Ch 4 Adult health, physical, nutritional and cultural 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)
101.60 cm (40 in)
A nurse is percussing a patient's abdomen. The nurse understands that which sound indicates tissue with the LEAST density? a)Dullness b)Tympany c)Hyperresonance d)Flatness
b)Tympany
When obtaining a health history from a patient, what should be the nurse's primary focus? (Select all that apply.)
-A comprehensive body systems review -Current and past medical problems -Family history
How can the nurse best provide culturally sensitive care?
Accept each client as a unique individual
What primary nutritional nursing consideration should be included in the physical assessment of an older adult patient?
Altered metabolism and nutrient use secondary to an acute or chronic illness
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?
Cultural Imposition
A nurse cares for an older adult client who is taking over ten different medications or supplements. What statement made by the nurse best assesses the client for medication interactions? a) "Have you read the prescribing information on your medications?" b)"What is your knowledge about medication interactions?" c) "Can you please tell me what each of your medications are for?" d) "At what pharmacy do you fill your medications?"
Can you please tell me what each of your medications are for?"
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.
Communication "Are you comfortable with the space between us?" Space "How close do you stand to a family member when asking a question?" Social Organization "What is your role in your family?"
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?
Cultural Imposition
Ethnocentrism is closely related to which of the following? a) Subculture b) Cultural imposition c) Ethnicity d) Cultural competence
Cultural imposition
When the nurse is percussing for measurement of the patient's liver span, what type of response should be heard?
Dull Sound
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?
Explaining the rationale for continuous bladder irrigation (CBI)
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?
Holistic
The yin/yang theory of harmony and illness is rooted in which paradigm of health and illness?
Holistic
Using the assessment technique depicted in the accompanying photo, the examiner would assess which of the following structures? a)Bladder b)Small bowel c)Liver d)Abdominal skin
Liver
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?
Liver Disease
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) Biomedical-scientific b) Magico-religious c) Spiritual chakra d) Holistic-naturalistic
Magic-religious
Nursing students are reviewing information about the U.S. Department of Agriculture's Center for Nutrition Policy & Promotion's MyPlate recommendations for food intake. The students demonstrate a need for additional review when they identify which of the following as one of the five major food groups?
Milk
A nurse is providing care for a female client who is Hispanic. The care team is discussing the client's nutritional status and one of the nurse's colleagues states, "I suppose we should try to get her some tacos or burritos since that's what she's probably used to." How should the nurse best interpret the colleague's statement?
The colleague may have stereotypical views of Hispanics
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?
The liver
A nurse is planning the care of a 48-year-old woman who has just received a diagnosis of breast cancer. The client has been explicit about her desire to integrate a variety of complementary therapies into her treatment regimen. What is the nurse's primary responsibility around the use of complementary therapies?
To assess the client's use of complementary therapies in order to promote safety
Which specialty in nursing involves providing nursing care in the context of the client's culture?
Transcultural Nursing
To calculate the ideal body weight for a woman, the nurse allows a) 100 lb for 5 ft of height. b) 6 lb for each additional inch over 5 ft. c) 106 lb for 5 ft of height. d) 80 lb for 5 ft of height.
a) 100 lb for 5 ft of height.
When obtaining a health history from an older adult patient, what should the nurse remember to do? (Select all that apply.) a) Ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing impaired. b) Conduct the interview in a calm, unrushed manner using eye-to-eye contact. c) Clarify the frequency, severity, and history of signs and symptoms of the present illness. d) Frequently touch the patient so that you may bring his or her attention back to the interview. e) Have a family member in the room when asking questions to make sure the patient's answers are accurate.
