Ch 13: Cultural Diversity and Community Health Nursing

A woman who spoke English was an immigrant from the Middle East, attending the clinic for the first time with two female friends. When a male nurse attempted to get a health history, the woman refused to respond to his questions. Which of the following actions should be taken by the nurse? a. Ask a female nurse to talk with the client b. Ensure that the client has privacy, with the two female friends waiting outside before trying again c. Explain that the woman cannot see a physician until the nurse obtains a health history and does an initial examination d. Stress that the clinic is free and she does not have to pay extra to see both the nurse and the physician

ANS: A He should ask a female nurse to talk with the client. Many culture groups have strong norms regarding appropriate gender behavior. Norms are the rules by which human behavior is governed and result from the cultural values held by the group. All societies have rules or norms that specify appropriate and inappropriate behavior. Individuals are rewarded or punished as they conform to, or deviate from, the established norms. Thus, this woman is likely to not deviate from these cultural norms and should be given the opportunity to speak with a female nurse. The other responses do not address the cultural needs regarding gender that this client needs to have addressed. DIF: Cognitive Level: Apply (Application) REF: pp. 225-226

In a client's culture it is exceedingly rude to ask any questions about income or wealth. Which of the following actions should be taken by the nurse to draw conclusions about the client's socioeconomic status (SES)? a. Ask about the client's education or employment position b. Ask his or her religious leader to share such information with the nurse c. Let the financial office deal with the problem d. Refer the issue to the social worker who has better sources of information

ANS: A SES may be determined by examining income, occupation, and educational level. If that is not possible, age, gender, possessions, location of residence, religion, and race may also be considered. DIF: Cognitive Level: Apply (Application) REF: p. 228

A nurse is called by a friend who complains of symptoms of a cold. Which of the following responses would be the most appropriate by the nurse? a. Ask the friend what she usually does for a cold and suggest that be done b. Tell her to go to the urgent care center for assistance c. Suggest that she make an appointment to see her health care provider d. Point out to her that nurses are unable to treat patients

ANS: A Seventy percent to 90% of all illness episodes are treated first, or exclusively, through self-care, often with significant success. Symptoms of a cold do not seem to require drastic action such as going to the urgent care center or seeing a health care provider. Engaging in traditional healing interventions, learned in the family, will be comforting and probably will help. DIF: Cognitive Level: Apply (Application) REF: p. 238

A patient had wrapped a tummy band around her newborn's abdomen. What should the nurse say to the new mother? a. "Can you explain to me the purpose of wrapping a band around the baby's tummy?" b. "In the hospital, we prefer to expose the umbilical cord to air so it's easier to put medication on it as it dries up." c. "Let me put some medication on the baby's cord, and then I'll put the tummy band back." d. "Please remove that band; it is not helpful as the umbilical cord needs to be kept clean and dry."

ANS: A Unless a particular action is harmful, the nurse should engage in culture care preservation and maintenance. Before acting, it is helpful to know why the mother is engaging in this behavior. If the mother responds, "I'm not sure; it's just always been done," the nurse can educate the mother on how to care for the cord. If the mother appears to believe the tummy band is very important, the nurse can cooperate with the behavior, because tummy bands will not hurt the baby. DIF: Cognitive Level: Apply (Application) REF: p. 223

A woman comes to the clinic, and the nurse believes that she is speaking French. She seems to understand English. A provider will need to complete a physical examination to confirm the health problem. Which of the following actions should be taken by the nurse? a. Ask the client if she prefers a male or female provider b. Ask a female provider to assume care c. Ask the physician provider to see her immediately d. Ask the secretary in the office who speaks French to assist in collecting a health history from the client

ANS: A When in doubt, the best way is to ask the client about culturally relevant aspects of male-female relationships. This should be done at the beginning of the interaction before an opportunity arises to violate culturally based practices. It is not appropriate to ask other staff members to serve as interpreters during nurse-client interactions. DIF: Cognitive Level: Apply (Application) REF: pp. 234-235

Which of the following best describes the challenges when providing care to someone from a minority group? (Select all that apply.) a. Communication, both words and gestures, may be unfamiliar. b. Few members of the minority group are nurses themselves. c. Immigrants will soon adapt to the mainstream culture, but in the meantime many are clinging to "the old ways." d. So few patients are minority group members that it is difficult to remember how they prefer to receive care. e. The nurse may have to confront personal values and beliefs.

