational tool for learning. Such a contract is based on assessment of client needs, health care data, and specific goals that are measurable. In a typical learning contract, a series of measurable goals is established, beginning with small, easily attainable objectives and progressing to more advanced goals. A list of exercises to complete, time to complete the exercises, and actions to take if an exercise cannot be performed would be content to include in the teaching plan and would not serve to motivate the client.

Which of the following is the consequence of a nurse equating the client's skin color and other physical features with culture? ○ Developing cultural competence ○ Stereotyping ○ Developing transcultural sensitivity ○ Generalizing

Stereotyping Explanation: Although ethnic and racial groups overlap, nurses must not equate skin color and other physical features with culture. Doing so may lead to erroneous assumptions that all people with certain physical attributes share the same culture and ethnicity. Such an attitude leads to stereotyping. Generalizing acknowledges common trends in a group and recognizes that more information is needed. Equating clients' skin color and other physical features with culture does not help develop cultural competence and transcultural sensitivity.

Which of the following refers to a group that shares characteristics identifying the group as a distinct entity? ○ Minority ○ Culture ○ Subculture ○ Race

Subculture Explanation: Subculture refers to a particular group that shares characteristics identifying the group as a distinct entity. The term minority describes a group of people who differ from the majority in a society in terms of cultural characteristics. Culture provides a means for understanding people's values and beliefs. Race refers to biologic differences in physical features, such as skin color and eye shape.

Which is a correctly written client outcome? ○ The client will eliminate a soft, formed stool. ○ The client understands what foods are low in sodium. ○ The client will ambulate 10 ft (3 m) with a walker by October 12. ○ The client correctly self-administers the morning dose of insulin.

The client will ambulate 10 ft (3 m) with a walker by October 12. Explanation: Outcomes are client-centered, use action verbs, identify measurable criteria, and include a time frame as to when the outcome should be achieved. A correctly written outcome will identify who (the client) will do what (ambulate), how well (10 ft; 3 m), under what circumstances (with a walker), and by when (October 12). "Understand" is vague and not action-oriented. The outcomes regarding eliminating a stool and self-administering insulin are missing the time frame.

A nurse is planning discharge instructions for a client from another culture. What does the nurse understand about the relationship of values and beliefs and the client's readiness to learn? ○ The client will likely accept health education regardless of values and beliefs. ○ The client will be less likely to accept health education unless the nurse and client share values and beliefs. ○ The client will be less likely to accept health education unless values and beliefs are respected. ○ The client will likely accept health education, but will take longer to learn.

The client will be less likely to accept health education unless values and beliefs are respected. Explanation: The role of the nurse is to make sure that the client's values and beliefs are respected, as this has a major impact on client learning. The nurse does not have to share values and beliefs with the client; however, the nurse has a professional obligation to respect the client's own values and beliefs.

The nurse is revising a client's plan of care. What is an example of an expected client outcome? ○ The client will have the ability to climb a flight of stairs without experiencing difficulty in breathing. ○ The client's blood pressure will be stable. ○ The client will buy a pair of reading glasses to help with reading. ○ The client will accept the option of attending church on weekdays.

The client will have the ability to climb a flight of stairs without experiencing difficulty in breathing. Explanation: The expected outcome needs to be precise and measurable, not general; otherwise, measurement could be generalized. The ability to climb a flight of stairs without experiencing difficulty in breathing is measurable. An expectation of stable blood pressure is not measurable. Purchasing a pair of glasses or attending weekday church is not specific.

Which statement is true regarding population demographics? ○ Homelessness is decreasing. ○ The culturally diverse population is increasing. ○ The birth rate is increasing. ○ Life spans are decreasing.

The culturally diverse population is increasing. Explanation: The population has become more culturally diverse as increasing numbers of people from different national backgrounds enter the country. The number of homeless people has significantly increased. There has been a decrease in the birth rate, and life spans are longer.

Which of these statements best defines the term culture? ○ The learned patterns of behavior, beliefs, and values that can be attributed to a particular group of people ○ A group of people distinguished by genetically transmitted material ○ The status of belonging to a particular region by origin, birth, or naturalization ○ The classification of a group based upon certain distinctive characteristics

The learned patterns of behavior, beliefs, and values that can be attributed to a particular group of people Explanation: Included among characteristics that distinguish cultural groups are manner of dress, values, artifacts, and health beliefs and practices. A group of people distinguished by genetically transmitted material describes the term race. The status of belonging to a particular region by origin, birth, or naturalization describes the term nationality. The classification of a group based upon certain distinctive characteristics describes the term ethnicity.