a) Ask questions slowly, directly, and in a voice loud enough to be heard by those who are hearing impaired. b) Conduct the interview in a calm, unrushed manner using eye-to-eye contact. c) Clarify the frequency, severity, and history of signs and
Three major paradigms are used to explain the causes of disease and illness. Which three of the following are the paradigms? Choose all three. a)Biomedical or scientific view b)Naturalistic or holistic perspective c)Magico-religious view d)Geographic view e) Dynamic perspective
a) Biomedical or scientific view b)Naturalistic or holistic perspective c)Magico-religious view
The nurse is caring for a patient who speaks only Spanish. To facilitate communication, which of the following is an appropriate action by the nurse? a) Follow the agency's policies to obtain an interpreter. b) Ask a relative of the patient to act as an interpreter. c) Find a Spanish-speaking employee to be the interpreter. d) Obtain an order from the physician for an interpreter.
a) Follow the agency's policies to obtain an interpreter.
The nursing instructor discussed the theory of energy forces existing between organisms and objects in the universe and called this yin-yang. Yin-yang is an example of which societal view of illness? a) Naturalistic perspective B) Magico-religious perspective C) Scientific perspective D) Biomedical perspective
a) Naturalistic perspective
A client with chronic obstructive pulmonary disease (COPD) visits the health care center with breathing difficulties. Which part of the client profile relates to the client's view of himself or herself and the impact of COPD? a) Self-concept b) Chief complaint c) Biographical information d) Stress and coping response
a) Self-concept
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) The nurse continues to collect information from the child's mother, knowing the informant will not always be the client. Allow the child's pediatrician to conduct the health history. b) The pediatrician can allow the child to participate in the assessment, as appropriate. c) 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. d) The nurse explains to Sara's mother that the child must be the primary informant while collecting the health history.
a) The nurse continues to collect information from the child's mother, knowing the informant will not always be the client.
Agency policies are important to achieve culturally competent care. When reviewing a hospital's current policy framework, what action has the most potential to improve the overall level of culture competence? a) Reducing the institution's dependence on English for communication b) Creating greater flexibility in visiting hours c) Eliminating written information from staff members' identification badges d) Promoting members of minority groups to higher profile positions
b) Creating greater flexibility in visiting hours
A newly admitted client has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters should the nurse include? Select all that apply. a)Coping strategies b)Wrist circumference c)BMI d)Dietary data e)Clinical examination findings
c ) BMI d)Dietary data e)Clinical examination findings
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)"Is there another way you have learned to lessen pain when you experience it?" b) "You have the right to make that decision. How can the nurses help you cope with your pain?" c) "Refusing medication can only hurt you by increasing your awareness of the pain experience." d) "Let a nurse know when you are in pain so you can be helped to decrease stimuli that may exaggerate your pain experience."
c) "Refusing medication can only hurt you by increasing your awareness of the pain experience."
While taking a nursing history, the nurse is made to feel uncomfortable when a client positions himself very close to the nurse. The nurse should do which of the following? a) Calmly ask the client to move back to a distance that is more comfortable for the nurse. b) Ask a colleague to complete the health history. c) Consider that the client's cultural preferences for space and distance may be a reason for this behavior. d) Report the inappropriate behavior to the nurse's supervisor.
c) Consider that the client's cultural preferences for space and distance may be a reason for this behavior.
Of the following nurse theorists, which one is considered the founder of transcultural nursing? a) Jean Watson b) Patricia Benner c) Madeline Leininger d) Dorothea Orem
c) Madeline Leininger
Hyperresonance is audible when which area is percussed? a) Air-filled stomach b) Thigh c) Overinflated lung tissue d) Liver
c) Overinflated lung tissue
Which of the following refers to a group that shares characteristics identifying the group as a distinct entity? a)Culture b)Minority c)Subculture d)Race
c)Subculture
Which of the following diagnostic findings is indicative of a protein deficiency in adults? a) elevated prealbumin level. b) high 24-hour urine creatinine. c) high lymphocyte count. d) low serum albumin.
d) low serum albumin.
The nurse is caring for an older adult client who lives alone and who has a BMI of 17. What risk does this client likely face? a)Low risk of chronic disease b)Increased incidence of falls c)High risk of diabetes d)Anorexia
d)Anorexia