ANS: A, B, E Nurses must understand how patients define health and illness, how their cultural group cures and cares for members, and how the nurse's personal cultural background influences the way in which care is delivered. The context and process of helping people involves at least two people who often have different cultural orientations and lifestyles. Very few nurses are members of a minority group. Although immigrants may adopt some of the ideas of the mainstream culture, many will continue to use traditional practices and the nurse must be aware and respect these cultural beliefs. Many minority group members represent the patient population who receives care, so nurses must be aware and respect these cultural beliefs. DIF: Cognitive Level: Understand (Comprehension) REF: p. 222 | p. 224 | p. 233

A client, accompanied by her son, spoke only Spanish while the nurse did not. Which of the following actions should be taken by the nurse to best meet the client's need? a. Ask the woman if it's OK if the son translates for her b. Call until she finds a Spanish interpreter employed by the agency c. Let the son translate because he's obviously informed about the problem d. Use gestures and pantomime to make oneself clear

ANS: B Asking the son would violate confidentiality, and gender issues may also arise. The only safe approach is to obtain a Spanish interpreter who is knowledgeable about medical terminology and procedures, as well as comfortable with cultural beliefs and health prac- tices. It is important to have an interpreter rather than trying to make gestures and pantomine so that the communication between the nurse and client is clear and accurate. DIF: Cognitive Level: Apply (Application) REF: p. 233

Which of the following statements best defines Leininger's term "culture universal"? a. The preference to be cared for by someone from their own cultural group for maximum ease and comfort b. The commonalities of values, norms, and life patterns that are held in all cultures c. The particular values, beliefs, and patterning of behavior that is universal within a particular culture d. The health care roles, norms, and behaviors that are involved when illness or injury occurs

ANS: B Culture universal is used by Leininger to refer to the commonalities of values, norms of behavior, and life patterns that are similarly held among cultures about human behavior and lifestyles and form the basis for formulating theories for developing cross-cultural laws of human behavior. DIF: Cognitive Level: Understand (Comprehension) REF: p. 223

At a military base, a family from Qatar, a Muslim Arabic country, came in to the prenatal clinic because the wife believed she was pregnant. Which of the following providers would be the most appropriate choice for this client? a. A male obstetrician, expert in high-risk pregnancies b. The female nurse midwife c. The male obstetrician with a female nurse always in the room with the wife d. Whichever provider was on duty until the pregnancy was confirmed

ANS: B During pregnancy, many female clients will prefer female health care providers and may refuse to be examined by a man. People from Arab Muslim countries feel even more strongly about males touching a female. DIF: Cognitive Level: Apply (Application) REF: p. 234

A nurse is caring for a client from a different culture. Which of the following actions would be the most helpful for the nurse to take? a. Ask to have a nurse from that culture assigned to the patient even if the nurse must be obtained from a different clinical area b. Be aware of cultural similarities and differences between the nurse and the client c. Explain that the patient must follow the rules of the hospital while a patient d. Verbalize the nurse's own discomfort, and ask for assistance with surmounting the cultural differences

ANS: B Recognizing both similarities and differences is being culturally aware. Although it would be helpful to have a nurse from the same culture give care, that is often not feasible. A nurse from another area cannot be expected to be clinically expert, to say nothing of the legal problems of having a nurse from a different agency give care. Asking the patient for help makes the problem belong to the patient, but it is the nurse's problem. Asking the patient to comply with the hospital regulations is being culturally insensitive. DIF: Cognitive Level: Apply (Application) REF: p. 244

Before interviewing an Hispanic family, what is the most important action for the nurse to take? a. Compliment each member on some visible asset b. Establish rapport, and gain trust and confidence c. Greet them in Spanish even if badly spoken and accented d. Recognize the male as the authority figure in the family

ANS: B Regardless of the culture of the client family, it is crucial to establish rapport and gain trust and confidence before attempting to gather data. First impressions are important and the nurse should ensure a mutually respectful relationship is created. Thus, starting by providing compliments, greeting them with poor Spanish, or assuming that the male is the authority in the family may all lead to an unacceptable first impression of the nurse to the family. DIF: Cognitive Level: Apply (Application) REF: p. 231 | p. 232

