Physiological Aspects of Care, 1.3 Culture EAQ, Culture adaptive quiz, Adaptive quiz: professional identity, 38 Case Study, section 2 1st semester

3 Requirements from nurses over competency

•Expected component of nursing education and professional nursing practice •Requires underlying acceptance of patient's health beliefs •Requires adapting care to meet unique needs and perspectives of individual

Cultural imposition

tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group

The nurse leader is teaching the staff that the health care provider continuously strives to work effectively within the cultural context of a client. Which cultural principle is the nurse leader explaining?

Cultural competence

While auditing unit documents, a nurse finds some omissions. Which term best describes when the nurse meets with the staff to discuss the findings and communicates ways to achieve the desired goals?

Management

What does the nurse understand is the collaborative definition of delegation according to the American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN)?

"Delegation is the process for the nurse to direct another person to perform nursing tasks."

A prescription is written for famotidine (Pepcid) 20 mg intravenous piggyback (IVPB) every 12 hours. The vial is labeled 10 mg/1 mL. How many milliliters should the nurse administer? Record the answer using a whole number. _______ mL

2 Explaination: Have 10 mg 1 mL 10x = 20 x = 20 ÷ 10 x = 2 mL

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: 1.Early ambulation 2.Coughing and deep breathing 3.Wearing anti-embolic elastic stockings 4.Maintenance of a nasogastric tube

2.Coughing and deep breathing

Neomycin, 1 gram, is prescribed preoperatively for a client with cancer of the colon. The client asks why this is necessary. How should the nurse respond? 1."It is used to prevent you from getting a bladder infection before surgery." 2."It will decrease your kidney function and lessen urine production during surgery." 3."It will kill the bacteria in your bowel and decrease the risk for infection after surgery." 4."It is used to alter the body flora, which reduces spread of the tumor to adjacent organs."

3."It will kill the bacteria in your bowel and decrease the risk for infection after surgery."

A client's chest tube has accidentally dislodged. What is the nursing action of highest priority? 1.Place the client in a left side-lying position. 2.Apply oxygen via non-rebreather mask. 3.Apply a petroleum gauze dressing over the site. 4.Prepare to reinsert a new chest tube

3.Apply a petroleum gauze dressing over the site

A nurse is with the parents of a 3-year-old child who has just died. The most therapeutic question for the nurse to ask the parents is: 1 "Do you feel ready to consent to an autopsy?" 2 "Have you made a decision made about organ donation?" 3 "Would you like to talk about how you'll tell your other children?" 4 "Can I be of any help with traditional practices that are important to you?"

4 The nurse should be sensitive to any cultural or religious beliefs that may help the parents cope with their grief. Immediately discussing the topic of autopsy or organ donation is insensitive to the parents' grief at this time. The parents are too involved with their own grief at this time to consider their other children's grief.

What clinical finding indicates to the nurse that a client may have hypokalemia? 1.Edema 2.Muscle spasms 3.Kussmaul breathing 4.Abdominal distention

4.Abdominal distention

3. Mr. Burke's respiratory rate as determined by Cyrus is 42 breaths/min. This means that he is experiencing apnea. A. True B. False

Answer: B Rationale: Apnea is the absence of breath sounds. Tachypnea is more than 20 breaths/min.

Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what?

Be aware of any personal bias about sexual assault

Ethnocentrism

Belief in the superiority of one's nation or ethnic group.

1. Cyrus finds Mr. Burke restless, agitated, and confused. His pulse is 102 beats/min, and respirations are 42 breaths/min and shallow. He is sitting up in bed grasping the side rails and trying to catch his breath. He is most likely experiencing which of the following conditions? A. Hyperventilation B. Hypoventilation C. Hypoxia D. Dysrhythmia

Answer: C Rationale: Hypoxia is the decreased diffusion of oxygen from the alveoli to the blood, as in pneumonia. Signs and symptoms of hypoxia include apprehension, restlessness, inability to concentrate, decreased level of consciousness, dizziness, and behavioral changes. Vital sign changes include increased pulse rate and rate and depth of respiration.

Culture

Is a pattern of shared attitudes beliefs, self-definition, norms, roles, and values that can occur among those who speak a particular language or live in the defined geographic region

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps client: 1 Become aware of their personal values. 2 Gain information related to their needs. 3 Make correct decisions related to their health. 4 Alter their value systems to make them more socially acceptable

1 Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? (Select all that apply.) 1.Clients have a right to refuse treatment. 2.Nurses are required to answer clients truthfully. 3.The health care provider should have been notified. 4.The client had insufficient knowledge to make such a decision. 5.Legally prescribed medications are administered despite a client's objections

1.Clients have a right to refuse treatment. 2.Nurses are required to answer clients truthfully. 3.The health care provider should have been notified.

