Prep U's - Chapter 4 - Adult Health and Physical, Nutritional, and Cultural Assessment

A client has monthly laboratory tests done. The nurse notes a decrease in the albumin level. What condition in the client's history could alter the albumin level? A. Liver disease B. Dehydration C. Pituitary cyst D. Endometriosis

Answer: A Rationale: Albumin levels are used as measures of protein in adults. Albumin synthesis depends on normal liver function. Decreased albumin levels may be caused by overhydration, liver or renal disease, or excessive protein loss.

The nurse collects data related to cultural beliefs as part of the comprehensive assessment process for a client admitted for the treatment of newly diagnosed type 2 diabetes mellitus (DM). The nurse is asking about cultural beliefs. Complete the table of cultural beliefs by choosing the best question from each list of options. Cultural Beliefs Assessment Questions Communication "Are you comfortable with the space between us?" "How do you usually respond when asked a question?" "Who usually helps you cope when faced with a difficult situation?" Space "How often do you wear a timepiece?" "What is your definition of good health?" "How close do you stand to a family member when asking a question?" Social organization "What diseases run in your family?" "What is your role in your family?" "How does it make you feel when a stranger touches you?"

Answer: "How do you usually respond when asked a question?" "How close do you stand to a family member when asking a question?" "What is your role in your family?" Rationale: Nurses need to ensure that clients of all cultures understand what the nurse is trying to accomplish by gathering cultural data during the assessment process to avoid misunderstanding. A question that is appropriate for the nurse to ask when determining the effect of culture on communication is: "How do you usually respond when asked a question?" The data obtained from this question provides the nurse with information important to the client's cultural beliefs regarding this topic. A question appropriate for the nurse to ask when determining the client's use of space is: "How close do you stand to a family member when asking a question?" Data obtained from this question provides the nurse with information important to the client's cultural beliefs regarding space. A question appropriate for the nurse to asking when determining the client's social organization is: "What is your role in your family?" The data obtained from this question provides the nurse with information important to the client's cultural beliefs regarding this topic. Asking about the space that is between the nurse and client address cultural beliefs about space, not communication. Additionally, asking the client about coping in difficult situations addresses biologic variations, not space. Asking the client about the use of a timepiece assesses the client's cultural beliefs about time, not space. Asking the client their definition of good health address biologic variations, not space. Asking the client about feelings associated with touch from a stranger assess the client's cultural beliefs about space, not social organization. Additionally, asking the client about diseases that run in the family address biologic variations, not social organization.

What would be important for the nurse to consider at the beginning of an interview? A. Establish rapport with the client and family members. B. Allow rest during the interview. C. Keep the room a comfortable temperature for the nurse. D. Address the client by his or her first name.

Answer: A Rationale: During the interview process, the nurse should start by establishing rapport with the client and family members and ensuring that the client is comfortable. During the introduction, the nurse should address the client by his or her surname. The nurse should avoid tiring older clients by allowing rest periods during the physical examination and should keep the room at a comfortable temperature for the client.

Which of these terms refers to the belief that one's values and beliefs are superior to others? A. Ethnocentrism B. Cultural taboo C. Acculturation D. Cultural imposition

Answer: A Rationale: Ethnocentrism is the belief that one's ethnic heritage is the "correct" one and superior to others. Acculturation involves the process of adapting to or taking on the behaviors of another group. Cultural imposition is the inclination to impose one's cultural beliefs, values, and patterns of behavior on people of a different culture. Cultural taboos are activities governed by rules of behavior that a particular cultural group avoids, forbids, or prohibits.

Giger and Davidhizar created an assessment model to guide nurses in exploring cultural phenomena that might affect nursing care. When using this model in the care of a client who has had a transurethral prostate resection (TUPR), what area of care would be influenced most directly? A. Explaining the rationale for continuous bladder irrigation (CBI). B. Documenting the client's vital signs and level of consciousness. C. Assessing the client's respiratory rate. D. Transferring the client from a stretcher to a bed.