A woman stood very close to the nurse and asked a question about her husband's condition. The nurse took a step back and shared the requested information. No other questions were asked. Was this a successful interaction? a. No, because the nurse should not answer any questions about a client, even if the wife is the one asking b. No, because the woman and the nurse had different perceptions of personal space c. Obviously yes, because the woman sought information, received it, and had no further questions d. Yes, because the nurse was knowledgeable and able to respond appropriately

ANS: B Sense of spatial distance is significant because culturally appropriate distance zones vary widely. Many cultures stand closer for important conversations, whereas the nurse stepped back because being so close made the nurse uncomfortable. DIF: Cognitive Level: Apply (Application) REF: p. 232

Which of the following actions was taken by the federal government to help improve health disparities among minorities? a. Created scholarships and traineeships only for minority applicants b. Created the National Center on Minority Health and Health Disparities c. Established grants that funded only minority health projects d. Legislated funds to create new colleges for preparing health professionals in minority neighborhoods

ANS: B The National Center on Minority Health and Health Disparities was developed in 2000 to assist in the investigation of factors affecting minority health. Its mission is to promote minority health and to ultimately eliminate health disparities. The federal government did not create scholarships and traineeships specifically for minority applicants, establish grants for minority health projects, or legislate funds to create new colleges to address the improvement in health disparities. DIF: Cognitive Level: Understand (Comprehension) REF: p. 241

Which of the following statements best describes how the population of the United States is changing? a. Growth will occur because of a decrease in the death rate. b. Growth will occur because of ongoing immigration. c. Growth will occur because of an increase in the birth rate. d. Growth will occur because of lengthening of the normal life span.

ANS: B The number of immigrants and refugees in the United States is projected to continue to increase. The U.S. has grown largely through immigration. The growth will not occur because of changes in death rate, birth rate, or life span. DIF: Cognitive Level: Understand (Comprehension) REF: p. 222

A nurse became frustrated because after each interview question there was a long pause before the client responded. Which of the following actions should be taken by the nurse? a. Accept the hesitation before receiving an answer b. Ask the client what silence after a question means c. Copy the client's behavior; insert a pause before asking the next question d. Recognize that the client was distracted, and reschedule the home visit

ANS: B Wide cultural variation exists when interpreting silence. Some individuals find silence uncomfortable, whereas others use silence to show understanding and respect. Because the nurse is uncomfortable, action should be taken. The only way to know the meaning of the silence is to ask. DIF: Cognitive Level: Apply (Application) REF: p. 233

Which of the following are the most important factors in reducing disparities in health outcomes between different cultural groups? (Select all that apply.) a. A strong family structure b. Access to a health care provider c. Access to transportation d. Health care insurance e. Having ongoing employment f. Owning one's own home

ANS: B, D Disparities in health care can be reduced or even eliminated when adults have health care insurance and a medical home defined as a setting that provides patients with timely, well-organized care and enhanced access to providers. According to the Commonwealth Fund (2007), when adults have insurance and a medical home, "their access to needed care, receipt of routine preventive screenings, and management of chronic conditions improve substantially." Thus, having a strong family structure, access to transportation, ongoing employment, and owning one's own home are not nearly as important as having health insurance and a medical home. DIF: Cognitive Level: Understand (Comprehension) REF: p. 223

A nurse felt very good about an Asian man who had responded positively to the instructions given to him. Later, the nurse heard him tell his wife that there was no way he could implement the suggestions. Which of the following best describes the problem that the client is experiencing? a. Polite response may not equal agreement. b. Men do not take instruction from women. c. His culture may value harmonious relationships over expressing disagreement. d. The nurse told him what to do but did not ask if he could do it.