A child is to receive 60 mg of phenytoin (Dilantin). The medication is available as an oral suspension that contains 125 mg/5 mL. How many milliliters should the nurse administer? Record the answer using one decimal place. ______ mL

2.4 mL

The nurse manager of the unit comes to work obviously intoxicated. The staff nurse's ethical obligation is to: 1.Call the security guard 2.Tell the nurse manager to go home 3.Have the supervisor validate the observation 4.Offer the nurse manager a large cup of coffee

3.Have the supervisor validate the observation

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? 1.Insert a urinary catheter. 2.Initiate Droplet Precautions. 3.Move the client to a private room. 4.Use a high efficiency particulate air (HEPA) respirator during care

3.Move the client to a private room

A client receiving intravenous vancomycin (Vancocin) reports ringing in both ears. Which initial action should the nurse take? 1.Notify the primary healthcare provider. 2.Consult an audiologist. 3.Stop the infusion. 4.Document the finding and continue to monitor the client

3.Stop the infusion.

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1.Diplopia 2.Dysphagia 3.Tachypnea 4.Bradycardia 5.Hypotension

3.Tachypnea 5.Hypotension

After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review there will be: 1 Increased cultural sensitivity 2 Decreased cultural imposition 3 Decreased cultural dissonance 4 Increased cultural competence

4 Cultural competence encompasses sensitivity as well as knowledge, desire, and skill in caring for those who are different from one's self. The nurses are already somewhat sensitive to those from different cultures and now must move forward in their ability to care for these clients. The nurses are not imposing their culture on the clients; they are avoiding them. There is no clashing of cultures in this situation.

After abdominal surgery a client reports pain. What action should the nurse take first? 1.Reposition the client. 2.Obtain the client's vital signs. 3.Administer the prescribed analgesic. 4.Determine the characteristics of the pain

4.Determine the characteristics of the pain

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1.Oral psyllium (Metamucil) 2.Oral potassium supplement 3.Parenteral half normal saline 4.Parenteral albumin (Albuminar)

4.Parenteral albumin (Albuminar)

A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? 1.Assign articles about various cultures so that they can become more knowledgeable. 2.Relocate the nurses to units where they will not have to care for clients from a variety of cultures. 3.Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. 4.Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work

4.Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work

Which skills would be essential for an effective nurse manager to develop and improve collaboration with others? Select all that apply.

Ability to share information and ideas Flexibility Ability to listen to others

The professional obligation of a nurse to assume responsibility for actions is referred to as what?

Accountability

A nurse providing care in a hospital witnesses a client's spouse shaking the client vigorously because the client has had an episode of incontinence. Because of the suspicion of physical abuse, legally the nurse should discuss the concerns with which party?

Adult protective services

4. Mr. Burke coughs up bloody sputum that Cyrus sends to the laboratory. Bloody sputum is referred to as ____________.

Answer: Hemoptysis Rationale: Hemoptysis is bloody sputum that often accompanies respiratory illnesses such as pneumonia.

A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? Prejudice Stereotyping Assimilation Ethnocentrism

Assimilation Rationale Assimilation involves incorporating the behaviors of a dominant culture. Maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

Bicuturalism

Duel pattern of identification

The registered nurse is organizing a community health care program for administering tetanus vaccinations. Which member of the health care team is most suitable for delegating the task of administering vaccinations?

Licensed practical nurse

The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? Yin/Yang balance Biomedical belief Determinism belief Magicoreligious belief

Magicoreligious belief Rationale An African American client may have magicoreligious beliefs, which focuses on hexes or supernatural forces that cause illness. Such clients may believe that illness is a punishment for sins. The yin/yang belief system does not consider illness as a punishment. The biomedical belief system maintains that health and illness are related to physical and biochemical processes with disease being a breakdown of the processes. The belief of determinism focuses on outcomes that are externally preordained and cannot be changed.

Obesity in children is an ever-worsening problem. What concept should a nurse consider when caring for school-aged children who are obese? Enjoyment of specific foods is inherited. There are familial influences on childhood eating habits. Childhood obesity is usually not a predictor of adult obesity. Children with obese parents are destined to become obese themselves.

