NCLEX Questions- HEALTH ASSESSMENT CH. 2

Which action will be important when caring for a patient from a different culture?

1 Evaluate the patient's knowledge of medicines. Correct 2 Examine one's feelings about cultural diversity. 3 Determine whether the patient is willing to be treated. 4 Recognize that the nurse cannot counsel the patient if beliefs and practices differ. The nurse would examine one's feelings about cultural diversity, because it helps avoid cultural biases and discrimination of the patient. Evaluating the patient's knowledge of medicines is not enough to understand the patient's cultural practices. In the assessment process, the nurse determines whether the patient is willing to be treated. The nurse can counsel the patient belonging to any culture, even if there is a difference in the health practices. It is the nurse's duty to understand the patient's health practices and include them in the patient's plan of care.

A nursing student reads the case studies of different patients and separates the subjective data and objective data as part of an

1 Patient A 2 Patient B Correct 3 Patient C 4 Patient D Information given by the patient during data collection is considered subjective data. The data obtained by the nurse during physical examination by inspecting, percussing, palpating, and auscultating the patient is known as objective data, as are any data obtained from laboratory findings, medical history, and diagnostic reports. The data collection for Patient C is correct because it separates subjective data (burning sensation during urination) from objective data (bronchitis and urinary tract infection) that is diagnosed from laboratory results and diagnostic reports. The entries for patients A, B, and D are all incorrectly recorded, because these entries confuse objective information, which can be verified with tests, and subjective data, which must be given by the patient.

Which nurse is most likely to skip steps and arrive at a clinical judgment instantly during the nursing process?

1 The novice nurse 2 The competent nurse 3 The proficient nurse Correct 4 The expert nurse The expert nurse is more likely to arrive at a clinical judgment instantly because of the ability to recognize patterns from the assessment data. The expert nurse has an intuitive grasp of a clinical situation, possesses the ability to see salient issues in a patient situation, and knows instant therapeutic responses. The novice nurse works based on a defined, structured rule because of lack of experience. It takes 2 to 3 years in similar clinical situations to become a competent nurse. The competent nurse can work with arching goals or daily plans. After a few more years of practice, the proficient nurse can understand a patient situation as a whole rather than as a set of tasks. The proficient nurse can identify long-term goals for the patient.

Which statement about culture is the most correct?

A group of people with one or more shared traits The learned behaviors shared by a particular group of people The classification of human beings on the basis of physical characteristics A complex system that includes knowledge, beliefs, and customs of a group* Culture refers to a complex system that includes knowledge, beliefs, and customs of a group of people. The members of a cultural group share all traits, knowledge, and skills. A person's race is determined by the classification of human beings on the basis of physical characteristics. Cultural behaviors are learned at birth and shared by all the members of the same cultural group, but this statement is not the most correct.

1. Assessment

ADOPIE 1. Assessment Correct 2. Diagnosis Correct 3. Outcome identification Correct 4. Planning Correct 5. Implementation Correct 6. Evaluation Although the nursing process is iterative, it follows a general sequence. The first phase of the process is the assessment phase. The nurse gathers subjective and objective data using evidence-based assessment techniques. In the diagnosis phase, the nurse identifies abnormal findings and interprets the data. The nurse then validates and documents the diagnoses. In the outcome identification stage, the nurse identifies expected outcomes that are individualized for the patient. The fourth phase of the nursing process is planning. The nurse establishes priorities, sets outcomes for the patient, and documents a plan of care for the patient. The implementation phase is the fifth phase. The nurse implements the plan of care in a safely and timely manner. The nurse evaluates the progress of the patient and may use ongoing assessment to revise diagnoses, outcomes, and plan of care.

Which culture would the nurse expect a patient to be from when told, "I've been taking a tonic given by a braucher for the past two weeks"?

Amish* Asian Hispanic American Indian Individuals belonging to the Amish culture may consult a braucher, a person who is a folk healer. The braucher uses herbs and tonics to treat patients. Therefore the nurse anticipates that the patient is Amish. Asians consult an herbalist, an acupuncturist, or a bonesetter to treat illness. Hispanics consult a curandero, espiritualista, yerbo, partera, or sabedor to treat illness. American Indians consult a shaman to treat illness. Therefore the nurse does not anticipate that the patient is Asian, Hispanic, or American Indian.

Which factors encompass evidence-based practice? Select all that appl

Clinical expertise* Research findings* Clinical knowledge* Nursing preference Patient preferences* Established protocols Evidence-based practice is a combination of clinical expertise, research findings, clinical knowledge, and patient values and preferences. It challenges current protocols and is not based on nursing preference.

Which patient characteristics comprise "culture"?

Color of skin and hair A system of beliefs and practices* Preference for education and studying Physical features such as eye shape Culture refers to a system of beliefs and practices that are learned and shared by a group of people. Color of skin and hair are genetically determined and not learned. A patient's preference for education and studying helps in understanding the social influences on the patient. A physical feature such as the shape of the eye has a genetic basis.

The nurse manager is explaining diagnostic reasoning in analyzing assessment data to a novice nurse before assessing a patient. Which are the components of this process? Select all that apply.

