Chapter 5: Cultural and Spiritual Assessment
A nurse knocks and enters a client room, makes introductions to the client and visitors, and explains to the client that she would like to conduct an interview so a plan of care can be completed. Which statement by the nurse would be most appropriate?
"Mrs. Smith, I would like to conduct an interview with you but I see you have visitors. I will come back in about 30 minutes so you can visit before you and I sit privately to talk." Explanation: Recognizing visitors but setting a time for returning to discuss privately gives everyone time to talk and visit but does not cause a long delay for the important interview.
Which of the following questions is most useful in the assessment of a client's diabetes management?
"What is your routine for checking your blood sugar these days?" Explanation: "What is your routine for checking your blood sugar these days?" is an open-ended question designed to elicit as much information as possible about how the client is monitoring blood sugar. The other choices are leading questions that clearly signal a "right" answer; the client might feel reluctant to respond "incorrectly." These questions also elicit yes-no responses; closed-ended questions such as these are appropriately used to clarify or obtain more accurate information about issues disclosed in response to open-ended questions.
During the comprehensive health assessment, the nurse asks several questions relating to the client's family history of illnesses, such as diabetes and cancer. Why does the nurse do this? Select all that apply.
-To help identify those diseases for which the client may be at risk -To provide counseling and health teaching in high-risk areas -To identify genetic family trends for which the client is at risk Explanation: The nurse asks the client about the health of close family members (i.e., parents, grandparents, siblings) to help identify those diseases for which the client may be at risk and to provide counseling and health teaching. Information concerning client and family history may be elicited to identify genetic family trends. The primary reasons are not to identify a negative family history or help the client feel at ease and not worry about being sick.
A client reports pain as being 7 on a scale from 1 to 10. In which area of the symptom should the nurse document this information?
Characteristic Explanation: The seven attributes of a symptom should be assessed. The mnemonic OLD CART is used to ensure are all areas are included. Pain is documented under characteristic of the symptom. Onset identifies when the symptom began. Location is the body area including any radiation. Duration is the length of time the symptom lasts
The nurse has been assigned to a group of clients on a medical surgical unit. What is the best action of the nurse prior to receiving a report on these clients?
Conduct a brief review of the client's charts. Explanation: During the pre-introductory phase of the interview, the nurse should review the client's chart. Information from the chart may assist the nurse with conducting the interview. Physical assessment is conducted during the working phase of the interview. The introduction is done during the introductory phase of the interview. Validating problems and goals is performed during the summary and closing phase of the interview.
A nurse is assigned to care for a client who practices a religion different from her own. After reading the client's medical record, the nurse takes time to talk with the client about how to make his hospital stay more comfortable. The nurse admits to the client that she is not familiar with his religion but would like to learn more. The nurse is in which stage of cultural awareness?
Conscious incompetence Explanation: The nurse is aware of the lack of knowledge about the client's religion. Unconscious incompetence is not being aware that one lacks cultural knowledge. Conscious competence involves learning about the differences and providing culturally relevant interventions. Unconscious competence is the ability to automatically provide culturally competent care.
What concept is an approach to caring for clients from culturally diverse backgrounds?
Cultural humility Explanation: The concept of cultural humility is another approach for caring for clients from culturally diverse backgrounds.
A client is experiencing acute pain and has asked the nurse for medication. The client rates the pain as an 8 on a scale of 0 to 10. During assessment, a physiological response from the client that the nurse can expect is:
Diaphoresis Explanation: Diaphoresis is an expected physiological response to pain resulting from sympathetic nerve stimulation. Decreases in pulse, blood pressure, and muscle tension are not expected findings when a client is experiencing pain.
A client of African descent tells the nurse they communicate with the dead. How should the nurse respond?
Document the client's statement. Explanation: In African societies communicating with the dead is not considered pathologic. It is termed a "spell," in which a person communicates with dead relatives or spirits, often with distinct personality changes. Because this is considered normal in the client's culture, the nurse would not request a psychiatric consultation. The nurse may perform a comprehensive neurological exam, but it is not indicated in this situation. Documenting that the client is hearing voices is inaccurate. The nurse would document that the client stated, "I communicate with the dead."
The nurse is collecting data for a comprehensive health history on a client new to the clinic. Under what component of the health history would the nurse place data on a chronic childhood illness?
Explanation: Past History-Childhood illnesses, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever, and polio, are included in the Past History. Also included are any chronic childhood illnesses.
How would the nursing instructor explain the goal of guided questioning to his or her students?
Facilitating the client's fullest communication Explanation: The main goal of guided questioning is to facilitate the client's fullest communication. The early generation of a plan is not a paramount goal and it is incorrect to suggest particular answers to the client.
What is an important part of being present with a client?
Listening Explanation: Listening is an important part of being present with a client.
As a nursing student you learn that mastering all the components of the comprehensive history provides what?
Proficiency Explanation: Mastery of all the components of the comprehensive history provides proficiency and the ability to select the elements most pertinent to the client encounter.
A clinic nurse is conducting a comprehensive assessment of a client. The nurse observes that the client rarely makes eye contact and holds his head low during the assessment. Using knowledge of cultural practices how should the nurse best interpret this practice?
The client may be showing the nurse respect. Explanation: Members of certain cultures tend to look down to show respect to the person talking. This does not necessarily rule out the other possible explanations, but is a cultural factor the nurse should consider.
A client, sipping hot tea, is scheduled for routine vital signs. Which illustration shows the least appropriate method for the nurse to use to obtain an accurate temperature reading?
The oral temperature would give a falsely elevated reading because the client is sipping hot tea. The axillary temperature will take the longest to register, but would not be affected by the client's tea consumption. Both the tympanic and temporal artery methods are considered safe, reliable, and noninvasive and either would be most appropriate to use.
One of the body's normal physiologic responses to pain is
diaphoresis. Explanation: Diaphoresis is associated with acute pain.
The nurse takes a client's family history to identify diseases for which she is at risk. A common tool used by nurses to understand family patterns is what?
genogram Explanation: The genogram is a graphic representation used to understand family patterns. Altruism indicates a true concern for the welfare of others. The functional framework and Gordon's framework are two words for the same approach, whereby the nurse assesses the strengths of clients as well as areas needing improvement.
During which of the following phases of the interview process will the nurse assure the client that all personal data the client discusses with the nurse will be kept confidential?
introductory Explanation: The introductory phase includes the nurse's introduction to the client, explaining to the client about the type of questions that will be asked, and assuring the client of confidentiality in all areas that are discussed during the interview. The preintroductory phase occurs before the nurse meets the client. During the working phase the nurse obtains biographical data, reasons for seeking care, history of the present concern, past medical history, family history, and review of body systems (ROS). During the summary and closing phase, the nurse summarizes information obtained during the working phase and validates problems and goals with the client.
A client reports pain in the knee. The knee is warm, swollen, and red and the client describes the pain as aching and gnawing. The nurse determines the client is experiencing which of the following types of nociceptive pain?
somatic Explanation: The client is experiencing somatic pain, pain that occurs when stimuli in the tissues (skin, muscles, joints, skeleton, connective tissue) are activated. Neuropathic pain results when there is damage or dysfunction to the nervous system. Referred pain occurs when pain is in a body region that is distant from the actual source of the painful stimulus, such as pain in the jaw and shoulder when a person is experiencing a myocardial infarction. Phantom pain occurs when there is pain in a part of the body that has been removed, such as when a client reports pain in the right foot after a right above-the-knee amputation.