There are familial influences on childhood eating habits. Rationale Studies have demonstrated that culture and family eating habits have an impact on a child's eating habits. Inheritance is not known to influence eating habits, although it is believed that other hereditary factors are associated with obesity. Childhood obesity is a known predictor of adult obesity. Children with obese parents are not necessarily destined to become obese themselves.

Acculturation

the adoption of the behavior patterns of the surrounding culture

Enculturation

the process by which culture is learned and transmitted across the generations

A client with asthma and depression is admitted to the hospital. Which tasks delegated by the delegator would indicate the task is applicable for the registered nurse?

"Teach the client how to use a meter dose inhaler." According to Gardner's tasks of leading/managing, a behavior of the executive position is to assist corporate leaders with planning and priority setting. Leading inspires client/families to achieve their vision. A behavior of the management position is to inspire the staff to achieve the mission of the organization. A behavior of the clinical position is to ensure that the organizational systems work on the client's behalf.

An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? "The prevalence of hypertension is about equal for women of all races." "The higher-risk population is composed of African-American men and women." "The highest-risk population consists of older Caucasian-American men and women." "The prevalence of hypertension is greater for African-American men than for African-American women."

"The higher-risk population is composed of African-American men and women." Rationale African-Americans represent a higher-risk population than Caucasian-Americans for hypertension; the reason is unknown. African-American women are more frequently affected by hypertension than are Caucasian women. African-Americans of both sexes have a higher prevalence than Caucasian-Americans of both sexes. African-American women have a higher risk than African-American men.

A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? Contact an interpreter provided by the hospital. Contact the client's family member to translate for the client. Communicate with the client using Spanish phrases the nurse learned in a college course. Communicate with the client with the use of a hospital-approved Spanish dictionary.

Contact an interpreter provided by the hospital. Rationale Interpreters provided by the healthcare organization should be used to communicate with clients with limited English proficiency to ensure accuracy of communicated information. In hospital settings, it is not suitable for family members to translate healthcare information, but they can assist with ongoing interactions during the client's care. The other options do not ensure accurate interpretation of language.

A female nurse has been caring for a depressed 75-year-old woman who reminds her of her grandmother. The nurse spends extra time with her every day and brings her home-baked cookies. What does the nurse's behavior reflect?

Countertransference

Multiculturalism

A perspective recognizing the cultural diversity of the United States and promoting equal standing for all cultural traditions

During a routine checkup a client reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the client's weight and BMI at a healthy range, but the client states, "I wish I were as thin as my co-workers." The client is at risk for what culturally-bound condition? Neurasthenia Anorexia nervosa Shenjing shuairuo Ataque de nervios

Anorexia nervosa Rationale Anorexia nervosa is a Western culture-bound eating disorder characterized by obsession with body image. A client who continues to follow weight loss diets despite being a healthy weight may be at risk for malnutrition. The client with neurasthenia may feel a lack of energy but not necessarily from following a strict diet to maintain body image. Shenjing shuairuo is a condition associated with Chinese culture that focuses on a weakness of nerves and is not associated with eating disorders or body image. Ataque de nervios is a Latino-Caribbean culture-bound syndrome and is not associated with body image.

A pregnant immigrant notices cultural differences in the way that pregnant women are cared for where she now lives. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept these differences? Cultural desire Cultural awareness Cultural knowledge Cultural encounters

Cultural desire Rationale The nurse is using cultural desire as a part of cultural competence. This component is related to motivation and commitment towards the care of an individual. Through this, an immigrant may become open to cultural differences and accept them. Cultural awareness is an in-depth self-examination of backgrounds and recognizing biases and prejudices. Cultural knowledge is a comparative study about the beliefs and care practices of other cultures. Cultural encounter is about transcultural interactions for effective communication and development.

The nurse leader states, "The people in rural America dress and act differently from those in urban centers." What concept describes this statement? Acculturation Ethnocentrism Cultural imposition Cultural marginality

Cultural marginality Rationale Cultural marginality is defined as situations and feelings of passive betweenness when people exist between two different cultures. refers to adapting to a particular culture. It is a process by which a person becomes a competent participant in the dominant culture. Ethnocentrism refers to the belief that one's own ways are the best, most superior, or preferred ways to act, believe, or behave. Cultural imposition is defined as the tendency of an individual or group to impose their values, beliefs, and practices on another culture for varied reasons.

A 5-year-old child who is newly arrived from Latin America attends a nursery school where everyone speaks English. The child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. What is the probable reason for the child's behavior? Culture shock Social immaturity Experience of discrimination Lack of interest in school activities

Culture shock Rationale The child learned to think and solve problems in a different culture and language and may feel helpless in the new classroom. There are no data to indicate that social immaturity, discrimination, or lack of interest is the precipitating factor for the child's behavior.

Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women? Most weight gain is caused by fluid retention. Different cultural groups favor different essential nutrients. Dietary allowances should not increase throughout pregnancy. Pregnant women must adhere to a specific pregnancy dietary regimen.

Different cultural groups favor different essential nutrients. Rationale The nurse should become informed regarding the cultural eating patterns of clients so that foods containing the essential nutrients that are part of these dietary patterns may be included in the diet. Fluid retention is only one component of weight gain; growth of the fetus, placenta, breasts, and uterus also contributes to weight gain. The need for calories and nutrients increases during pregnancy. Pregnancy diets are not specific; they are composed of the essential nutrients.

The registered nurse (RN) is caring for an older client who has been admitted to the hospital. The RN allocates several tasks to the unlicensed nursing personnel (UNP). In order to evaluate the understanding of the UNP, the RN asks the UNP to describe which tasks have been allocated. Which responses given by the UNP indicate effective understanding of the tasks? Select all that apply

I must assist the client with oral care. "I must give a sponge bath to the client every morning." "I must monitor the blood pressure of the client at regular intervals.

What does the professional nurse consider to be the center of decision-making when providing client care?

Ethics of care

After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? Increased cultural sensitivity Decreased cultural imposition Decreased cultural dissonance Increased cultural competence

Increased cultural competence Rationale Cultural competence encompasses sensitivity as well as knowledge, desire, and skill in caring for those who are different from one's self. The nurses are already somewhat sensitive to those from different cultures and now must move forward in their ability to care for these clients. The nurses are not imposing their culture on the clients; they are avoiding them. There is no clashing of cultures in this situation.

The nurse leader mentors the staff on types of conflict. Which statement of the leader describes intrapersonal conflict?

It arises due to imbalances between the nurse's personal and professional priorities.

What should a nurse consider about the past experiences of clients who have immigrated to this country? It affects all of their inherited traits. There will be little impact on their lives today. It is important that their values be assessed first. How they will interact is permanently established.

It is important that their values be assessed first. Rationale Past experiences are important and must be recognized because they help set the individual's values throughout life. Past experiences will not affect inherited traits. Past experiences play an important role in an individual's life. Nothing establishes how an individual responds forever; new experiences continue to influence future responses.

A foreign language-speaking client needs to undergo chemotherapy; a signed consent form is required. What should the nurse do to explain the terms of the consent to the client? Seek the help of an official interpreter. Seek the help of the primary healthcare provider to assist the client. Seek help from the client's family friend who speaks the client's language. Seek help from the client's caregiver who speaks the same language as the client.

Seek the help of an official interpreter. Rationale The nurse should seek the help of an official interpreter to explain the terms of consent to the client. The nurse should not ask for the primary healthcare provider's assistance because he or she might not know the language. The nurse should not seek help from the client's family friend who speaks the language because he or she is not authorized to interpret health information. The nurse should not seek help from the client's caregiver who speaks the same language because he or she should not interpret health information.

A nurse is caring for an adult client who immigrated to this country 5 years ago. What does the nurse know about the past experiences of clients who have immigrated to this country? They affect their inherited traits. They have little effect on their lives today. They are important in assessment of their values. They establish personal interactions throughout life.

They are important in assessment of their values. Rationale Past experiences are important and must be recognized because they set the parameters for the individual's enduring values throughout life. Past experiences do not affect inherited traits. Past experiences play an important role in an individual's life. Nothing establishes how an individual responds over a lifetime; new experiences continue to influence future responses.

Which behavior would the nurse consider suitable for an executive position according to Gardner's tasks of leading/managing?

To assist corporate leaders with planning and priority setting According to Gardner's tasks of leading/managing, a behavior of the executive position is to assist corporate leaders with planning and priority setting. Leading inspires client/families to achieve their vision. A behavior of the management position is to inspire the staff to achieve the mission of the organization. A behavior of the clinical position is to ensure that the organizational systems work on the client's behalf.

A resident in a nursing home recently immigrated to the United States from Italy. How does the nurse plan to provide emotional support? 1 By offering choices consistent with the client's heritage 2 By ensuring that the client understands American beliefs 3 By assisting the client in adjusting to the American culture 4 By correcting the client's misconceptions about appropriate health practices

1 Adherence to a plan of care is enhanced by the nurse's providing choices consistent with the client's cultural beliefs and practices. The nurse's cultural or personal beliefs and biases should not influence or interfere with the implementation of appropriate care. Helping the client adjust to the American culture is not the priority at this time; care should be adapted to the client's needs and culture. The person's cultural practices should not be addressed unless they are detrimental to the person's health.