A nurse is planning a health education program for a group of high school students regarding the dangers of texting and driving. Which action by the nurse illustrates the understanding of health education as a primary nursing responsibility? ○ The nurse gathers evidenced-based information related to texting and driving and coordinates the education with the school. ○ The nurse obtains the name of the school's medical director and obtains a health care provider's order to conduct the education program. ○ After consulting the literature and preparing the educational program, the nurse contacts the school's medical director for approval of the planned educational program. ○ The nurse prepares a permission slip for all students to have signed by their parents, allowing the student to participate in the educational program.

The nurse gathers evidenced-based information related to texting and driving and coordinates the education with the school. Explanation: Health education is an independent function of nursing practice and is included in all state nurse practice acts. Teaching, as a function of nursing, is included in all state nurse practice acts. As an independent nursing function a health care provider order or approval is not required. Health education is a primary responsibility of the nursing profession. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness. Prior parental consent is not required for education related to health/safety promotion.

A home care nurse is planning to visit a client newly diagnosed with diabetes. Further review of the chart reveals the client is of Japanese heritage. Upon arriving at the home, the home care nurse observes several pairs of shoes on a mat next to the door. Which of the following actions by the nurse demonstrates cultural competence? ○ The nurse removes her shoes and announces her arrival. ○ The nurse places shoe covers on her shoes and proceeds with the visit. ○ The nurse removes her shoes then teaches the client the importance of wearing shoes because of peripheral neuropathy. ○ The nurse leaves her shoes on and explains standard precautions to the client.

The nurse removes her shoes and announces her arrival. Explanation: Home care nurses need to adapt to the cultural environment of the client. In this situation, removing the shoes demonstrates the nurse's cultural competence. Shoe covers protect the transfer of potentially contaminated blood and body fluids to the nurse's shoes and are not indicated in this situation. Removing the shoes demonstrates cultural competence; however, teaching needs to demonstrate acceptance of cultural norms and can be directed at the importance of frequent and thorough assessment of the feet for unidentified injury related to neuropathy.

The nurse is providing education to the patient about wound care and the patient changes the subject to talk about the weather. What does the nurse understand may be the cause of the abrupt change of subject? ○ The patient is bored with the conversation. ○ The patient has a hearing deficit. ○ The patient may not understand what is being explained by the nurse. ○ The patient already knows how to do the wound care.

The patient may not understand what is being explained by the nurse. Explanation: Efforts to change the subject could indicate that the listener does not understand what was said and is attempting to talk about something more familiar.

The nurse is preparing to educate a patient about the home care of an abdominal wound. What patient behaviors does the nurse notice that demonstrate readiness to learn? (Select all that apply.) ○ The patient shows the motivation to learn. ○ The patient has accepted the therapeutic regimen. ○ The patient is unable to look at the wound. ○ The patient tells the nurse the family member will take care of it. ○ The patient requests a contact number if there are questions.

The patient shows the motivation to learn. The patient has accepted the therapeutic regimen. The patient requests a contact number if there are questions. Explanation: One of the most significant factors influencing learning is a person's learning readiness. For adults, readiness is based on culture, personal values, physical and emotional status, and past experiences in learning (Schumacher, 2011). The "teachable moment" occurs when the content and skills being taught are congruent with the task to be accomplished (Miller & Stoeckel, 2011).

The nurse develops outcome criteria for a patient with chronic obstructive pulmonary disease. Which outcome criteria are appropriate for this patient? ○ The patient will have the ability to climb a flight of stairs without experiencing difficulty in breathing. ○ The patient will not experience an alteration in skin integrity. ○ The patient will perform passive range-of-motion exercises once daily. ○ The nurse will obtain a pulse oximetry reading twice a day.

The patient will have the ability to climb a flight of stairs without experiencing difficulty in breathing. Explanation: Outcomes of teaching strategies can be stated in terms of expected behaviors of patients, families, or both. Outcomes should be realistic and measurable, and the critical time periods for attaining them should be identified. The desired outcomes and the critical time periods serve as a basis for evaluating the effectiveness of the teaching strategies.

Which specialty in nursing involves providing nursing care in the context of the client's culture? ○ Transcultural nursing ○ Multicultural nursing ○ Biocultural nursing ○ Multilingual nursing

Transcultural nursing Explanation: Transcultural nursing, founded by Leininger (1977), is considered a specialty in nursing. It refers to nursing care that is provided within the context of another's culture. Multiculturalism is a philosophy that recognizes ethnic diversity within a society; it is not a nursing specialty. Biocultural refers to physical characteristics or behavior related to or resulting from a person's cultural background; it is not a nursing specialty. A nurse who is multilingual is fluent in more than one language.