Answer: A Rationale: Giger and Davidhizar identified communication, space, time orientation, social organization, environmental control, and biologic variations as relevant phenomena. Explaining CBI requires clear communication. Transferring a client to a bed, assessing respirations, and documenting are nursing responsibilities that are less directly relevant to this model.

Hyperresonance is audible when which area is percussed? A. Overinflated lung tissue. B. Air-filled stomach. C. Thigh D. Liver

Answer: A Rationale: Hyperresonance is audible when overinflated lung tissue is percussed, such as in a client with emphysema. Percussion over the liver produces a dull sound. Percussion of the thigh produces a flat sound. Tympany is the drum-like sound produced by percussing an air-filled stomach.

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

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

Which statement made by the nurse would be a nontherapeutic response when the patient says, "I will not take pain medication when I am in pain"? A. "Refusing medication can only hurt you by increasing your awareness of the pain experience." B. "Let a nurse know when you are in pain so you can be helped to decrease stimuli that may exaggerate your pain experience." C. "You have the right to make that decision. How can the nurses help you cope with your pain?" D. "Is there another way you have learned to lessen pain when you experience it?"

Answer: A Rationale: People who seek health care for a specific problem are often anxious. Their anxiety may be increased by fear about potential diagnoses, possible disruption of lifestyle, and other concerns. With this in mind, the nurse attempts to establish rapport, put the patient at ease, encourage honest communication, make eye contact, and listen carefully to the patient's responses to questions about health issues.

Which of the following refers to a group that shares characteristics identifying the group as a distinct entity? A. Subculture B. Culture C. Race D. Minority

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

The nurse is assessing a client's abdomen and percusses a large area of dullness on the right side of the abdomen, not the expected tympany. What has the nurse percussed? A. Liver B. Lungs C. Empty stomach D. Full bladder

Answer: A Rationale: The assessment technique of percussion produces sounds based on the density of the underlying structure. Certain densities produce sounds as percussion notes. Percussion of the liver produces a dull sound, while percussion over the air-filled stomach produces tympany. A full bladder will produce a dull sound, but it is not located on the right side of the client's abdomen.

Which observation made by the nurse reflects the first fundamental technique used in physical examination? A. "Patient appears older than stated age." B. "Abdomen is soft and nontender in all four quadrants." C. "Crackling is noted in right lower lung." D. "Hyperresonance is noted in the left lower lung."

Answer: A Rationale: The first fundamental technique is inspection or observation. General inspection begins with the first contact with the patient. Percussion translates the application of physical force into sound. Light and deep palpation can be used on the abdomen. Auscultation is the skill of listening to sounds produced by the movement of air or fluid within the body.

During the health history, a client is making conflicting statements and has difficulty focusing. Which nursing action would be appropriate? A. Redirect the questions of concern to the client's spouse for clarification. B. Frequently remind the client how important it is to answer these questions. C. Continue with the questions but allow more time for answers. D. Allow the client 30 minutes to sleep, and then ask the health history questions.

Answer: A Rationale: The informant providing the health history may not always be the client. Examples include mentally impaired, disoriented, confused, or developmentally delayed clients. The nurse must make a clinical judgment about the reliability of the information from the client. If the information is conflicting and the client cannot focus during the health history, the nurse must gather the information from another reliable source, such as a spouse.

In a small, rural hospital the nurse is caring for a client who speaks a language other than English. The nurse needs to use an interpreter to communicate but the hospital does not have access to an interpreter who speaks the client's language. When choosing another individual to interpret for this client, what characteristic should the nurse prioritize? A. Interpreter should ideally be fluent in several dialects of the client's language. B. Interpreter should be able to conduct the conversation quickly to avoid misinterpretation. C. Interpreter should recognize the need to speak in a loud voice. D. Interpreter should know that repetition must be avoided while interpreting.

