Nursing Process Exam 5 Class 18

A nurse is preparing to care for her newly admitted patient. The person who accompanied the patient informs her that he is from the Middle East and speaks very little English. He is unsure of the patient's primary language. The hospital has no interpreters available who speak any Middle Eastern language. List at least four alternative interventions the nurse can use to communicate with the patient.

-Greet the client with respect, and be aware of nonverbal cues. If you are able to identify one, use a third language or one that is similar to their spoken language (e.g. French is spoken by some Vietnamese). -Speak in English slowly and clearly, using simple sentences to talk about one problem or need at a time, using gestures. -Restate information in different words if it appears the client does not understand your initial attempts. -Use pictures or diagrams. -Use written language in short, simple sentences. -Use the Internet or computer software to translate words into the Middle Eastern language. -Have the patient type information in his native language, using the Internet or computer software, and convert it into English.

A patient reports experiencing gas, abdominal bloating, and diarrhea after consuming milk or cheese. Lactose intolerance might immediately be suspected if the patient is of which heritage? 1) African American 2) Mexican American 3) European American 4) Arab American

1) African American

The nurse is admitting a Roman Catholic adult patient who is critically ill. Based on her knowledge of the patient's religion, for which religious practice should she expect to notify the hospital chaplain? 1) Anointing of Sick 2) Baptism 3) Eucharist 4) Sacrament of Reconciliation

1) Anointing of Sick

A Muslim client has asked the nurse to pray with her. Which item should the nurse anticipate that the patient may request before praying? 1) Bathing water 2) Rosary beads 3) Mala beads 4) Prayer cloth

1) Bathing water

Which is the first stage of sexual arousal? 1) Desire 2) Excitement 3) Stimulation 4) Orgasm

1) Desire

Which statement best describes theology? 1) Discussions and theories related to God and His relation to the world 2) Doctrines about the human soul and its relation to eternal life 3) A lifelong journey involving accumulation of experience and understanding 4) Codes of conduct that integrate beliefs and values

1) Discussions and theories related to God and His relation to the world

A 17-year-old woman with Down syndrome is brought to the emergency department by her parents after an incident of sexual assault by her uncle. What would you do when providing care to her after the incident? Select all that apply. 1) Document pregnancy status with a urine or blood sample. 2) Advise parents to have her tested for STIs 1 week after the incident. 3) Administer the hepatitis B and HPV vaccines, as ordered. 4) Refer the victim to a sexual assault center for further information and counseling.

1) Document pregnancy status with a urine or blood sample 2) Advise parents to have her tested for STIs 1 week after the incident 3) Administer the hepatitis B and HPV vaccines, as ordered

Which core issue of spirituality includes a patient's basic human need for achievement? 1) Hope 2) Faith 3) Love 4) Forgiveness

1) Hope

A patient who came from Central America is admitted with diabetes mellitus. The nurse is collecting biographical information. Which information provided by the patient represents his ethnicity? 1) Latino 2) Catholic 3) White 4) Teacher

1) Latino

A Hispanic patient is frustrated because the healthcare team does not understand the importance of hot and cold therapies. Which nursing diagnosis is most appropriate for this patient? 1) Powerlessness 2) Impaired Verbal Communication 3) Spiritual Distress 4) Risk for Noncompliance

1) Powerlessness

You are caring for 35-year-old man who tells you that he feels distress about being a male, and ever since he was a young child has thought of himself as a female. He describes the isolation he feels and concern about fitting in socially and at work because of these recurrent thoughts. How would you respond to your patient? 1) Provide information about support groups and other community resources for transsexual people. 2) Reassure him that he is normal, saying there are more people than we know who feel this way. 3) Share with him that you personally have had thoughts like this but have coped with these thoughts. 4) Suggest your patient seeks mental health care for medication to help him deal with his anxiety.

1) Provide information about support groups and other community resources for transsexual people

An agnostic nurse is caring for a devoutly religious patient. The client says, "I am so frightened. Please say a prayer with me." The patient begins praying aloud. What should the nurse do? 1) Remain quietly beside the bed until the client finishes the prayer. 2) Walk quietly from the room while the client is praying. 3) Stop the client and say, "I am not comfortable with prayer. I will get someone to join you." 4) Stay during the prayer and say "Amen" at pauses and when the prayer is finished.

