313 exam 4

A nurse experienced in doing community assessments realizes that the following is true regarding education?

The higher the community's education level, the healthier the community.

A client requests to be care for by a nurse who is a member of his own culture. The nurse recognizes that which barrier exists in regards to this client's nursing care?

ethnocentrism

The nursing instructor is discussing the importance of spiritually assessing a patient in order to be able to provide holistic care. What suggestion can she give to the student who is not sure of the correct questions to ask?

" You may use the FICA spiritual assessment tool."

Which statement by the nurse demonstrates a cultural bias?

"American healthcare is really so much better than that provided by any other country."

An 88-year-old woman has been admitted to the acute medical unit for the treatment of a urinary tract infection that is thought to be progressing to urosepsis. When assessing the client's orientation, how should the nurse best gauge the client's orientation to time?

"Are you able to tell the month and the year that we're in?"

Which statement by the nurse who is caring for a practicing Muslim patient demonstrates cultural sensitivity?

"I will bring you a basin of water for your prayer time."

A teenage client is in the ED. The client has a long medical history of injuries including burns, bruises, and broken bones. The nurse suspects abuse and asks the client's mother to wait outside. She hesitates but finally agrees. The nurse senses that the client wants to talk about experiences. How should the nurse ask about the injuries?

"Injuries like yours could have been caused by someone hurting you. Did someone hurt you?"

The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client?

"It looks like someone has hurt you. Tell me about it."

A client tearfully admits to the nurse that her husband beats her when he drinks alcohol excessively. How should the nurse best respond to the client's statement?

"It took a great deal of courage for you to tell me that."

Emergency medical services bring a client to the hospital after finding her unconscious in an alley. When the client regains consciousness, responses to assessment questions indicate to the nurse that the client may have been abused but that the client appears uncomfortable discussing the events. What open-ended question might be helpful when assessing abuse with this client?

"What would you like me to know?"

What open-ended question might be helpful when assessing abuse with a client demonstrating discomfort discussing the issue?

"What would you like me to know?"

An older patient is demonstrating mental status changes. Which question would the nurse ask when conducting a mini-mental state examination of this patient?

"Whats todays date?"

A nurse recognizes the need to assess a client's spirituality after the client has been admitted from the emergency department to the medical unit. How should the nurse best initiate this assessment?

"Would you describe yourself as being a religious or spiritual type of person?"

The nurse is preparing to conduct a mental status examination with a patient. Which areas will the nurse include when assessing the patient's appearance and behavior? (Select all that apply.) You Selected:

-Posture -Level of consciousness -Facial expression

Which of the following are forms of psychological (emotional) abuse? Select all that apply.

-Threatening to destroy property -Humiliating -Insulting

A nurse is working with her first client form Muslim culture. The nurse quickly realizes that the culture has a major impact on health and health care. What are examples of culture affecting health care?

-client refuses meal because it has pork -demands having a male nurse -time of silence in afternoons to pray

A nurse administrator is leading a seminar on cultural awareness in health care, beginning the seminar by defining culture. Which of the following elements should the nurse administrator include, based on the definition provided by Purnell and Paulanka (2008)?

-forms wordlview -socially transmitted -affects decision making -characteristic of a population or people

A nurse admits a client to hospital who is African American. The nurse recognizes that this client is at an increased risk for what conditions due to ethnicity or culture?

-peripheral artery disease -asthma -cardiovascular disease

The nurse recognizes that which factors can influence the metabolism of drugs that a client may be prescribed?

-stress level -nutritional status -smoking

In the assessment of a Chinese client, a nurse asks the client several questions pertaining to the client's culture. The client asks the nurse why she is asking questions about her culture. Which of the following should the nurse mention?

-to learn about beliefs and usual behaviors associated with health and illness -assess health relative to diseases prevalent in cultural grouo -compare and contrast beliefs and practices to standard health care -to avoid stereotyping

The "evil eye" is an example of what?

A cultural-bound syndrome

Illness can be affected by which of the following spiritual beliefs?

All of the above

When depression goes undiagnosed, what consequences occur eight times more frequently than in the general population?

Death

Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons originating from which geographical regions?

Mediterranean and Africa.

During the health-history interview, which of the following components of cognitive function can the nurse quickly assess?

Memory and attention

A nurse is planning care that is grounded in the fact that clients are holistic beings. Which of the following lists of components constitute the view of clients as holistic beings?