Answer: A Rationale: The nurse must be aware of culturally-based gender and age differences and diverse socioeconomic, educational, and tribal or regional differences when choosing an interpreter. In order to minimize or address some of these differences, fluency in varied dialects is beneficial. In choosing an interpreter, you do not want one who speaks in an excessively loud voice, conducts the conversation too quickly, or avoids repetition.

A parent informs the nurse that immunizations are contrary to her religious beliefs, and she does not want her child to receive them. The nurse proceeds to inform the parent that the child will be in grave danger of illness all her life and will not be allowed to start school unless she is immunized. The nurse also informs the parent that she had all of her own children vaccinated with no adverse effects. The nurse's behavior is an example of what? A. Cultural imposition B. Cultural blindness C. Acculturation D. Cultural taboos

Answer: A Rationale: The nurse's behavior is an example of cultural imposition, defined as the tendency to impose one's cultural beliefs, values, and patterns of behavior on a person from a different culture. Acculturation is the process by which members of a cultural group adapt to or learn how to take on the behaviors of another group. Cultural blindness is the inability of people to recognize their own values, beliefs, and practices and those of others because of strong ethnocentric tendencies. Cultural taboos are activities or behaviors that are avoided, forbidden, or prohibited by a particular cultural group.

To calculate the ideal body weight for a woman, the nurse allows for which of the following? A. 100 lb for 5 ft of height. B. 6 lb for each additional inch over 5 ft. C. 80 lb for 5 ft of height. D. 106 lb for 5 ft of height.

Answer: A Rationale: To calculate a woman's ideal body weight, the nurse allows 100 lb for 5 ft of height and adds 5 lb for each additional inch over 5 ft. The nurse allows 106 lb for 5 ft of height in calculating the ideal body weight for a man. The nurse adds 6 lb for each additional inch over 5 ft in calculating the ideal body weight for a man. Eighty pounds for 5 ft of height is too little.

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

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

A nurse is performing percussion on a client during a focused exam. While documenting the exam results, which terms will the nurse use? Select all that apply. A. Resonance B. Flatness C. Dullness D. Hollow E. Tympany

Answer: A, B, C, E Rationale: Percussion is the application of physical force into sound. The sound produced by percussion reflects the density of the underlying structure. Tympany, resonance, flatness, and dullness are all terms used to describe sounds associated with percussion. Hollow is not used to describe any findings with percussion.

A client who has lost weight asks a nurse about how much physical activity is needed to prevent regaining the weight. Which of the following would the nurse recommend? A. 30 minutes per day. B. 60 minutes per day. C. 45 minutes per day. D. 15 minutes per day.

Answer: B Rationale: According to MyPyramid, an individual should engage in 60 minutes of physical activity each day to prevent weight gain. Routinely, a person should engage in 30 minutes of physical activity each day to maintain health and 60 to 90 minutes per day to sustain weight loss.

Which statement made by the nurse indicates that the nurse is performing a holistic health history versus a traditional health or medical history? A. "Tell me about your family's history with heart disease." B. "How has the stroke affected your ability to perform your daily activities?" C. "What have your daily blood pressure and pulse rate readings been?" D. "Have you been taking your blood pressure medication exactly as prescribed?"

Answer: B Rationale: An emphasis on functional assessment is viewed as being more holistic than the traditional health or medical history. A client's functional status is the ability of the client to function normally and perform his or her usual physical, mental, and social activities. Questions related to blood pressure readings, family history, and medication regimen indicate a traditional or medical model versus a holistic health assessment.

Two nursing students are role-playing a client assessment situation. One of the students is acting as the nurse, and the other student is acting as the client. The task is to focus on assessing the client's lifestyle. Which question would be most appropriate for the student acting as the nurse to ask? A. "Where do you currently live?" B. "What do you usually do for fun?" C. "Where do your parents come from?" D. "Can you tell me about your childhood?"