1) Remain quietly beside the bed until the client finishes the prayer

A patient is prescribed a low-sodium, low-fat diet. How can the nurse best ensure that the patient follows the prescribed diet during hospitalization? 1) Make sure dietary services sends a low-sodium, low-fat meal tray. 2) Arrange for meals that accommodate his cultural dietary practices and specified diet. 3) Ask the patient's family to bring in from home the foods he typically eats. 4) Sit with the patient while he eats to make sure he consumes the prescribed diet.

2) Arrange for meals that accommodate his cultural dietary practices and specified diet

During the admission assessment, a patient tells the nurse that he does not believe there is a God. The nurse should document his religious affiliation as: 1) Agnostic 2) Atheist 3) Christian Scientist 4) Rastafarianism

2) Atheist

A long-term care facility has started a program to increase the cultural competence of its employees. When notified of this, a nurse thinks to himself, "I don't have time for this nonsense. I already know all I need to about culture, and I don't really like taking care of so many different kinds of people anyway." This most clearly illustrates the nurse's lack of cultural: 1) Awareness 2) Desire 3) Exposure 4) Knowledge

2) Desire

North American healthcare culture typically reflects which culture? 1) Asian 2) European American 3) Latino 4) African American

2) European American

The nurse is caring for a 42-year-old, Chinese American patient who underwent emergency coronary artery bypass graft surgery. He is self-employed and has no health insurance. Each day members of his family spend hours at his bedside. Which is the most important factor for the nurse to focus on when planning the patient's discharge? 1) Ethnic background 2) Family support 3) Employment status 4) Healthcare coverage

2) Family support

A 65-year-old widow is being given an annual physical exam. She states she has been dating a widowed man for 9 months and that the relationship is fulfilling in most areas. However, she is unable to have sexual relations because she feels she is "cheating" on her husband, who died 5 years ago. Her partner is very understanding, although her inability to have sexual relations is becoming a strain on their relationship. What is an appropriate nursing diagnosis for this woman? 1) Sexual Dysfunction related to conflicted sexual orientation 2) Ineffective Sexuality Patterns related to values conflicts 3) Ineffective Sexuality Patterns related to impaired relationship with partner 4) Sexual Dysfunction related to fear of the unknown

2) Ineffective sexuality patterns related to values and conflicts

Which topic is most important to include when educating all clients about sexuality? 1) Contraception 2) Sexually transmitted infections (STIs) 3) Sexual orientation 4) Sexual identity

2) Sexually transmitted infections (STIs)

A patient of Mormon faith is admitted to the hospital with new onset diabetes mellitus. Based on his religious affiliation, which item(s) should the nurse remove from the patient's dinner tray? Select all that apply. 1) Pork 2) Tea 3) Meat 4) Coffee

2) Tea 4) Coffee

The nurse preparing a Latino patient for a diagnostic procedure states, "After the cardiac catherization, you will need to be supine. We will also assess you for a thrombus." Which statement below is true? 1) The statements are appropriate to teach the patient about the procedure. 2) The nurse is using healthcare jargon in her explanation to the patient. 3) The nurse should use an interpreter to explain the procedure to the patient. 4) The information will have to be repeated to a family member, when he/she arrives.

2) The nurse is using healthcare jargon in her explanation to the patient

Which of the following questions would provide information about "O" in a HOPE assessment and "S" in a SPIRIT assessment? 1) Do you have any dietary restrictions or needs on religious holidays? 2) What is your religion or what church do you go to? 3) How comfortable are you with discussing spirituality? 4) Do you have an advance directive?

2) What is your religion or what church do you go to?

Which of the following is a DSM category of sexual deviation that a client might require mental health care? 1) Homosexuality 2) Voyeuristic disorder 3) Bisexuality 4) Transgenderism

2) voyeuristic disorder

A patient who moved to the United States from Italy comes to the clinic for medical care. The patient has been in this country for several years and has adopted some elements of her new country. Yet, she still retains some customs from her homeland. This patient is experiencing: 1) Assimilation. 2) Socialization. 3) Acculturation. 4) Immigration.