Mind, body, spirit

The nurse assesses the client to have a Glasgow Coma score of 15. The nurse anticipates what degree of impairment?

None

A woman and her boyfriend bring the woman's 8-year-old daughter to the ED. The child has a fractured forearm and multiple bruises on her torso in various stages of healing. The fracture has already begun to heal. With what are these assessment findings consistent?

Physical abuse

The nurse begins the health history with a focus on the client's mental status. Why does the nurse ask for the client's age?

Provides a reference point for psychosocial developmental level

To determine the sources of strength for a patient, the nurse could ask, "In what ways do they help?"

True

which child should a nurse suspect may be a victim of child abuse?

a three-year old who is unable to put words together to make a sentence.

A nurse is assessing a Navajo client, who has presented to the health clinic with complaints of feeling endangered, confusion, bad dreams, and hallucinations. Which culture-bound syndrome should the nurse suspect in in this client?

ghost sickness

A female client is assessed to have a score of 6 points on the AUDIT. This would alert the nurse that this client

has a hazardous alcohol consumption.

A 27-year-old woman comes to the office with her mother, who tells the nurse that her daughter has had schizophrenia for the last 8 years and is starting to decompensate despite medication. The client states that she has been taking her antipsychotic and is doing fine. Her mother retorts that her daughter has become quite paranoid and gives an example. She says that her daughter goes and gets the mail every day and then microwaves the letters. The client agrees that she does this but only because she sees the mailman flipping through the envelopes. She says that she knows he's putting anthrax on the letters. Her mother turns to her and says, "He's only sorting the mail!" Which best describes the client's abnormality of perception?

illusion

Risk factors for mental disorders

may be specific to an ethnic group.

Violence has many effects on the mental health of clients. Some mental health problems that may be related to violent experiences include which of the following? Select all that apply.

• Posttraumatic stress disorder (PTSD) • Relationship and marital problems • Acting out violently • Depression

Which of the following assessment questions is most likely to allow the nurse to assess a client's judgment?

"How do you plan to meet your responsibilities at work?"

The nurse suspects that a client is experiencing alcohol abuse. When completing the CAGE questionnaire, the nurse can confirm the client is having guilty feelings when she makes which statement?

"My family doesn't deserve my bad behavior."

Which question is appropriate for a nurse to ask a client to assess the client's recent memory?

"What did you eat for breakfast today?"

The nurse is completing a mental health assessment. When the nurse asks the patient to interpret a proverb, the nurse is assessing which of the following?

Abstract reasoning

During a patient interview, the nurse is focusing on cultural influences particularly when assessing: (Select all that apply.)

Health care beliefs and practices Nutrition High-risk behaviors

What is an important part of being present with a patient?

Listening

A patient asks the nurse if there are church services in the hospital because the patient attends mass every Sunday. The nurse realizes that this patient is demonstrating:

Religion

During a spiritual assessment, the nurse asks if a patient's faith is helpful to them. The nurse is assessing the patient's:

Religious practices

Susanne is a 27-year-old woman who has had headaches, muscle aches, and fatigue for the last 2 months. The nurse has completed a thorough history, examination, and laboratory workups, the results of which are normal. What would the next action be?

Screening for depression

A nurse recognizes that the belief that one's wordlview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called what?

ethnocentrism

The nurse is counseling a female victim of intimate partner violence. What should the nurse encourage the client to have prepared as part of a safety plan? Select all that apply.

Driver's license Marriage license Cash Bank account numbers

A nursing instructor is describing formal and informal channels of communication that occur within a community. The instructor determines that the teaching was successful when the students identify which of the following as an example of informal communication?

filers

Which statement represents a clanging speech pattern?

"Peas are good. Trees are wood. I'd leave if I could."

Skin color is

A valid characteristic that differentiates racial groups.

The nurse needs to assess the visual, perceptual, and constructional ability of a client. Which of the following assessments should the nurse use?

Have the client draw the face of a clock

When a nurse asks a patient "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

Suicide Ideation

After assessing a client and finding her positive for intimate partner violence (IPV), which of the following should the nurse do next?

Have the client fill out a danger assessment questionnaire

A client opens the eyes and answers questions however falls back asleep within seconds. How should the nurse document this assessment finding?

Lethargy

Which assessment notation describes a client's level of consciousness?

"Client was alert and cooperative during the assessment."

The nurse in a prenatal clinic is performing an assessment on a pregnant client. When it is noted that clumps of hair are missing from the client's scalp, the nurse should ask what assessment question?