Answer: B Rationale: Assessing a client's lifestyle involves questions related to behaviors such as sleep patterns, exercise, nutrition, and recreation, as well as personal habits such as smoking and the use of illicit drugs, alcohol, and caffeine. The question about what the client does for fun reflects activities. The question about where the client lives provides information about the physical environment; the question about where the client's parents came from provides information about culture, which is also part of the environment. The question about the client's childhood provides information about the client's past life events related to health.

Which describes the inability to recognize the values, beliefs, and practices of others because of one's strong ethnocentric preferences? A. Acculturation B. Cultural blindness C. Cultural taboo D. Cultural imposition

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

When taking a health history, which of the following would most likely be the primary source of information? A. Referring physician. B. Client C. Patient's spouse D. Medical record

Answer: B Rationale: In most instances, the client is the informant unless the client is developmentally delayed, mentally impaired, disoriented, confused, unconscious, or comatose. In these cases, another individual close to the client would provide the necessary information. The nurse could collect additional data from the referring physician and the medical record, but these would not be the primary sources of information.

The nurse is discussing a newly diagnosed cancer with a patient when the patient comments that the cancer was "God's will." The nurse documents that the client ascribes to which type of world view/perspective related to the cause of illness? A. Holistic-naturalistic B. Magico-religious C. Spiritual chakra D. Biomedical-scientific

Answer: B Rationale: In the magico-religious view, people view illness/health as a result of supernatural forces of good or evil. In the holistic-naturalistic view, illness is viewed as stemming from a break in the laws of nature. The biomedical-scientific perspective views the body as functioning like a machine and supports the idea that illness has a cause and effect. There is no worldview known as a spiritual chakra.

The nurse is reviewing the laboratory test results of a patient who is suspected of having a nutritional deficiency. Which of the following would the nurse identify as helping to support this diagnosis? A. high prealbumin level. B. low serum albumin levels. C. high transferrin levels. D. high lymphocyte count.

Answer: B Rationale: Low serum albumin and prealbumin levels are most often used as measures of protein deficiency in adults. In addition, transferrin levels decrease in response to protein depletion. The total lymphocyte count may be reduced in people who are acutely malnourished as a result of stress and low-caloric feeding.

Of the following nurse theorists, which one is considered the founder of transcultural nursing? A. Patricia Benner B. Madeline Leininger C. Dorothea Orem D. Jean Watson

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

A nurse determines that a patient has poor nutrition based on which assessment finding? A. Firmly developed muscles. B. Beefy-red tongue. C. Pink conjunctiva. D. Nonpalpable thyroid gland.

Answer: B Rationale: Signs of poor nutrition include a beefy-red tongue, palpable thyroid gland, pale eye membranes, and flaccid, poorly toned, wasted, or underdeveloped muscles.

The nurse is completing discharge instructions for a client. The nurse can best evaluate the likeliness of the client to adhere to the instructions by use of which method? A. Observe the client's face to see if the client is smiling, which can be interpreted as agreement. B. Assess the client's beliefs regarding health maintenance, promotion, and remedies. C. Ask if the client agrees with the instructions that are outlined. D. Make the client promise to follow the instructions and be compliant with the plan.

Answer: B Rationale: Some individuals will not openly disagree with people in authority or who possess advanced education, so it is best for the nurse to assess the client's beliefs regarding health maintenance, promotion, and remedies. A client smiling, agreeing to, or promising to comply is not proof of agreement because the client may believe it impolite to disagree with someone seen as being in a position of authority.

During a physical examination, the nurse finds that a client has thin, dry hair with flaky skin, recessed gums, and ridged, brittle nails. The nurse can conclude what from these data? A. Poor hygiene practices. B. Poor nutritional status. C. Inability to perform activities of daily living. D. Lower income status.

Answer: B Rationale: The state of nutrition is often reflected in a person's appearance. Hair, teeth, nails, and skin can serve as indicators of general nutritional status and intake of specific nutrients. Indicators of good nutrition in the hair include that it is shiny and firm, not dry and thin. Flaky skin can be a sign of poor nutrition. Nails indicating good nutrition are firm and pink, not brittle and ridged. Recessed gums are seen with poor nutrition.