3) Acculturation

Based on a nursing diagnosis of Ineffective Sexuality Patterns related to values conflicts, what would be the most effective nursing intervention for a patient? 1) Educate the patient about sexual orientation and function. 2) Encourage the patient to discuss relationship problems with her partner. 3) Advise the patient to discuss her value conflict with a counselor. 4) Instruct the patient on effective methods to identify fears.

3) Advise the patient to discuss her value conflict with a counselor

When taking a cultural history, all of the following are important. Which one is most important to later plan for patient safety? 1) Obtain data directly from the patient. 2) Show empathy and respect; build rapport. 3) Ask about use of alternative medicine and folk remedies. 4) Ask open-ended questions when beginning the assessment.

3) Ask about use of alternative medicine and folk remedies

An 18-year-old high-school senior comes to the local family planning clinic requesting birth control pills. When discussing sexual health with the adolescent girl, your first nursing priority would be to do which of the following? 1) Urge the teen to practice healthful sexual behaviors. 2) Inform her about the risk of pregnancy and STIs. 3) Assess the teen's knowledge of sexuality and reproduction. 4) Provide detailed information about birth control pills.

3) Assess the teen's knowledge of sexuality and reproduction

A patient of Scandinavian heritage is admitted for observation after sustaining injuries in a motor vehicle accident. The nurse expects that he may endure pain stoically, without grimacing or vocalizing. The nurse's thinking is an example of a/an: 1) Archetype 2) Bias 3) Prejudice 4) Stereotype

3) Prejudice

Which of the following is considered a religious denomination within the tradition of Christianity? 1) Buddhism 2) Rastafarianism 3) Mormonism 4) Islam

3) mormonism

When performing a spiritual assessment, who is the preferred source of information? 1) Durable power of attorney 2) Next of kin 3) Patient 4) Patient's clergy person

3) patient

You are caring for a healthy 28-year-old man with a fractured tibia (bone in the lower leg). The patient has asked you to place his penis in the urinal and hold it while he voids. You should: 1) assist the patient as he has requested. 2) immediately leave the room. 3) tell him his behavior is inappropriate. 4) report him to your supervisor.

3) tell him his behavior is inappropriate

A patient remarks to the nurse, "What's the point of going through all these medical treatments? They make me feel so bad, and I will never be well anyway." What is the most helpful action for the nurse to take? 1) Explore with the patient what has triggered his emotions. 2) Treat the patient with dignity and respect. 3) Pray with the patient in a private setting. 4) Assist the patient to identify areas of hope in life.

4) Assist the patient to identify areas of hope in life

Which of the following is the most important information to collect at a women's health examination for a 52-year-old woman? 1) Age at first sexual encounter 2) History of PMS 3) Birth control method used 4) Date of last menstrual period

4) Date of last menstrual period

Because of religious beliefs, which of the following patients will most likely refuse a blood transfusion? One who is affiliated with? 1) Islam 2) Mormonism 3) Hinduism 4) Jehovah's Witnesses

4) Jehovah's witness

Which intervention by the nurse best indicates that she values a Native American patient's beliefs and indigenous healthcare system? 1) Incorporating Native American practices into care based on consultation with a cultural resource book 2) Explaining the values and beliefs of the traditional healthcare system to the patient so that the patient understands what is occurring 3) Contacting a Native American resource group for information about the culture 4) Planning how to incorporate traditional practices and beliefs through discussion with the patient

4) Planning how to incorporate traditional practices and beliefs through discussion with the patient

While admitting a patient with a particular religious heritage, the nurse comments to another nurse, "This is going to be a pain. This kind of patient always has a million family members in and out, and they're always so noisy and demanding." This illustrates: 1) Discrimination 2) Sexism 3) Ethnocentrism 4) Prejudice

4) Prejudice

Which factor is held in common by many of the world religions? 1) Strict health code, including dietary laws 2) Belief that one must submit to a god or supernatural being 3) Rules prohibiting alcohol consumption 4) Sacred writings that reveal the nature of the Supreme Being

4) Sacred writings that reveal the nature of the supreme being

What is the term for a person who feels a personal identity as the opposite gender for which he or she was born? 1) Transvestite 2) Intersexual 3) Homosexual 4) Transsexual

4) Transsexual

What do shared touching, celibacy, masturbation, and developing intimate relationships have in common? They are all: 1) forms of sexuality or sexual orientation. 2) cues to use in formulating a nursing diagnosis. 3) important in the development of sexual identity. 4) forms of sexual expression.