"Do you feel safe in your home setting?"

The nurse notes that an older adult client is wearing multiple layers of clothing on a warm fall day. Which of the following would be the nurse's priority assessment at this time?

Asking whether the client often feels cold

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what?

In coma

In preparing to assess a client form a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which is a factors the nurse should consider that primarily affects the client's approach to providers?

time, space, eye contact and fact positioning, body language and hand gestures, silence, and touch

Which parameter should a nurse identify as a developmental variation in childhood when assessing a 2 month old infant?

timing of motor development

In working with a Japanese woman, a nurse assesses the environment and high-risk behaviors associated with this client's cultural group. Why is it important for the nurse to take these factors into account?

to find clues to current health statues of an individual

The biggest obstacle to the use of facilities and services within a community is the lack of what among its members?

transportation

A community health nurse assesses the economics of a community because income definitely has a direct relationship to the health of the residents.

true

What is a culture bound syndrome of Asia that features symptoms including fear of wind or cold exposure causing a loss of yang energy.

wild illnes

What questions should be included in a spiritual assessment? Select all that apply.

• "Do you need a private place to pray?" • "What gives you meaning to your life?" • "How does your spiritual practices help you to deal with pain?

The nurse recognizes that which of the following are signs of a healthy local government? Select all that apply.

• Government leaders are accessible to the community • A high percentage of the community members are registered to vote • Open community meetings are regularly held • There is an atmosphere of tolerance among different groups

Spirituality is a human experience that (Select all that apply.)

• includes a supreme being • seeks to transcend self

The nurse is setting an outcome with the patient experiencing social isolation. Which goal would be appropriate?

The patient will express meaning and purpose in life.

The nurse is setting an outcome with the patient experiencing spiritual distress. Which goal would be appropriate?

The patient will express meaning and purpose in life.

What outcome should the nurse prioritize when addressing a patient's social, cultural, and spiritual issues?

The patient will express meaning and purpose in life.

A nurse is assessing an African woman who recently immigrated to the US. Which is important for nurse to understand regarding this race?

it is socially constructed

The client states his pain is "intolerable" and requests pain medication. The nurse observes the client to be talking and laughing with visitors. How should the nurse best respond?

"I will be back with your pain medication."

Participating in the community allows the nurse to be accepted as a member of it. This method of data collection allows the nurse to participate in the daily life of the community, obtain information about the structures and influences of the community, and also do which of the following?

Make observations.

Within the 45-64 years of age group, a nurse knows that the most common cause of mortality is from what source?

Malignant neoplasms

An auditory hallucination is considered an alteration in which component of the mental health assessment?

Perceptions

The patient states, "I don't know why God as abandoned me; I am a good person." The nurse suspects the patient is at risk for:

Suicide

When a nurse asks a client "Do you have any thoughts of wanting to harm or kill yourself?" for what is the nurse assessing?

Suicide risk

Healthy People identifies a goal of reducing the annual rate of rape or attempted rape, and other sexual assaults. What action best facilitates this goal?

Teaching children about healthy touch

An important concept to teach preschoolers in an effort to prevent attacks of sexual abuse would be to first teach them

That their body belongs to them and they have the right to decide who can touch or look at it.

The eudaimonistic model of health emphasizes:

The biopsychosocial and spiritual wellness of the person.

A nurse knows that the most important risk factor for assessing health related problems is what demographic information?

age

When assessing the client's ability to make sound judgments, what question should the nurse ask?

"How do you plan to pay rent if you lose your job?"

A nursing instructor is teaching students about communication in different cultures. When discussing the meaning of hand gestures and body language in different cultures, the nurse realizes that further instruction is necessary when a student makes which statement?

"I can make a circle with my thumb and forefinger and people of all cultures know it means OK."

Which client statements suggest to the nurse that the client is experiencing a somatic symptom? Select all that apply.

"I can't recall doing anything to cause this back pain I've been having." "My partner complains that I'm just not as interested in sex as I was before the baby was born." "I can't have this headache; I've got final exams tomorrow."

From a critical cultural perspective, culture refers to which of the following?

A dynamic process enacted between people and their families

Which Glasgow Coma Score indicates the client is in a deep coma?

3

Which of the following is a stage in Walker's cycle of violence?

Period of reconciliation.

A nurse is caring for a patient who is an American Indian. When working with this patient, the nurse consider that the patient believes which of the following as true about eye contact?