Which action would be incorporated in a teaching strategy for a hearing-impaired client? ○ Use of slow, directed, and deliberate speech ○ Use of large-print materials ○ Arrangement of materials in a clockwise pattern ○ Having the person perform a return demonstration

Use of slow, directed, and deliberate speech Explanation: When teaching clients with a hearing impairment, the nurse should use slow, directed, and deliberate speech. Use of large-print materials and arrangement of materials in a clockwise position would be used for clients with a visual impairment. Demonstrating information and having the person perform a return demonstration would be appropriate for a person with a developmental disability.

A middle-aged female client is overweight and sedentary, has slightly elevated blood pressure, and is seeking ways to begin exercise. The client wishes to lose weight and improve her blood pressure. The nurse plans an exercise program in which the client ○ Lifts weights three times each week with increasing sets, repetitions, and weights ○ Takes a 1-hour spinning class four times each week ○ Walks for 30 minutes three times this week and is re-evaluated ○ Joins a local gym and obtains the services of a personal fitness trainer

Walks for 30 minutes three times this week and is re-evaluated Explanation: Exercise should be individualized, started gradually, and increased slowly based on the client's response. The option in which the client walks for 30 minutes and is re-evaluated best meets these criteria. Exercise needs to be realistic and cost effective. The other options are not realistic for someone who has been sedentary, nor are they cost effective.

Which of the following nursing action exemplifies the evaluation of the teaching-learning process to determines how effectively the patient has responded to teaching? ○ Watching a return demonstration of insulin administration from a client newly diagnosed with diabetes ○ Asking a new diabetic, "What are your questions about giving yourself an insulin injection?" ○ Setting short-term educational goals for the client newly diagnosed with diabetes ○ Teaching injection sites to a client newly diagnosed with diabetes

Watching a return demonstration of insulin administration from a client newly diagnosed with diabetes Explanation: Evaluation includes observing the patient, asking questions, and then comparing the patient's behavioral responses with the expected outcomes. Observation of a return demonstration is a form of evaluation. Assessment includes determining the patient's readiness regarding learning. Planning includes identification of teaching strategies, writing the teaching plan, and setting goals of the teaching strategies. Implementation is the step during which the teaching plan is put into action.

A community health nurse understands the importance and impact of cultural competence when caring for clients in the community. In what situation will the nurse find that cultural competence is particularly important? ○ When members of the community request religious resources ○ When the nurse works in a larger city versus a small community ○ When the nurse is new to the job and the role within the community ○ When members of the community share a heritage that is unfamiliar to the nurse

When members of the community share a heritage that is unfamiliar to the nurse Explanation: When members of the community share a heritage that is unfamiliar to the nurse, the nurse must be very aware of the importance of cultural competence. Although the other answer choices may present challenges to the nurse, these are not universally true and are therefore not the best answer choices.

A new client is admitted to the unit, and the nurse's initial assessment will include a systematic appraisal of the client's cultural characteristics, health practices, and beliefs. What type of assessment will the nurse perform to gather this information? ○ cultural ○ biocultural ○ multicultural ○ procedural

cultural Explanation: A cultural nursing assessment is a systematic appraisal or examination of individuals, families, groups, and communities in terms of their cultural beliefs, values, and practices. The nurse should include cultural beliefs and health practices in any initial assessment. When assessing any client, the nurse must consider general appearance and obvious physical characteristics, components that make up biocultural assessment.

A client with severe anemia is prescribed 2 units of packed red blood cells. The client refuses to sign the consent form for blood administration because to do so conflicts with the client's Jehovah's Witness faith. What did the nurse fail to assess prior to witnessing consent? ○ learning readiness ○ cultural beliefs ○ emotional readiness ○ learning environment

cultural beliefs Explanation: Clients may not accept health treatments if those treatments conflict with the values of their culture. The nurse was not aware of the client's cultural values as a Jehovah's Witness, which include prohibition of the transfusion of blood, prior to attempting to gain consent for the prescribed treatment.

The inability of a person to recognize his or her own values, beliefs, and practices and those of others because of strong ethnocentric tendencies is termed ○ cultural blindness. ○ cultural taboo. ○ cultural imposition. ○ acculturation.

cultural blindness. Explanation: Cultural blindness results in bias and stereotyping. Acculturation is the process by which members of a culture adapt to or learn how to take on the behaviors of another group. Cultural imposition is the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture. Cultural taboos are those activities governed by rules of behavior that are avoided, forbidden, or prohibited by a particular cultural group.