A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote: 1.Dental health. 2.Growth and development. 3.Improved hearing. 4.Night vision

1.Dental health.

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1.Monitor for signs of electrolyte imbalance. 2.Change the tube at least once every 48 hours. 3.Connect the nasogastric tube to high continuous suction. 4.Assess placement by injecting 10 mL of water into the tube

1.Monitor for signs of electrolyte imbalance.

A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity? 1.Nausea 2.Urticaria 3.Photophobia 4.Yellow vision

1.Nausea

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) 1.Take the aspirin with meals or a snack. 2.Make an appointment with a dentist if bleeding gums develop. 3.Do not chew enteric-coated tablets. 4.Switch to Tylenol (acetaminophen) if tinnitus occurs. 5.Report persistent abdominal pain

1.Take the aspirin with meals or a snack. 3.Do not chew enteric-coated tablets 5.Report persistent abdominal pain

A nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP? (Select all that apply.) 1.Taking routine vital signs. 2.Applying a sterile dressing. 3.Answering clients' call lights. 4.Administering saline infusions. 5.Changing linens on an occupied bed. 6.Assessing client responses to ambulation.

1.Taking routine vital signs. 3.Answering clients' call lights 5.Changing linens on an occupied bed

8 questions associated with the RESPECT Model when working with patients

1.What do you call the problem? 2.What do you think has caused the problem? 3.Why do you think it started when it did? 4.What do you think the sickness does? How does it work? 5.How severe is the sickness? Will it have a long or short course? 6.What kind of treatment do you think the patient should receive? 7.What are the chief problems the sickness has caused? 8.What do you fear most about the sickness?

Which topic should the nurse determine is most appropriate when presenting health-related instruction to clients from an African-American community? 1 Osteoporosis 2 Hypertension 3 Uterine cancer 4 Thyroid disorders

2 Hypertension is 78% more prevalent in African Americans than among Caucasian Americans; 30% of African Americans have hypertension. African Americans have approximately 50% less risk for osteoporosis than Caucasian Americans. Caucasian-American women are 30% more likely to be diagnosed with uterine cancer than African-American women. Statistics indicate that African Americans are less likely to develop thyroid disorders than Caucasian Americans.

A nurse is caring for a client who is receiving an intravenous (IV) infusion. What should the nurse do first if the IV infusion infiltrates? 1.Elevate the IV site. 2.Discontinue the infusion. 3.Attempt to flush the tubing. 4.Apply a warm, moist compress

2.Discontinue the infusion.

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? 1.Contact the family 2.Document the incident 3.Report the incident to the nurse manager 4.Escort the client to the radiology department

2.Document the incident

Based on the client's reported pain level, the nurse administers 8 mg of the prescribed morphine. The medication is available in a 10 mg syringe. Wasting of the remaining 2 mg of morphine should be done by the nurse and a witness. It is most appropriate for the nurse to ask which member of the health care team to be the witness? 1.Nursing supervisor 2.Licensed practical nurse (LPN) 3.Client's health care provider 4.Designated nursing assistant

2.Licensed practical nurse (LPN)

What are the clinical indicators that a nurse expects when an intravenous (IV) line has infiltrated? (Select all that apply.) 1.Heat 2.Pallor 3.Edema 4.Decreased flow rate 5.Increased blood pressure

2.Pallor 3.Edema 4.Decreased flow rate

A nurse is caring for a client with a diagnosis of polycythemia vera. The client asks, "Why do I have an increased tendency to develop blood clots?" Which effect of the polycythemia vera should the nurse include in the teaching session?

Increased blood viscosity

What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.) 1.Count the client's respirations. 2.Document the intensity of the client's pain. 3.Withhold the medication if the client reports pruritus. 4.Verify the number of doses in the locked cabinet before administering the prescribed dose. 5.Discard the medication in the client's toilet before leaving the room if the medication is refused

1.Count the client's respirations 2.Document the intensity of the client's pain. 4.Verify the number of doses in the locked cabinet before administering the prescribed dose.

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will: 1.determine adequate dosage levels of the drug." 2.detect if you are having an allergic reaction to the drug." 3.permit blood culture specimens to be obtained when the drug is at its lowest level." 4.allow comparison of your fever to when the blood level of the antibiotic is at its highest."

1.determine adequate dosage levels of the drug."