Shows disrespect

What must occur before a client will be willing to teach the nurse about her culture?

The nurse needs to establish rapport and trust

A male nurse is caring for an elderly woman who has become withdrawn and somewhat confused since the nurse has come on duty. When the nurse goes into the room to bathe the patient, she refuses to allow it. The best explanation for her actions would be which of the following?

cultural differences

A older adult client is brought to the clinic by the client's daughter who voices concerns about changes in her parent's mental status. What behavior would the nurse look for to formulate a plan of care for dementia in this client?

defers to family members to answer questions directed to the client

Elder abuse can include

economic exploitation.

As a novice nurse caring for a patient from a different culture, what may you find confusing or upsetting?

Patient's nonverbal communication

When observing a patient diagnosed with mania, the nurse observes his mood to be elated. Another term for this type of mood includes which of the following?

Euphoric

A nurse has been asked to complete a mental status examination of a psychiatric-mental health client. Which of the following is included in this assessment?

Evaluation of insight and judgement

How can a nurse determine if the members of a community are involved in the government and political structures?

Percentage of registered voters that actually vote

A nurse must perform a nonformal spiritual assessment of a client. Which tool would be most appropriate for the nurse to use?

SPIRIT assessment tool

The nurse is conducting the initial prenatal visit with a patient who is in her second trimester. After a few minutes of interaction, the nurse suspects intimate partner violence. Which comment by the patient describes isolation?

"I have not seen my parents in 6 months; they live only 30 minutes away."

A nursing instructor realizes that a student needs further instruction on giving culturally competent care when the student states which of the following?

"I should use my own culture as the standard for all other cultures."

The nursing instructor is educating her students on the important of assessing for victims of abuse and violence. What statement by the students indicate an understanding of when to assess for abuse and violence?

"I will assess a client for abuse and violence with every client encounter."

A nurse is conducting an initial interview with a client who has paranoid delusions. What statement by the nurse can help to establish rapport as well as alleviate some of the suspicion the client may experience?

"I will be asking you a series of questions that I ask of all of my clients."

The client states his pain is "intolerable" and requests pain medication. The nurse observes the client to be talking and laughing with visitors as they help to provide care to him. How should the nurse best respond?

"I will be back with your pain medication."

The nurse suspects that a female client is the victim of abuse. What physical assessment finding caused the nurse to come to this conclusion? Select all that apply.

-Bruises around the wrists, -Healing circular wounds along the inner thighs, -Welts across the back, -Bruising around the left eye and neck

Which of the following would the nurse identify as indicating psychological or emotional abuse? Select all that apply.

-Calling the victim names -Threatening to hit the victim -Forcing the victim to perform a degrading or humiliating act

A student nurse says, "I will not be able to do a good spiritual assessment, because I am not very religious." The instructor addresses this issue with which of the following statements?

"The patient is the focus of the spiritual assessment."

An emergency department nurse asks a client to complete an intimate partner violence assessment screening. How should the nurse best explain the rationale for this assessment?

"We routinely screen everyone because violence affects so many people."

A 4-year-old has been sexually abused. As you watch her play with anatomically correct dolls, she inserts the male doll's penis into the female doll's mouth. What is your best response to this action?

"What are the dolls doing?"

As part of the mental status examination, a nurse assesses the cognitive abilities of a client. Which question should the nurse ask to assess the judgment ability in the client?

"What do you do if you have pain?"

Which of the following would be most appropriate for the nurse to ask when beginning to assess a client's spirituality?

"What gives you hope or peace?"

A nurse is assessing a patient's spirituality. Which question would be most appropriate to ask?

"What gives your life meaning?"

The nurse is performing an admission assessment with a patient and is questioning the patient about religious preference. The patient says that they have no religious or spiritual preference. What statement by the nurse demonstrates a non-judgmental attitude?

"What provides you strength in dealing with stress or illness in your life?"

Which question asked by the nurse assesses judgment of the patient?

"What will you do if you feel the need to use cocaine again?"

A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?

'He tells me that he is sorry and that he will never hit me again."

The nurse is helping a client who is a victim of intimate partner violence (IPV) develop a safety plan. Which of the following should be included in the safety plan? Select all that apply.

- Locations to go to if it becomes necessary to leave - What to pack and where to hide a bag or suitcase - A code word to use with kids, family, and friends that alerts them to danger

A nurse is screening an elderly woman for signs of elder mistreatment. Which of the following would be considered forms of elder mistreatment? Select all that apply.

