Saunders Nclex Fundamentals review
The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? a. Continue with the instructions, verifying client understanding. b. Walk around the client so that the nurse conb. stantly faces the client. c. Give the client a dietary booklet and return later to continue with the instructions. d. Tell the client about the importance of the instructions for the maintenance of health care.
a. Continue with the instructions, verifying client understanding. Most Chinese Americans maintain a formal distance with others, which is a form of respect. Many Chinese Americans are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with this cultural practice. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading
A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply. a. Ensures that a close relative stays with the client b. Makes a referral for a Catholic priest to visit the client c. Removes the crucifix from the wall in the client's room d. Administers the sacrament of the sick to the client if death is imminent e. Offers to provide a means for praying the rosary if the client wishes f. Reminds the dietary department that meals served on Fridays during Lent do not contain meat
a. Ensures that a close relative stays with the client b. Makes a referral for a Catholic priest to visit the client e. Offers to provide a means for praying the rosary if the client wishes In times of illness, a Roman Catholic client may turn to prayer for spiritual support. This may include rosary prayers or visits from a priest, who is the spiritual leader in the Roman Catholic faith. Close family members usually want to stay with a dying family member in order to hear the wishes of the client, allowing the soul to leave in peace. A priest, not a nurse, would administer the sacrament of the sick. Roman Catholics would not ask for the crucifix to be removed. Members of other religious groups such as Islam or Judaism may request the removal of the crucifix. Dietary rituals are not a concern at this time.
Which clients have a high risk of obesity and diabetes mellitus? Select all that apply. a. Latino American man b. Native American man c. Asian American woman d. Hispanic American man e. African American woman
a. Latino American man b. Native American man d. Hispanic American man Because of their health and dietary practices, Latino Americans, Native Americans, Hispanic Americans, and African Americans have a high risk of obesity and diabetes mellitus. Owing to dietary practices, Asian Americans have a lower risk for obesity and diabetes mellitus.e. African American woman
he nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? a. Reassess the client. b. Conduct a staff meeting to describe the fall. c. Document in the nurse's notes that an incident report was completed. d. Contact the nursing supervisor to update information regarding the fall.
a. Reassess the client. After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior a. Reflecting a cultural value b. An acceptance of the treatment c. Client agreement to the required procedures d. Client understanding of the preoperative procedures
a. Reflecting a cultural value Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure.
he nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia. a. U waves b. Absent P waves c. Inverted T waves d. Depressed ST segment e. Widened QRS complex
a. U waves c. Inverted T waves d. Depressed ST segment The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.
The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response? a. "A group of individuals identifying as a part of the Iroquois tribe among Native Americans." b. "A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S." c. "A group of individuals living in the Azores that identify autonomously but are a part of the larger population of Portugal." d."A person who has grown up in the Philippines and chooses to stay there because of the sense of belonging to his or her cultural group."
b. "A person who moves from China to the United States (U.S.) and learns about and adapts to the culture in the U.S." Acculturation is a process of learning a different culture to adapt to a new or changing environment. Options 1 and 3 describe a subculture. Option 4 describes ethnic identity
When communicating with a client who speaks a different language, which best practice should the nurse implement? a. Speak loudly and slowly. b. Arrange for an interpreter to translate. c. Speak to the client and family together. d. Stand close to the client and speak loudly.
b. Arrange for an interpreter to translate. Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation
The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. a. Peas b. Raisins c. Potatoes d. Cantaloupe e. Cauliflower f. Strawberries
b. Raisins c. Potatoes d. Cantaloupe f. Strawberries The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, and tomatoes. Peas and cauliflower are high in magnesium.
The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? a. Sustained tissue damage b. Requires nasogastric suction c. Has a history of Addison's disease d. Uric acid level of 9.4 mg/dL (559 mmol/L)
b. Requires nasogastric suction The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia. Test taking strategy Note that the subject of the question is potassium deficit. First recall the normal uric acid levels and the causes of hypokalemia to assist in eliminating option 4. For the remaining options, note that the correct option is the only one that identifies a loss of body fluid
The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? a. Weight loss and dry skin b. Flat neck and hand veins and decreased urinary output c. An increase in blood pressure and increased respirations d. Weakness and decreased central venous pressure (CVP)
c. An increase in blood pressure and increased respirations A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit Test-Taking Strategy: Focus on the subject, fluid volume excess. Remember that when there is more than one part to an option, all parts need to be correct in order for the option to be correct. Think about the pathophysiology associated with a fluid volume excess to assist in directing you to the correct option. Also, note that the incorrect options are comparable or alike in that each includes manifestations that reflect a decrease.
Which is the best nursing intervention regarding complementary and alternative medicine? a. Advising the client about "good" versus "bad" therapies b. Discouraging the client from using any alternative therapies c. Educating the client about therapies that he or she is using or is interested in using d. Identifying herbal remedies that the client should request from the health care provider
c. Educating the client about therapies that he or she is using or is interested in using Complementary and alternative therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role. Options 1, 2, and 4 are inappropriate actions for the nurse to take because they provide advice to the client.
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action? a. Advise the client to read the labels of herbal therapies closely. b. Tell the client that herbal substances are not safe and should never be used. c. Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). d. Tell the client that if he takes the herbal substance he will need to have his blood pressure checked frequently
c. Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be encouraged to avoid herbal substances because the combination may lead to an excessive reaction or to unknown interaction effects. The nurse should advise the client to discuss the use of the herbal substance with the HCP. Therefore, options 1, 2, and 4 are inappropriate nursing actions.
An Asian American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method? a. Prayer b. Magnetic therapy c. Foods considered to be yin d. Foods considered to be yang
c. Foods considered to be yin In the Asian American culture, health is believed to be a state of physical and spiritual harmony with nature and a balance between positive and negative energy forces (yin and yang). Yin foods are cold and yang foods are hot. Cold foods are eaten when one has a hot illness (fever), and hot foods are eaten when one has a cold illness. Options 1 and 2 are not health practices specifically associated with the Asian American culture or the yin and yang theory.
Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet? a. Pork roast, rice, vegetables, mixed fruit, milk b. Crab salad on a croissant, vegetables with dip, potato salad, milk c. Sweet and sour chicken with rice and vegetables, mixed fruit, juice d. Noodles and cream sauce with shrimp and vegetables, salad, mixed fruit, iced tea
c. Sweet and sour chicken with rice and vegetables, mixed fruit, juice Members of Orthodox Judaism adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven hoofed, and ritually slaughtered
The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? a. "I cannot have surgery." b. "I cannot have any medicine." c. "I believe the soul lives on after death." d. "I cannot have any food containing or prepared with blood."
d. "I cannot have any food containing or prepared with blood." Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. For a Jehovah's Witness, administration of medication is an acceptable practice except if the medication is derived from blood products. This religious group believes that the soul cannot live after death. Jehovah's Witnesses avoid foods prepared with or containing blood.
The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories? a. "CAM includes biologically based practices." b. "Whole medical systems are a component of CAM." c. "Mind-body medicine is part of the CAM approach." d. "Magnetic therapy and massage therapy are a focus of CAM."
d. "Magnetic therapy and massage therapy are a focus of CAM." The 5 main categories of CAM include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. Magnetic therapy and massage therapy are therapies within specific categories of CAM