Which specialty in nursing involves providing nursing care in the context of the client's culture? A. Multicultural nursing B. Transcultural nursing C. Multilingual nursing D. Biocultural nursing

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

When calculating ideal body weight for women, the health care professional adds how many pounds for each inch of height over 5 feet? A. 3 B. 5 C. 7 D. 1

Answer: B Rationale: When calculating ideal body weight for women, add 5 lb for each additional inch of height over 5 ft. The other numerical values are incorrect.

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

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

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

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

A waist circumference greater than which value is indicative of excess abdominal fat in men? A. 76.20 cm (30 in.) B. 63.50 cm (25 in.) C. 101.60 cm (40 in.) D. 88.90 cm (35 in.)

Answer: C Rationale: A waist circumference >101.60 cm (>40 in.) for men or >88.90 cm (>35 in.) for women indicates excess abdominal fat. Those with a high waist circumference are at increased risk for diabetes, dyslipidemia, hypertension, cardiovascular disease, and atrial fibrillation.

Which describes the inability to recognize the values, beliefs, and practices of others because of one's strong ethnocentric preferences? A. Cultural taboos B. Acculturation C. Cultural blindness D. Cultural imposition

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

The yin/yang theory of harmony and illness is rooted in which paradigm of health and illness? A. Religious B. Scientific C. Holistic D. Biomedical

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

A nurse is reviewing the medical records of several patients and their risk for health problems. The nurse determines that the patient with which body mass index (BMI) would have the lowest risk? A. 28 B. 18 C. 23 D. 31

Answer: C Rationale: Patients with a BMI of 23 would have the lowest risk for health problems. Those with a BMI of 18 might have the increased risk associated with poor nutritional status. Those with a BMI of 28 are considered overweight, and those with a BMI of 30 to 39 are considered obese. Both of these groups have an increased risk for health problems.

The nurse demonstrates culturally competent nursing care by doing which of the following? A. challenging the beliefs and values of patients from diverse cultures. B. providing the same nursing interventions for all clients without exceptions. C. respecting the personal beliefs of the client while acknowledging the nurse's own biases. D. recognizing that the healthcare system is void of culture and not acknowledging cultural differences.

Answer: C Rationale: Providing culturally competent nursing care means that care is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse cultural populations within society. To provide culturally competent care, the nurse must be aware that the healthcare system itself is a culture and that cultural imposition and ethnocentrism must be avoided.

During the initial physical examination, a client's pulse rate was 71 beats per minute (bpm). Four hours later on reassessment, the pulse rate was 40 bpm. How should the nurse proceed? A. Call for the crash cart just in case. B. Attach the client to a heart monitor. C. Thoroughly assess the client; then notify the physician. D. Have the client get up and walk around the room; then take another pulse.

Answer: C Rationale: The ability to assess a client accurately is an integral nursing skill. The nurse will use appropriate assessment skills to identify psychological problems. Unexpected changes and values that deviate from a client's normal value are to be brought to the attention of the physician.

The nurse is preparing the client file for an 8-year-old child. The child's mother informs the nurse that the child has difficulty breathing at night and makes a whistling sound while sleeping. Because of the child's age, her mother continues to provide the child's health history to the nurse. Which action by the nurse demonstrates that the nurse understands the importance of collecting a client's health history? A. Allow the child's pediatrician to conduct the health history. The pediatrician can allow the child to participate in the assessment, as appropriate. B. The nurse repeats the information back to the child so that the child can confirm that the information provided to the nurse by the mother is correct. C. The nurse continues to collect information from the child's mother, knowing the informant will not always be the client. D. The nurse explains to Sara's mother that the child must be the primary informant while collecting the health history.

Answer: C Rationale: The informant, or the person providing the health history, may not always be the client. The nurse assesses the reliability of the mother and the usefulness of the information provided. It is within the scope of the nurse to collect the health history.