- Refusing to assist the elder to the bathroom - Refusing to give the elder her medications - Having the elder sign papers she doesn't understand

Which clients are most at risk for depressive symptoms? (Select all that apply.)

-Divorced patients -Females -Chronically ill patients

A nurse is aware that pregnancy and childbirth hold different taboos among various cultures. Some of these taboos include which of the following? (Select all that apply.)

-Having the mother avoid reaching over her head to prevent the umbilical cord from going around the baby's neck -Not buying baby clothes before birth -Not permitting the father to see mother or baby until the baby is cleaned

What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply.

-whether there are any existing language barriers -nutritional or dietary considerations -alternative medicine practices

A client arrives at the clinic accompanied by her husband. When the client is in the examination room she says to the nurse, "He loves me so much. He only lets me go out when he is with me because he says other men look at me." What type of behavior is this husband exhibiting?

Isolation

The nurse plans to assess a 35-year-old female client for family violence. In which order should the nurse complete the HITS assessment tool? Rank the statements into the proper order.

1. How often does your partner physically hurt you? 2. How often does your partner insult or talk down to you? 3. How often does your partner threaten you with physical harm? 4. How often does your partner scream or curse at you?

A nurse suspects that a 9-year-old girl who is in the office today regarding a sprained wrist has been physically abused. The nurse would like to screen the girl for signs of abuse. The girl's father is in the examination room. What should the nurse do in this situation?

Ask the father to leave the room so that the nurse can talk with the child in private

An Asian patient comes in to the clinic accompanied by her son. He explains that his mother has "not been feeling well". The nurse observes scars that resemble cigarette burns. What is the nurses best intervention to this assessment finding?

Ask the patient if she has had moxibustion.

Which approach would be most appropriate when counseling a woman who is a suspected victim of violence?

Ask, "Have you ever been physically hurt by your partner?"

A woman from a foreign country is admitted to the obstetric unit. While doing a transcultural assessment, what would the nurse do first to individualize questions for this client?

Assess if the client speaks and understands English

A woman newly immigrated to the United States is admitted to the obstetric unit. While doing a transcultural assessment, how would the nurse individualize questions for this client?

Assessing if the client speaks and understands English

As part of assessing the client's level of consciousness, the nurse asks questions related to person, place, and time. Which of these statements is true?

Orientation to time is usually lost first and orientation to person is usually lost last.

The nurse documents findings from the client's Mini-Mental State Examination. The following information will be documented as a result of this test.

Orientation, memory, and cognitive function.

The city police department has had to make significant budget cutbacks and have been forced to decrease their workforce. The nurse has seen in increase in injuries caused by violent crimes in the emergency department. What would be a priority nursing diagnosis for this issue?

Other-Directed Violence related to insufficient police protection

A nurse has just assessed a client using the St. Louis University Mental Status (SLUMS) exam. From his health record, the nurse sees that the client graduated from high school. Which of the following scores would indicate mild cognitive impairment in this client?

25

A nurse interviews a client who reports pain in the chest. The client is accompanied by her husband. During the interview which observation by the nurse may indicate that the client is abused by her partner?

Partner attempts to speak for the client

The client is brought to the clinic by his son, who states, "My father just doesn't seem to be able to function as well as he used to." When assessing this client the nurse is aware that she will be a what?

Patient advocate

The nurse is admitting a client to the unit for surgery the next morning. The nurse notes that the client speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would the nurse document about this patient?

Patient demonstrates flight of ideas

A nurse assesses a client who was physically assaulted by his brother. The nurse learns that the client has been punched and kicked. After marking the area of injury on the body map, what score should the nurse document for this abuse? 4 5 3 1

3 (1 = Threats of abuse including use of a weapon 2 = Slapping, pushing: no injuries and/or lasting pain 3 = Punching, kicking, bruises, cuts and/or continuing pain 4 = Beating up, severe contusions, burns, broken bones 5 = Head injury, internal injury, permanent injury 6 = Use of weapon; wound from weapon)

When reviewing the demographics of various communities, the nurse would identify a community with a large percentage of which age as most likely to have health-related concerns?

Elderly

A nurse assesses a client who was physically assaulted by her boyfriend. The nurse learns that the client was stabbed in the thigh with a knife. After marking the area of injury on the body map, what score should the nurse document for this abuse?