Complete the following sentence by choosing from the lists of options. The nurse should determine the adult client's learning readiness by assessing _(cultural identification, intelligence, present experience)_ followed by _(education mandates, personal values, societal constraints)_ followed by _(physical status, attention to detail, mobility status)_ and followed by _(financial status, emotions, legal mandates)_

cultural identification personal values physical status emotions Explanation: Assessing adult learner readiness is a critical part of health education and health promotion. Learning readiness refers to the optimal time for learning to occur and the determination of adult learner readiness is based on culture, personal values, physical and emotional status, and past experiences in learning. Culture has a huge effect on one's ability to be ready to learn, because it encompasses values, ideals, and behaviors that serve as the framework for learning and adaptation. Being aware of the client's personal values helps to set the stage for learning readiness. One's physical state affects the ability to be ready to learn, because health and well-being allow the mind to proceed when the body is in homeostasis. Emotional readiness is a key factor in learning readiness, because it helps to support engagement and motivation to incorporate information. Intelligence is not a primary consideration in determining adult learning readiness, because learning readiness focuses on culture, personal values, physical and emotional status and past experiences in learning. Past experiences in learning rather than present experiences help to assess adult client's learning readiness. Societal constraints are not considered to be a relevant factor in determining adult learning, because adult learning is based on the variety of interactive factors noted. Education mandates do not affect adult learning readiness but can affect what content may be taught. Attention to detail impacts learning style but does not directly impact adult client's learning readiness. One's mobility status does not directly the adult client's learning readiness, because it is not critical to a specific teaching moment. Legal mandates do not impact the adult client's learning readiness, because it is not critical to a specific teaching moment. Financial status does not impact the adult client's learning readiness, because it is not critical to a specific teaching moment.

The nurse is teaching an elderly client about heart failure. What action will the nurse do to enhance learning? ○ provide the necessary information in one teaching session ○ sit in a chair a few feet away from the client ○ look at notes to ensure all information is covered ○ frequently repeat the provided information

frequently repeat the provided information Explanation: Effective teaching strategies for older adults include frequent repetition of information. Giving small amounts of information in multiple sessions is more effective for learning than providing a lot of information in one teaching session. The nurse needs to look at the client rather than notes to assist the client with speech reading. The nurse should sit near the client so the client can hear the nurse.

Staff at the local public health department have generated a list of topics that were identified by community members. Which location(s) will the staff identify to hold educational programs for the participants? Select all that apply. ○ high school ○ health clinic ○ recreation center ○ community college ○ place of worship

high school health clinic recreation center community college place of worship Explanation: Health promotion programs can be offered in many different community venues. Common physical sites used for these programs include high schools, recreation centers, colleges, local health clinics, places of worship, and even private homes. Health promotion programs can occur almost anywhere, and the outreach idea is based on serving the needs of many adults who otherwise would not avail themselves of these opportunities to improve their health.

Health education of a client by the nurse ○ is an independent function of nursing practice. ○ requires a physician's order. ○ must be approved by the physician. ○ must focus on wellness issues.

is an independent function of nursing practice. Explanation: Health education is an independent function of nursing practice and is included in all state nurse practice acts. Teaching, as a function of nursing, is included in all state nurse practice acts. Health education is a primary responsibility of the nursing profession. Health education by the nurse focuses on: promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

A nurse has engaged a translator to help in communicating with a client. When asking questions of the client and obtaining answers, the nurse should: ○ look at the client while asking questions and carefully listen to the client's response. ○ record each session to avoid any later confusion or disputes over what was said. ○ take careful notes as the translator speaks. ○ make sure that a family member is present at all times.

look at the client while asking questions and carefully listen to the client's response. Explanation: When using a translator with clients who speak little or no English, the nurse must look at the client, not the translator, when asking questions and listening to the client's response. There is no need to record the communication. Notes may be taken, but this is not the approach for asking questions and obtaining answers. Although family may be present, it is not mandatory for communication using a translator and, in some cases, may actually hinder the communication.

The nurse is instructing a client on the preparation and self-administration of insulin. Which technique will the nurse use to facilitate the client's emotional readiness to learn the skill? ○ lecture ○ follow-up ○ teach-back ○ online instruction

teach-back Explanation: Emotional readiness can be promoted by creating a warm, accepting, positive atmosphere and by establishing realistic learning goals. One strategy that facilitates learner success is the teach-back technique. This technique is used to evaluate the recall and understanding by the learner after health teaching has occurred. It is a useful, in-the-moment feedback and evaluation method because it allows the educator to discover if the learner can effectively verbalize information or demonstrate a particular health behavior. Actively involving the client in the teaching promotes receptivity and motivation. The feedback provided on the client's performance and progress also motivates learning. Lectures are explanation methods of teaching and should be accompanied by discussion because this affords learners opportunities to express their feelings and concerns, ask questions, and receive clarification. Lectures, however, are not identified as a technique to support emotional readiness to learn. Follow-up sessions promote confidence and serve to determine additional teaching sessions; however, they do not support emotional readiness to learn. Online instruction is used to provide health information; however, this method may not be appropriate for the client needing to learn a skill. This technique is not identified as facilitating emotional readiness to learn.