4) forms of sexual expression

The process a person goes through to adapt to a new culture is referred to as which of the following? A. Acculturation B. Cultural competence C. Culture shock D. Phenomena of culture

A. Acculturation

Stereotyping in nursing may result in which of the following? A. Inaccurate assessments and inappropriate interventions B. More frustration on the part of the nurse than the client C. Less frustration on the part of the nurse and the client D. Enhanced participation of family and patients

A. Inaccurate assessments and inappropriate interventions

Mr. Caruthers and Mrs. Duncan are older adults, widowed, and live in separate rooms in an assisted living facility. The nurse aide reports to the nurse that she has just seen the couple kissing and holding hands. The nurse aide then begins to laugh. What is the best nursing action? A. Instruct the nurse aide that older adults still experience sexual pleasure. B. Call the administrator and inform her of the couple's action. C. Tell the nurse aide to confront the couple and tell them to act their age. D. Laugh with the nurse aide, and tell her that nothing will happen anyway because the couple is old.

A. Instruct the nurse aide that older adults still experience sexual pleasure

When a patient is giving his sexual history to the nurse, he states that he has a same-sex partner. What is the nurse's best response? A. "I have some material that will help you to overcome your condition." B. "Tell me about your partner." C. "I can put you in touch with a wonderful psychiatrist." D. "It will be better for you if you do not share that information with the rest of the staff."

B. "Tell me about your partner."

Mrs. Blankenship is a 52-year-old woman who has come to the clinic for her "well woman" check. She states to the nurse, "I think I'm beginning menopause." What is the nurse's best response? A. "Oh, it will be so wonderful for you not to be bothered by your monthly menses anymore." B. "What are your feelings about that?" C. "You will need to start taking hormone replacement therapy now." D. "Menopause is a normal occurrence, and you don't need to worry about it at all."

B. "What are your feelings about that?"

A nurse is using a interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and his family? Select all that apply. A. Talk to the interpreter about the family while the family is in the room B. Ask the family one question at a time C. Look at the interpreter when asking the family questions D. Use lay terms if possible E. Do no interrupt the interpreter and the family as they talk

B. Ask the family one question at a time D. Use lay terms if possible E. Do no interrupt the interpreter and the family as they talk

A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the client? A. I will make sure the menu includes kosher options B. I will discuss the daily schedule with the client to make sure the client will have time for prayer C. I will make sure to use direct eye contact when speaking with this client D. I will make sure daily communion is available for this client

B. I will discuss the daily schedule with the client to make sure the client will have time for prayer

Mary, a young adult female, has experienced a miscarriage after 10 weeks of pregnancy. She is crying and states that this probably happened because her husband does not believe in God. What is your best your best response to Mary? A. "God doesn't punish people for their beliefs." B. "Do you want to talk about your anger at your husband's lack of faith?" C. "You sound very upset. Would you like to talk about these feelings?" D. "You sound really upset. Would you like to see the hospital chaplain?"

C. "You sound very upset. Would you like to talk about these feelings?"

When a newborn baby is identified as a boy, we are noting the baby's A. gender role. B. gender identity. C. gender. D. gender choice.