6

A nurse is assessing the religious beliefs of a community. Which of the following would be a sign of a healthy community?

A Jewish synagogue and Christian church that partner together to operate a food pantry

The nurse is performing a community health assessment. When performing data collection, the nurse should seek out what informants?

A combination of community leaders and "typical" residents

A Hispanic woman brings her school age child to the clinic for an intestinal ailment that has lasted for 5 days. Based on the client's culture, which of the following options would be most likely as a response when the family is asked about possible alternatives for treating the child's ailment?

A curandera

A nurse has a regular client who is an immigrant from China and who follows the traditional medical system of that culture. To improve the ability to understand and work with this client, the nurse researches this client's cultural view of health. Which of the following would the nurse most likely discover?

A focus on maintaining balance between yin and yang

Which of the following would be the best indication that a community's police department is inadequate?

A high rate of homicides

Several pregnant patients have recently been told that the obstetrics unit at their local rural hospital will be closing, effective in 1 month. This is the second obstetric unit in a rural facility that has closed within a 40-mile radius. What is the problem is the community facing?

A lack of accessibility to meet health care needs.

With which of the following is the documentation most consistent?

A patient who has had a recent stroke

After using the SLUMS tool to test a client's mental status, the nurse calculates a score of 12. The nurse should make

A referral to the primary health care provider for further evaluation.

A nurse is counseling a woman who has been abused by her husband and who is at risk for serious injury and even death. The woman has two school-aged children at home. Which of the following should the nurse tell the woman to make sure her children know? Select all that apply.

A safe place to go when abuse of the client occurs Who is safe to tell when they are unsafe How and when to call 911

The nurse is caring for a woman in the prenatal clinic who comments that she just cannot seem to get things "right" anymore at home and that her husband says she knows so little about life. Which type of abusive or controlling behavior is the woman describing?

Emotional abuse

When the nurse asks the client to explain similarities and differences between objects, what cognitive ability is being tested?

Abstract reasoning

A nurse is planning a program to address measures to reduce the leading cause of mortality in children age 1 to 14 years. Which of the following topics would best address this cause of death?

Accident prevention

A nurse is planning a program to address measures to reduce the leading cause of mortality in children age 1 to 14 years. Which of the following would the nurse include?

Accident prevention

When working with victims of abuse, there are many ways the nurse plays the part of a client advocate. What can the nurse do to be a client advocate? Select all that apply.

Acknowledge injustice Help the client plan for future safety Respect client confidentiality Respect the client's autonomy

A toddler has been admitted to the pediatric intensive care unit (PICU) with scald wounds from a pan of hot water. The mother has been charged with child neglect, and the father is in denial of the cause of the injury to his son. A nursing diagnosis of dysfunctional family processes related to child neglect has been identified. The nurse caring for this client would use what appropriate nursing intervention in the client's care plan?

Acknowledge the emotions experienced during stressful times

A nursing instructor is discussing mental health assessment with a class of nursing students. While reviewing risk factors for mental illness, what would the instructor be sure to identify as a factor that cannot be changed?

Age

The incidence of infant mortality varies in the United States. What group has 1.4 times the number of infant deaths than Whites and is more likely to begin prenatal care in the third trimester?

American Indians

If a client seems reluctant to make eye contact, a health care provider should consider the possibility that this is which of the following?

An indication of discomfort or intimidation

The nurse is planning to assess a community. Which of the following activities would be most appropriate for the nurse to do when collecting objective data about a community?

Analyze census data.

The CAGE assessment is used by the nurse to determine if further assessment is needed. The nurse may assess that it is highly likely the client has a problem and would seek additional assessments if the client

Answered yes to three of the four CAGE questions

The nurse observes a client's entire body posture to be somewhat stiff, with his shoulders elevated upward toward the ears. The nurse would most likely interpret this to indicate that the client is experiencing which of the following?

Anxiety

A client demonstrates nervousness and fear with a worsening loss of memory. Which nursing diagnosis should the nurse select to help guide this client's care?

Anxiety related to awareness of increasing memory loss

A client who practices Catholicism is chronically ill and states that he feels disconnected from his support system, because he is unable to attend church services. What is the most appropriate action by the nurse?

Arrange for the chaplain to meet the client

A Navajo Native American client states having "bad dreams, and feelings of confusion and danger." The nurse notes the client's mother died one month ago. What would the nurse do next?

Ask how long the client slept last night.