ANS: C Asian clients may provide the nurse with the answers they think the nurse wants to hear. This behavior is consistent with their cultural value for harmonious relationships with others. The other responses do not recognize this cultural variation among this population that the nurse should recognize. DIF: Cognitive Level: Apply (Application) REF: p. 233

Which of the following helps to balance the fact that poverty is typically a major factor in certain groups having poorer health? a. A strong community health center in the neighborhood b. Intact families where fathers are married to children's mothers c. Strong family and community support for healthy behaviors d. The large number of programs available to be of assistance in fighting poverty

ANS: C Latino children who live in poverty enjoy relatively good health compared with children in other low socioeconomic groups. It is believed that strong family-community support fosters optimum family health behaviors. Many of these behaviors are integrated into the culture as part of the family identity, traditions, and history. Without strong family and community support having other resources in the community is insignificant. Strong support structures can exist in communities where fathers are not married to children's mothers. DIF: Cognitive Level: Understand (Comprehension) REF: p. 240

A nurse set up a clinic appointment for Friday of the following week. An Arab patient asked to come earlier in the week. As those days were heavily booked, the nurse left the appointment on Friday. The patient was a "no show." Which of the following best explains what happened? a. A lot of people do family errands such as shopping on Fridays, Saturdays, and Sundays. b. It was inconvenient for the client so he did not come. c. A Muslim's holy day is from sunset Thursday to sunset Friday. d. Patients do not like being told what to do.

ANS: C The nurse should know the days of religious worship. Protestants usually worship on Sundays; Muslims' day of worship is from sunset Thursday to sunset on Friday; and Jews and Seventh-Day Adventists' holy day is from sunset on Friday to sunset on Saturday. The other responses do not address the recognition by the nurse of the significance of the days of worship that were indicated as a priority for the client when an appointment was requested for earlier in the week. DIF: Cognitive Level: Apply (Application) REF: p. 230

Crying, a clinic patient explained that she knew she had this breast lump because she had spread nasty gossip about her neighbor. Which of the following actions by the nurse would likely be the most successful? a. Explain the causes of a breast lump and the usual treatments b. Refer the woman for an immediate biopsy to determine the status of the lump c. Suggest that she has to repent and as much as possible undo her sin, but also make an appointment for a biopsy d. Suggest that she has to repent, apologize to her neighbor, and pray for forgiveness

ANS: C The woman has expressed a magico-religious perspective on illness. Because evil has caused her illness, she must undo the evil. However, the nurse, as a practitioner of the biomedical perspective, must also arrange for a biopsy as soon as possible so treatment can be begin. DIF: Cognitive Level: Apply (Application) REF: p. 236

The nurse made a follow-up appointment for a client at the clinic, but the client did not come. Two days later the client presented at the clinic explaining that a temporary job had come up and he could not come back until he had finished and been paid for that job. Which of the following actions should be taken by the nurse next? a. Explain that patients are seen by appointment only, and set up another appointment for the client b. Reinforce the need to plan ahead before arranging another appointment c. Stress that health is the number one priority, and try to fit the client in sometime the same day d. Understand that some clients are present oriented, and fit the client in so care can be given

ANS: D Although health care systems are set up according to the expectation that clients can plan for the future, some clients focus on the present with little attention to the future. For the patient to receive care, the nurse should try to fit him in that day. Setting up an appointment would possibly be useless because the client may not attend the future appointment either. Poverty-stricken persons would be wise to accept employment when it becomes available. DIF: Cognitive Level: Apply (Application) REF: p. 226

A nurse was assigned to create and implement a community education program with the goal of preventing diabetes among the Hispanic population. As the nurse did not speak Spanish and was just beginning to be comfortable with the neighborhood Hispanic culture, which of the following would be the best approach for the nurse to take? a. Be sure to use appropriate images in the handouts. b. Copy literature and procedures found successful in other Hispanic communities. c. Tell the supervisor the nurse is not competent for this task. d. Try to find Hispanic volunteers who may be able to do the actual teaching.

ANS: D By using volunteers, the program can disseminate culturally appropriate information in a culturally appropriate way. The success of educational efforts is often determined by the credibility of the source and the sensitivity of the speaker in communicating information in a culturally appropriate manner. DIF: Cognitive Level: Apply (Application) REF: p. 239

After being given negative news about a health problem, the client, with tears running down her face, asks, "Why did this happen to me?" Which of the following is the most appropriate response by the nurse? a. "Could someone have cursed you?" b. "Do you feel your life is out of balance?" c. "God has a plan for each of us even if we do not understand it." d. "Why do you think it might have happened?"