Correct 1 Evaluating each hypothesis* Providing patient education Attending to initial available cues* Administering prescribed medications Formulating hypotheses based on data* Gathering data to develop speculative hypotheses* Diagnostic reasoning is an evidence-based method of analyzing subjective and objective data and drawing conclusions to identify diagnoses. This process has four major components, which include attending to initially available cues; formulating diagnostic hypotheses; gathering data relative to the tentative hypotheses; and evaluating each hypothesis with the new data collected, thus arriving at a final diagnosis. Providing patient education and administering medications are nursing interventions.

For which information would the nurse refer to the Guide to Clinical Preventive Services regularly? Select all that apply.

Correct 1 Up-to-date screening methods for disorders* Incorrect 2 Updates on various health insurance policies Correct 3 Description of various health counseling strategies* 4 Health-related beliefs and practices for various cultural groups Correct 5 Identification of the preventive measures for various disorders* The Guide to Clinical Preventive Services is a pocket guide that provides updates on the new screening methods that would help provide effective treatment to the patient. It also provides information on various patient counseling methods. This would help the nurse enhance coping skills in the patient. The guide also provides information on preventive measures, which helps the nurse reduce the risk of disease in the patient. The Guide to Clinical Preventive Services provides a positive approach to health assessment and risk reduction. It does not cover health insurance or cultural competency care, so the nurse would not find updates on various health insurance policies or on beliefs and practices of various cultural groups in this guide.

Which is the best action for the nurse to take when caring for a patient whose beliefs differ from those held by the majority population?

Incorrect 1 Analyze the patient's beliefs to determine their significance. 2 Ask the patient to adapt the beliefs to fit with the majority culture. 3 Ignore the patient's beliefs to prevent health risks. Correct 4 Accept the patient's differences in beliefs. The nurse would accept the different beliefs that the patient may have regarding health care or illness. Doing so would ensure unbiased and culturally sensitive care. Each culture has a set of beliefs that are important to its members. Therefore the nurse would not analyze the significance of the patient's beliefs. The nurse would not ask the patient to adapt his or her beliefs to fit with the majority culture, because the patient may like to retain the cultural beliefs. All cultural beliefs do not pose a risk to the patient's health. Therefore the nurse would not ignore the patient's beliefs.

Which factors are characterized as societal dimensions of acculturative stress? Select all that apply.

Legal status Correct 2 Discrimination Correct 3 Political forces 4 Family separation 5 Lack of education Societal dimensions of stress include legal status, discrimination, and political forces. Family separation is a social/interpersonal dimension of acculturative stress. Lack of education is an instrumental/environmental dimension of acculturative stress.

Which information will the nurse learn about a patient using the Brief RCOPE assessment tool?

Religious coping* 2 Intensity of pain 3 Psychological symptoms 4 Cognitive development Brief RCOPE is an assessment tool that contains 14 questions about the patient's belief in and perception of God. This helps the nurse identify religious coping in the patient and prevent negative health outcomes resulting from negative religious coping. A patient's religious coping can play a major role in determining the effectiveness of the treatment. Some patients may believe that illness is caused by God's punishment or an act of the devil. Such beliefs may affect the patient's coping skills and may hinder treatment effectiveness. Brief RCOPE does not contain questions related to pain intensity. Therefore the nurse cannot assess the intensity of pain in the patient by using this tool. Brief RCOPE does not contain questions related to psychological symptoms and cognition. Therefore the nurse does not identify psychological symptoms or cognitive development in the patient by using Brief RCOPE.

Which indicates a potential social determinant of an individual's health?

Spiritual beliefs Language barrier Educational level* Health care practices A person's educational level is a social determinant of health care. Spiritual beliefs, language barriers, and health care practices fall within cultural practices, not social.

Which interpersonal dimensions are responsible for acculturative stress? Select all that apply.

Unemployment Correct 2 Family Seperation* Correct 3 Loss of social status* Correct 4 Lack of social network* Lack of health care access Social or interpersonal factors such as unemployment, family separation, and lack of a social network result in acculturative stress. Immigrant patients have difficulty in adjusting to new social routines and beliefs; this may result in acculturative stress. The patient may be unable to cope with separation from family and may experience despair because of a new cultural milieu, which leads to acculturative stress. A loss of social status in the new society because of different cultural beliefs may result in acculturative stress. The lack of a social network or friends with whom to communicate and mingle may also result in acculturative stress. Unemployment and lack of health care access also result in this type of stress. However, unemployment and lack of health care access are instrumental or environmental dimensions.

The patient states, "I'm visiting a traditional healer who has taken care of all the women in my family during pregnancy." The nurse uses which term to document this patient's alternative medicine choice

Yerbo Partera* Sabedor Espiritualista A partera is a lay midwife who provides treatment and cares for pregnant women. Therefore the nurse anticipates that the patient is visiting a partera. A yerbo is an herbalist who treats illness by administering herbal leaves and oils but does not provide treatment exclusively for pregnant patients. A sabedor is a traditional healer who manipulates the bones and muscles. An espiritualista is a traditional healer who treats illness by using spiritual methods.