A client presents with a severe stiff neck, shuffling gate, and other extrapyramidal symptoms. Benztropine 2.5 mg by mouth is prescribed. The medication is available in 1-mg scored tablets. How many tablets should the nurse administer? Record the answer using one decimal place. _________ tablets

2.5 tabs

Who functions as a liaison between team leaders and other healthcare providers?

Charge nurse

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers?

Inspecting the skin daily

Assimilation

Process by which a person gives up his or her original Identity by becoming absorbed into the dominant culture group

A nursing assistant is frequently late for work and often tells the nurse manager that although he leaves his apartment early, he is delayed by heavy traffic. What defense mechanism is being used by the nursing assistant?

Rationalization

What is the function of the Professional Standards Review Organizations (PSROs) set up by the federal government?

To review the quality, quantity, and cost of hospital care

A woman who has just delivered an infant asks to take the placenta home with her upon discharge. What is the most appropriate response by the nurse? "I'll wrap that right up for you." "I'm sorry, but you can't do that." "I'll give it to you for your husband to take home now." "I need to check the hospital protocol for our policy on that practice."

"I need to check the hospital protocol for our policy on that practice." Rationale The placenta is a part of the body and therefore contains body fluids. It must first be assessed by the healthcare provider to be sure that it is not infected and to be sure that all parts of the placenta have been accounted for. The nurse must follow hospital policy regarding the release of the placenta to the family. All necessary documentation must be signed and the policies must be followed before the release of the placenta to the family.

Which role does a nurse play when helping clients to identify and clarify health problems and to choose appropriate courses of action to solve those problems?

Counselor

As a part of informed consent, a surgeon explains to the client who is scheduled for surgery the details of the surgery and the related care. The nurse as a leader witnesses the complete procedure. What information does the nurse leader ensure was provided to the client? Select all that apply.

Surgery procedures Name of surgeon Description of the risk

The preschool-age client is learning sociocultural mores. What should this imply to the nurse regarding this client? The child is developing a conscience. The child is learning about gender roles. The child is developing a sense of security. The child is learning about the political process.

The child is developing a conscience. Rationale Learning the sociocultural mores of the family implies that the child is developing a conscience. This does not imply that the child is learning gender roles, developing a sense of security, or learning about the political process.

The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? 1.Sunken eyes 2.Dry, flaky skin 3.Change in mental status 4.Decreased bowel sounds

3.Change in mental status

An adolescent is taken to the emergency department of the local hospital after stepping on a nail. The puncture wound is cleansed and a sterile dressing applied. The nurse asks about having had a tetanus immunization. The adolescent responds that all immunizations are up to date. Penicillin is administered, and the client is sent home with instructions to return if there is any change in the wound area. A few days later, the client is admitted to the hospital with a diagnosis of tetanus. Legally, what is the nurse's responsibility in this situation? 1.The nurse's judgment was adequate, and the client was treated accordingly. 2.The possibility of tetanus was not foreseen because the client was immunized. 3.Nurses should routinely administer immunization against tetanus after such an injury. 4.Data collection by the nurse was incomplete, and as a result the treatment was insufficient

4.Data collection by the nurse was incomplete, and as a result the treatment was insufficient

The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL

495 Explaination: Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL; output includes voidings of 150, 220, and 235 mL, for a total output of 605 mL. Subtract 605 mL from 1100 mL for a difference of 495 mL.

2. Mr. Burke's condition is causing the clinical sign of shortness of breath. Shortness of breath is referred to as _______________.

Answer: Dyspnea Rationale: Dyspnea is shortness of breath often found in hypoxia.

The nurse is assessing a Latino-Caribbean client who was brought to the hospital by family members. The family reports the client started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? Bulimia nervosa Anorexia nervosa Shenjing shuairuo Ataque de nervios

Ataque de nervios Rationale Ataque de nervios is a Latino-Caribbean culture-bound syndrome that usually happens in response to specific stressors. This culture-bound syndrome is characterized by crying, uncontrollable spasms, trembling, shouting, dissociation, and trance-like states. Bulimia nervosa and anorexia nervosa are culture-bound syndromes in the form of eating disorders, but they are not characterized by crying, spasms, and shouting. Shenjing shuairuo is not associated with the Latino-Caribbean culture; instead, it is associated with Chinese culture.

A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? Become aware of their personal values Gain information related to their needs Make correct decisions related to their health Alter their value systems to make them more socially acceptable

Become aware of their personal values Rationale Value clarification is a technique that reveals individuals' values so the individuals become more aware of them and their effect on others. Gaining information, making correct health decisions, and altering value systems to make them more socially acceptable are not outcomes of value clarification.