ANS: D Each response represents a particular belief about illness, but without knowing the patient's perspective, the wrong one could easily be chosen. It is difficult to be comforting without knowing the client's beliefs about the causation of illness. The best way to discover this is to query the patient. DIF: Cognitive Level: Apply (Application) REF: p. 235

When one woman asked her friend to stay while a painful procedure was done, it was explained that only one immediate family member could be in the room. The woman asked the nurse, "How do you define family?" Which of the following would be the best response by the nurse? a. "A person's husband, wife, or children" b. "Anyone related to you by law or by blood ties" c. "Someone who lives with you and has ties of commitment" d. "Whoever you tell us is your family"

ANS: D Families are changing from the norm of husband, wife, and children to single parents, blended, extended, committed, or cohabitation with domestic partners. Consequently, rather than debate the definition of family, it is more practical and comprehensive to ask the client whom he or she considers to be family. DIF: Cognitive Level: Apply (Application) REF: p. 227

The clinic was seeing a great number of Hmong immigrants from the mountainous regions of the Far East. If the nurse could not obtain a translator, which of the following would be the next best action? a. Require each patient to bring a family member fluent in English b. Start teaching Hmong patients English on each clinic visit c. Suggest Hmong patients might be more comfortable seeking care elsewhere d. Try to make flash cards with common phrases used during clinic visits

ANS: D If a translator is not available, the nurse can try many approaches such as pantomime, but it would also be helpful to have common phrases used with many patients on flash cards so basic information can be obtained. Other Hmong patients or family members should not be used as interpreters. It is unrealistic to teach English to patients at clinic visits. This population needs care, so suggesting that they receive care elsewhere is not a therapeutic response by the nurse. DIF: Cognitive Level: Apply (Application) REF: p. 234

A nurse made a home visit for prenatal care and teaching for an Asian woman. The nurse noted the woman was having a hot lunch of foods the nurse did not recognize. When the nurse suggested some appropriate cold protein foods be added to the meal, the woman looked horrified and distrusting. Which of the following best describes what has happened in this situation? a. The interference with eating seemed incredibly intrusive and inappropriate. b. The nurse was giving advice when advice had not been sought. c. The nurse had suggested foods unknown to the woman. d. The yin and yang theory requires only hot food be eaten when female yin energy is dominant.

ANS: D Many Asians ascribe to the yin-yang theory in which health is believed to exist when all aspects of the person are in perfect balance. Yin energy is female. Yin Yang foods are hot. Therefore to maintain balance, she has to eat hot foods. Thus, in the other responses the nurse is not considering the cultural background and needs of the client in this situation. DIF: Cognitive Level: Apply (Application) REF: pp. 235-236

A nurse was responsible for setting up a health fair with free pizza being served during lunch. The nurse observed a few people who did not eat but just talked quietly during lunch. Which of the following actions should be taken by the nurse? a. Assume it was a religious fast day, and not worry about it b. Discuss with the supervisor what are traditional foods in that neighborhood c. Offer to let those who did not eat take the leftover pizza home for a meal later in the day d. Talk to the group, and ask what foods might have been more acceptable

ANS: D Many ethnic groups prefer certain foods as part of their cultural identity. The nurse should take this opportunity to learn foods preferred by the community. It cannot be assumed a supervisor would know preferred foods of the community. Making assumptions about the community or offering the leftovers to those who did not eat would not be culturally sensitive approaches for the nurse to take with this population. DIF: Cognitive Level: Apply (Application) REF: p. 230

A nurse was explaining a problem to the client so the client could make an informed decision about alternative treatment approaches. The client responded, "The doctor will choose the best treatment. Do whatever the doctor says." Which of the following actions should be taken next by the nurse? a. Ask if the client would like to discuss the choices with her family b. Explain that the client has to decide, and wait for the client's decision c. Explain that physicians cannot decide; perhaps the client could just flip a coin? d. Nothing; simply accept that some fatalistic-oriented clients literally do not know how to choose e. Suggest that the client discuss the situation with her ancestors and wait for guidance

ANS: D One of the three ways people are oriented is destiny, in which people must endure and accept whatever comes in a fatalistic, inevitable manner, as destiny cannot be changed. The other responses do not address the perspective of destiny that has been indicated by the client in the initial response. DIF: Cognitive Level: Apply (Application) REF: p. 226

A baby was dehydrated because of diarrhea. The mother explained that she had finally gone to a folk healer who told her to give the baby herbal tea, which did seem to be helping a bit, but the baby still seemed ill. Which of the following statements would be the most appropriate reply by the nurse? a. "Folk healers cannot cure such problems; let me give you appropriate fluids for your baby." b. "Let's go back to feeding the baby formula, and see how the baby does." c. "You continue to give the baby herbal tea, but let's put some sugar and salt in the tea." d. "Your healer is correct; fluids are crucial for your baby. Let me give you some special fluids for you to give the baby."