Which question would help the nurse gather information about a client's lifestyle that may be a factor in the client's present illness? A. "What language is spoken at your home?" B. "How many steps do you have to climb to enter your house?" C. "How many cups of coffee do you drink each day?" D. "Is God important to you?"

Answer: C Rationale: The lifestyle section of the client profile provides information about health-related behaviors, including patterns of sleep, exercise, and nutrition and personal habits such as caffeine intake.

What should the nurse do when caring for a client with alcoholism who is diagnosed with Imbalanced Nutrition: Less than Body Requirements? A. Encourage daily exercise. B. Avoid providing liquid sleep medications. C. Obtain a baseline weight. D. Avoid providing foods that contain alcohol.

Answer: C Rationale: The nurse should obtain a baseline weight. Documenting the client's current weight helps evaluate whether the client's nutritional intake is maintained or has increased. Encouraging daily exercise may not really help balance the client's nutrition. Avoiding liquid sleep medication or foods with alcohol content will not help the client balance nutrition requirements.

The nurse is caring for a client who expresses the belief that her illness (cellulitis) is a result of bacteria that has caused an infection. To which of the following views of disease/illness does this client allude? A. Magico-religious B. Naturalistic and/or holistic C. Biomedical and/or scientific D. Modernistic and/or physician oriented

Answer: C Rationale: The three major views that attempt to explain the cause of disease/illness are biomedical or scientific (cause and effect), naturalistic or holistic (forces of nature), and magico-religious (supernatural forces). The idea of bacteria causing an infection relates to the scientific or cause-and-effect theory.

A nurse is preparing to conduct a health assessment with a 78-year-old man who wears a hearing aid in his left ear. The patient is accompanied by his wife. Which of the following would be most appropriate? A. Keep the examination door open during the interview so the nurse can ask for help if needed. B. Direct the interview to the patient's wife to ensure adequate information is obtained. C. Check to make sure that the patient has his hearing aid turned on and in place in his left ear. D. Have the patient sit at an angle to the nurse, with his good ear facing the nurse.

Answer: C Rationale: When obtaining information from an older adult with a hearing deficit, the nurse should make sure that the patient's hearing aid is turned on and in place in the appropriate ear. The patient should be positioned so that he can read lips and facial expressions to augment verbal communication. Distracting noises should be kept to a minimum. Keeping the door open would increase the chances of distracting noises and could violate privacy. There is no need to direct the interview to the patient's wife just because the patient has a hearing deficit.

During a nutritional assessment, the nurse measures a woman's waist at 38.5 inches (98 cm). Based on this finding, which of the following is a priority intervention? A. Alert the physician immediately for necessary treatment. B. Educate the client on the need to increase her caloric intake. C. Record the obtained results and continue with the assessment. D. Educate the client regarding her increased risk for hypertension and diabetes.

Answer: D Rationale: A waist circumference greater than 35 inches (89 cm) for a woman indicates excess abdominal fat. Those with an increased waist circumference are at risk for diabetes, dyslipidemias, hypertension, cardiovascular disease, and atrial fibrillation. It is necessary at this time to educate the client about her risks for such health deviations.

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

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

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

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

The nurse observes that a coworker is unable to understand that an intelligent person would engage the services of a medicine man. The nurse's coworker has strong ethnocentric tendencies and an inability to recognize others' values, beliefs, and practices. The nurse understands that the coworker's behavior is an example of which attitude? A. Cultural imposition B. Cultural taboo C. Acculturation D. Cultural blindness

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

Effective, individualized care that shows respect for the dignity, personal rights, preferences, beliefs, and practices of people receiving care while acknowledging the bias of the caregiver and preventing that bias from interfering with care. This is a definition of? A. The School of Nursing's mission statement. B. The Patient's Bill of Rights. C. A nursing pledge written by Florence Nightingale. D. Culturally competent nursing care.