How can the lines of communication be improved in a healthcare organization during the process of delegation? By considering all aspects of client care By selecting experienced nursing assistants as delegatees By appreciating and valuing each other's cultural perspectives By selecting a delegatee having similar strengths as that of the delegator

By appreciating and valuing each other's cultural perspectives Rationale The lines of communication in a healthcare organization can be improved by appreciating and valuing each other's cultural perspectives, which balances strengths between the delegator and delegatee and improves client care outcomes. Considering all aspects of client care ensures that all of the client care needs are addressed. Selecting experienced nursing assistants as delegatees increases the chances of the delegatee to adapt to changing situations. Selecting a delegatee having similar strengths as that of the delegator may decrease the lines of communication because the delegatee might do the task of the delegator.

A resident in a nursing home recently immigrated to the United States (Canada) from Italy. How does the nurse plan to provide emotional support? By offering choices consistent with the client's heritage By assisting the client in adjusting to American culture By ensuring that the client understands American beliefs By correcting the client's misconceptions about appropriate health practices

By offering choices consistent with the client's heritage Rationale Adherence to a plan of care is enhanced by the nurse's providing choices consistent with the client's cultural beliefs and practices. The nurse's cultural or personal beliefs and biases should not influence or interfere with the implementation of appropriate care. Helping the client adjust to American culture is not the priority at this time; care should be adapted to the client's needs and culture. The person's cultural practices should not be addressed unless they are detrimental to the person's health.

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? Irish Americans African Americans Chinese Americans Egyptian Americans

Chinese Americans Rationale Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density. Irish Americans have taller and broader bones than other Euro-Americans. African Americans have a decreased incidence of osteoporosis. Egyptian Americans are shorter in stature than Euro-Americans and African Americans.

According to Gardner's tasks of leading/managing, a behavior of the executive position is to assist corporate leaders with planning and priority setting. Leading inspires client/families to achieve their vision. A behavior of the management position is to inspire the staff to achieve the mission of the organization. A behavior of the clinical position is to ensure that the organizational systems work on the client's behalf.

Critical analysis Critical analysis by the registered nurse serves as a guide for delegation in the nursing process. It is applied in assessment, planning, implementation, and evaluation for safe and effective client care. Leadership is a role in which a nurse has charge of the personnel as they perform their tasks. Psychomotor tasks are the common characteristics and essential components that a nurse should possess to provide client care. Time management is essential in performing tasks within specified deadlines during delegacy.

A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? Cohesiveness Educational level Cultural background Socioeconomic status

Cultural background Rationale During the developing awareness stage of grief the degree of anguish experienced or expressed is influenced by the cultural background of the individual and family. Although cohesiveness does enter into the grief process, it is not as important in the developing awareness stage as cultural background is. Educational level has no relationship to the grieving process. Socioeconomic status is not a defining factor in how a family will respond to the loss of a loved one.

An Asian client arrives at the mental health clinic with symptoms of anxiety and panic. While speaking with the client, the nurse notes that the client makes very little eye contact. What does this assessment data suggest? Shyness Cultural variation Symptom of depression Shame regarding treatment

Cultural variation Rationale As a show of respect, people in Asian cultures tend to make little eye contact, particularly with people perceived as authority figures. A lack of eye contact may connote shyness in some clients, but further assessment is needed. A lack of eye contact may suggest a depressed mood; however, there is no indication of depression in this client. A lack of eye contact may indicate shame or low self-esteem in the American culture; however, it is important not to make this same interpretation of behavior for someone from another culture.

A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client is withdrawn and eating very little from the meals provided. Which intervention is most important for the nurse to implement? Report these findings to the healthcare provider. Encourage the family to bring in special foods preferred in their culture. Order a high-protein milkshake to supplement between meals. Call the dietitian to work with client to plan high calorie meals for the client to eat.

Encourage the family to bring in special foods preferred in their culture. Rationale In family-centered childbearing, care should be adapted to the client's cultural needs and preferences whenever possible. Discussing the problem with the healthcare provider is the nurse's responsibility but will not address the client's preferences. Ordering a high-protein milkshake as a between-meal snack may offer the client an option but is unlikely to meet the cultural preferences. Having the dietitian assist with planning meals does not address the underlying problem.