ANS: D Rejecting the folk healer's advice may cause the mother not to trust Western medicine. If possible, the nurse should build on what the mother is doing. It is usually helpful to include any behaviors that may be helpful or neutral in effect. In this case, the mother is encouraging fluid, which is crucial, and tea is boiled, so the water is clearly safe. Just adding salt and sugar is risky because of the need for careful measurement. Nothing in the example suggests the nurse recognizes what kind of tea is being given. It is easier to give the mother fluids with the appropriate electrolytes while supporting at least some aspect of the healer's advice. It must be remembered that most indigenous healing practices are innocuous. DIF: Cognitive Level: Apply (Application) REF: p. 224 A nurse carefully explained that the medication had to be taken three times a day, with each meal. The patient came to the clinic with symptoms of medication overdose. How should the nurse respond? a. "Can you explain what you believe happened to make you so ill now?" b. "Can you tell me when in the day you and your family eat?" c. "Please review with me when I taught you to take your medication." d. "Why did you take more medication than we suggested?" @ANS: B It is not helpful to confront the patient or accuse someone of noncompliance. A review of the prescription may have been helpful, but because the patient had an overdose, one might assume the medication is being taken more than three times a day. The nurse has engaged in cultural imposition—that is, assuming the patient's beliefs, values, and patterns of behavior are identical to hers. Not everyone eats exactly three times a day. The family may eat more or less than three times a day. DIF: Cognitive Level: Apply (Application) REF: p. 224

When a nurse visited a client's home, it was apparent that the client had not begun to implement the needed exercise program. Rather, the client had been doing drawings about his illness experience. Which of the following actions would be most appropriate for the nurse to take next? a. Express admiration for his artistic ability, and do not schedule future visits because the patient is noncompliant b. Point out the negative consequences that will ensue if the client does not begin exercising c. Review with the client why exercise is so crucial to his recovery d. Suggest drawing might be more forceful after exercising

ANS: D The dominant cultural value is action oriented, so the client would be expected to have begun to exercise. Dominant cultural values include an emphasis on productivity and being busy. However, some persons are not action oriented but being oriented, with a focus on expression of impulses and desires. DIF: Cognitive Level: Apply (Application) REF: p. 227

An unidentified patient was injured in a hit-and-run accident and was conscious. When asked how he felt, the patient looked very confused and responded in a language the nurse did not recognize. Which of the following actions should the nurse take next? a. Look closely at the person, try to determine the patient's ethnic background, and then seek someone fluent in his language b. Report the language barrier to administration, and let them handle the problem c. Tell the unit supervisor so various translators can be brought to the floor until the language is recognized and communication can be established d. Use gestures and pantomime until the nurse is able to determine what language the patient is speaking

ANS: D The nurse can report the problem and request a translator, but in the meantime the nurse should pantomime words and simple actions while verbalizing them until communication can be established using a translator from his culture. Just looking at a patient will not allow you to assume his or her ethnic background. DIF: Cognitive Level: Apply (Application) REF: p. 234

A nurse reviewed the treatment the surgeon recommended for a woman's breast lump. When the nurse asked the woman if she could be admitted to the hospital for immediate surgery, the husband thanked the nurse for her time and said they would get back in touch after they speak with other family members. Which of the following actions would be most appropriate for the nurse to take? a. Ask if there was some reason the woman could not be immediately admitted for treatment b. Explain to the woman why postponing the surgery was dangerous c. Point out it that it's the woman's decision, and stress that she should go to the hospital immediately d. Recognize that the husband and other family members may need to have input into this decision

ANS: D We typically focus on the individual as the central figure in decisions about the self. However, in other cultures female clients may seek assistance from other members of the family and allow male relatives to make decisions about important health-related matters. The husband has indicated by his response that collateral relationships are valued, thus decisions about the client may be interrelated with the influence of illness on the entire family or group. The other responses do not address the value of collateral relationships that the nurse must recognize and address. DIF: Cognitive Level: Apply (Application) REF: p. 227