Answer: D Rationale: Culturally competent nursing care is defined as effective, individualized care that shows respect for the dignity, personal rights, preferences, beliefs, and practices of people receiving care while acknowledging the bias of the caregiver and preventing that bias from interfering with care.

When the nurse attempts to obtain vital signs, the client pulls away, gathers the bed covers to their chin, and speaks in a language unfamiliar to the nurse. What is the best action for the nurse to take? A. Use gesturing and pictures to explain current actions. B. Talk slowly and explain current actions. C. Smile and take the vital signs anyway. D. Attempt to find an interpreter.

Answer: D Rationale: Ideally, obtaining an interpreter will increase the communication between client and nurse. Talking slower or gesturing may not provide a clear understanding for client or nurse. Proceeding without the approval of client could violate the client's cultural beliefs.

A client has a newly diagnosed heart murmur. During the nurse's subsequent health education, he asks if he can listen to it. What would be the nurse's best response? A. "Heart murmurs are pathologic and may require surgery. If you would like to listen to your murmur, I can provide you with instruction." B. "Listening to the body is called auscultation. It is done with the diaphragm, and it requires a trained ear to hear a murmur." C. "Listening is called palpation, and I would be glad to help you to palpate your murmur." D. "If you would like to listen to your murmur, I'd be glad to help you and to show you how to use a stethoscope."

Answer: D Rationale: Listening with a stethoscope is auscultation and it is done with both the bell and diaphragm. The diaphragm is used to assess high-frequency sounds such as systolic heart murmurs, whereas the bell is used to assess low-frequency sounds such as diastolic heart murmurs. It is also important to provide education whenever possible and actively include the client in the plan of care. Teaching an interested client how to listen to a murmur should be encouraged. Many heart murmurs are benign and do not require surgery.

Which method of physical examination refers to the translation of physical force into sound? A. Manipulation B. Auscultation C. Palpation D. Percussion

Answer: D Rationale: Percussion translates the application of physical force into sound. Palpation refers to examination by nonforceful touching. Auscultation refers to the skill of listening to sounds produced by the movement of air or fluid within the body. Manipulation refers to the use of the hands to determine motion of a body part.

The belief that clients with the same skin color belong to a similar social group is an example of which of the following? A. Ethnicity B. Race C. Subculture D. Stereotyping

Answer: D Rationale: Stereotyping means assuming that all people in a particular cultural, racial, or ethnic group share the same values and beliefs, behave similarly, and are basically alike. Ethnicity is the bond or kinship that people feel with their country of birth or place of ancestral origin. Race refers to biologic differences in physical features, such as skin color and eye shape. Subculture refers to a particular group that shares characteristics identifying the group as a distinct entity.

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

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

When the nurse is percussing for measurement of the patient's liver span, what type of response should be heard? A. Resonant sound B. Tympanic sound C. Flat sound D. Dull sound

Answer: D Rationale: The sound produced reflects the density of the underlying structure. Certain densities produce sounds as percussion notes. These sounds, listed in a sequence that proceeds from the least to the densest, are tympany, hyperresonance, resonance, dullness, and flatness. Tympany is the drum-like sound produced by percussing the air-filled stomach. Hyperresonance is audible when one percusses over inflated lung tissue in a person with emphysema. Resonance is the sound elicited over air-filled lungs. Percussion of the liver produces a dull sound, whereas percussion of the thigh produces a flat sound.

The nurse notes hyperresonance over inflated lung tissue when performing a physical assessment on a patient with emphysema. What process does the nurse use for this assessment? A. Inspection B. Palpation C. Auscultation D. Percussion

Answer: D Rationale: With percussion, the provider sets the chest wall or abdominal wall into vibration by striking it with a firm object. The sound produced reflects the density of the underlying structure. Hyperresonance is audible when one percusses over inflated lung tissue in a person with emphysema. Auscultation means listening to sounds produced by the movement of air or fluid in the body. Percussion uses the sense of touch, not hearing, and inspection involves vision.