C. Gender

You are assigned a patient who speaks Vietnamese. He is to begin chemotherapy in the morning. To explain his treatment to him, you will use which of the following people? A. Family member B. Asian staff member C. Hospital interpreter D. Friend of the patient

C. Hospital interpreter

A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? A. Contact the hospital's spiritual services B. Ask him what is making him cry C. Provide quiet times for these moments D. Turn on the television for a distraction

C. Provide quiet times for these moments

A person who spends a great deal of time reviewing his belief system and comparing and contrasting it with alternatives is experiencing which of the following? A. Spiritual growth B. Religiosity C. Religious struggle D. Spiritual distress

C. Religious struggle

A male clinical instructor tells a female nursing student that she will definitely pass her clinical rotation if she agrees to go on a date with him. This is an example of which of the following? A. Date rape B. Negative intimate relationship C. Sexual harassment D. Sexual masochism

C. Sexual harassment

A nurse is caring for a client who shares the nurse's religious background. Which of the following information should the nurse anticipate? A. Members of the same religion share similar feelings about their religion B. A shared religious background generates mutual regard for one another C. The same religious beliefs can influence individuals differently D. The nurse and client should discuss the differences and commonalities in their beliefs

C. The same religious beliefs can influence individuals differently

What religion teaches reliance on God for healing rather than medicine or surgery?

Christian Scientist

List the six cultural specifics affecting health.

Communication Space Social organization Time orientation Environmental control Biological variations

Mr. Jones, a former patient who survived a serious illness, comes to your patient care unit on Saturday afternoon. He has packets of literature about his religion; its philosophy, values, meeting places; and some prayers. He asks if he can place the information in the family waiting area. What is your best response? A. "Yes, this would be helpful for many of the families. B. "No, hospital policy doesn't allow for it." C. "I would be happy to do it for you. Let's place the literature in the staff lounge." D. "I will need to check the hospital's policy and discuss your request with my manager."

D. "I will need to check the hospital's policy and discuss your request with my manager."

Of the following cultural groups, which is at high risk for sickle cell anemia? A. Alaskan Native B. Pacific Islander C. Hispanic D. African American

D. African American

A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses should the nurse make? A. I believe in this case you should really make an exception and accept the blood transfusion B. I know your family would approve of your decision to have a blood transfusion C. Why does you religion mandate that you cannot receive any blood transfusions? D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.

D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.

What is Painful intercourse called?

Dyspareunia

What is it called when someone exposes genitals to an unsuspecting person?

Exhibitionism

List three core issues of spirituality.

Faith Hope Love

What three key dimensions are assessed with the JAREL spiritual well-being scale?

Faith/belief Life/self-responsibility Life satisfaction/self-actualization

True or False? A nurse and client of the same race who speak the same language will not experience problems in communication.

False

True or False? After having surgery for benign prostatic hypertrophy, a male patient will always experience impotence.

False

True or False? Shared touch can be a way to maintain celibacy.

False

True or False? The nursing diagnosis Ineffective Sexuality Patterns can be used when describing vaginismus.

False

What is it called when someone is born with ambiguous sex organs?

Hermaphrodite

What religion uses five pillars of faith; forbidden to eat pork?

Islamic

What religion will not accept whole blood transfusions but will allow the administration of albumin?

Jehovah's Witness

What religion observes strict dietary laws, wears skull cap (yarmulke or kippah) and follows written law (Torah)?

Jewish

Beginning of menstruation is called?

Menarche

Follows strict health code; avoids alcohol, tea, coffee, and smoking

Mormon

What religion believes all harmony and disease is based in spirituality?

Native American

What is Libido?

Sex drive or desire

True or False? A stereotype is a preconceived and untested belief about people or groups of people.

True

True or False? An important issue about sexually transmitted infections is that many patients are asymptomatic.

True

True or False? Race is defined as the physical characteristics that are shared by a specific ethnic group.

True

NANDA-I has two nursing diagnoses for describing sexual problems: Ineffective Sexuality Patterns and Sexual Dysfunction. How would you determine which diagnosis to use on a client? 1) Use Ineffective Sexuality Patterns when the patient expresses concern about the ability to achieve his perceived sex role. 2) Use Ineffective Sexuality Patterns when the patient is seeking confirmation of desirability. 3) Use Sexual dysfunction when the patient is experiencing values conflicts in the area of sexuality. 4) Use Sexual Dysfunction when the patient expresses dissatisfaction with an actual change in sexual functioning.

Use Sexual Dysfunction when the patient expresses dissatisfaction with an actual change in sexual functioning (e.g., difficulty maintaining an erection).