What does the professional nurse consider to be the center of decision-making when providing client care? Ethics of care Nursing skills Analytical skills Research based practice

Ethics of care Rationale A professional nurse always follows the ethics of care and considers caring to be the center of decision-making. The nurse must know what behavior is ethically appropriate while caring for a client. A nurse's effectiveness in performing tasks is important to client care; however, client satisfaction comes from the effective dimension of care. Because ethics of care are unique to each client, the nurse should not base decision-making only on analytical skills. The nurse should not provide client care based only on intellectual principles or research knowledge. Caring is the most important factor because it considers client preferences and values.

What qualities does the professional nurse require to lead, manage, and follow in a team? Select all that apply.

Exercising self-awareness Managing emotions in self and others Motivating self and others

Which activity indicates improper follow-through on the part of the delegatee?

Failure to report results

During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? Spiritual belief Family practices Emotional factors Cultural background

Family practices Rationale Family practices influence the client's perception of the seriousness of diseases. The client does not feel the need to seek preventive care measures because no family member practices preventive care. The client is not influenced by spiritual beliefs in this instance. An individual's spiritual beliefs and religious practices may restrict the use of certain forms of medical treatment. Emotional factors such as stress, depression, or fear may influence an individual's health practice; however, this client does not show signs of being affected by emotional factors. The client is said to be influenced by cultural background if he or she follows certain beliefs about the causes of illness and uses customary practices to restore health.

The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? Monitor for nonverbal cues of pain Check the pressure dressing for bleeding Assist the client to ambulate around his room Irrigate the client's nasogastric tube with sterile water

Monitor for nonverbal cues of pain Rationale Asian clients tend to be stoic regarding pain and usually do not acknowledge pain; therefore, the nurse should assess these clients further. This type of surgery does not require pressure dressings. First, the client must be assessed further for pain. If there is pain, the client should ambulate after, not before, receiving pain medication. Postoperatively, nasogastric tubes are irrigated when needed, not routinely.

A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? Call the chaplain to convince the client to receive the blood transfusion. Discuss the case with coworkers. Notify the primary healthcare provider of the client's refusal of blood products. Explain to the client that they will die without the blood transfusion.

Notify the primary healthcare provider of the client's refusal of blood products. Rationale The nurse serves as an advocate for the client to uphold their wishes. Synthetic blood products are available but must be prescribed by the primary healthcare provider. Therefore the primary healthcare provider needs to be notified of the client's refusal for blood so alternatives can be considered. The chaplain's role is to offer support, not to convince the client to go against beliefs. It is a Health Insurance Portability and Accountability Act (HIPAA) (Canada: Personal Health Information Protection Act [PHIPA]) violation to discuss the case with coworkers unless they are involved in the care of the client. The nurse should not use threats or fear to coerce the client.

According to Gardner's tasks of leading/managing, a behavior of the executive position is to assist corporate leaders with planning and priority setting. Leading inspires client/families to achieve their vision. A behavior of the management position is to inspire the staff to achieve the mission of the organization. A behavior of the clinical position is to ensure that the organizational systems work on the client's behalf.

Occasionally offering derogatory comments This registered nurse who has limited clinical experience should make an attempt to adapt delegation decisions to organization policies. The nurse should not offer derogatory or offensive comments, which can detract from a collaborative and productive work environment. Asking open-ended questions allows the registered nurse to gain pertinent information from the nursing assistant delegated to perform client care. The registered nurse should provide feedback about behavior that will best shape performance. Maintaining an open line of communication with the nursing assistant yields a collaborative and productive work environment.

A nurse understands that when a client is a member of a different ethnic community it is important to do what? Ensure that the nurse's biases are understood by the family. Make plans to counteract the client's misconceptions about therapies. Offer a therapeutic regimen compatible with the lifestyle of the family. Recognize that the client's responses will be similar to other clients' responses.

Offer a therapeutic regimen compatible with the lifestyle of the family. Rationale The client cannot be expected to accept or even respond to a plan that is incompatible with the family's lifestyle. The family should not have to adjust to the nurse's biases; the nurse must self-identify biases and ensure that they do not interfere with nursing care. There is no evidence that misconceptions will occur. All individuals respond differently to situations.

The emergency department nurses are caring for a group of clients injured in a community disaster. Which action of the nurse needs correction?

Removing people from danger

The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? Dietary practices Concept of space Immigration status Role within the family

Role within the family Rationale If an Asian-American client adheres to traditional Asian practices, the nurse must recognize that the family is the central and most important social force acting on the individual. Dietary practices, concept of space, and immigration status are not as significant as family dynamics.

What factors are most important for the nurse to consider when delegating responsibilities?

Staff member's level of education and expertise