When a nurse suspects that a client may have been abused, the first action should be to:

Ask the client about the injuries and if they are related to abuse.

The nurse notes that a client hesitates when responding to questions. With which part of the mental health assessment is this client having difficulty?

Attention

A nursing student demonstrates understanding of the different communities when classifying Mothers Against Drunk Driving (MADD) as which type of community?

Based on specific function

While preparing a Hindu client for surgery, it becomes apparent that the client's view about spirituality is entirely different from the nurse's. What is the most appropriate action by the nurse?

Be respectful, open, and willing to discuss spiritual issues as appropriate

A nurse is assigned to care for a client who has been physically abused by her husband. The nurse finds that client has an abuse score of 4 in her documents. Which of the following descriptions corresponds to the abuse score?

Beating up and severe contusions

A nurse assesses a 4-year-old boy who experiences gas, a stomachache, and diarrhea after consuming lactose products. The nurse recognizes the data as what type of biological variation?

Biochemical

The client comes to the health care provider stating he has a sore throat and believes he needs an antibiotic. This is an example of of what type of model for health?

Biomedical

In preparing to assess a client from a different culture, a nurse is aware that one needs to assess both factors that affect the client's approach to providers and factors that affect the client's disease, illness, and health state. Which of the following is a factor the nurse should consider that primarily affects the client's approach to providers?

Body language

Which of the following statements is true about biologic variation?

Both genetics and environment produce biologic variation.

A 72-year-old man comes to the clinic with his daughter for a follow-up visit after a recent hospitalization. He had been admitted to the local hospital for speech problems and weakness in his right arm and leg. On admission his MRI showed a small stroke. The client was in rehabilitation for 1 month following his initial presentation. He is now walking with a walker and has good use of his arm. His daughter complains, however, that everyone is still having trouble communicating with him. The nurse asks the client how he thinks he is doing. Although it is hard to make out his words, the nurse believes the client's answer is "well . . . fine . . . doing . . . okay." His prior medical history involved high blood pressure and coronary artery disease. He is a widower and retired handyman. He has three children who are healthy. He denies tobacco, alcohol, or drug use. He has no other current symptoms. On examination he is in no acute distress but does seem embarrassed when it takes him so long to answer. Blood pressure is 150/90; other vital signs are normal. Other than his weak right arm and leg, physical examination findings are unremarkable. What disorder of speech does he have?

Broca's aphasia

A culture-based syndrome in North American and Western European countries involves an intense fear of obesity, eating binges, and self-induced vomiting is called what?

Bulimia Nervosa

The Healthy People 2020 objectives where distributed during a staff meeting. Which objectives relate to the prevention of violence? Select all that apply.

Bullying Homicides Firearm injuries Fatal and nonfatal assaults

The spouse of a client believed to be a victim of intimate partner violence refuses to leave the room for the nurse to complete an assessment. What should the nurse do first?

Ensure for personal safety

Which technique should a nurse implement when interviewing with a child who has suffered physical abuse by the father?

Establish a reassuring environment

The nurse suspects that a client may have an alcohol problem. Which of the following assessments should the nurse use to confirm this suspicion?

CAGE questionnaire

A nurse admits a client to the hospital who is African American. The nurse recognizes that this client is at increased risk for what conditions due to ethnicity or culture? Select all that apply.

Cardiovascular disease Peripheral artery disease Asthma

When describing the cycle of violence to a community group, the nurse explains that the first phase usually is:

Characterized by tension-building and minor battery

A mental status examination consists of various components. Which assessment data is associated with cognitive function? Select all that apply.

Client is able to successfully multiple 24 times 32. Client correctly names the last three presidents of the United States.

The nurse is performing an admission assessment on a patient with a diagnosis of pancreatic cancer. The nurse asks the patient about religious preference. The patient states, "Leave me alone about religion. I don't want to talk about it with you!" What is the best intervention by the nurse?

Collaborate with the hospital clergy.

A client comes to the ED with lower abdominal pain. She is extremely emotional and moving wildly on the gurney. A nurse says to another nurse that the client is "way overdoing it." What action should the nurse take to best provide care for this client?

Conduct a cultural assessment to better understand the client's perception of pain and illness.

A nurse is examining a 16-year-old girl who is visibly distraught. The client has a bruise on her face and tells the nurse that her boyfriend got rough with her recently. On further questioning, the client tells the nurse that her boyfriend raped her. Which of the following is the priority nursing intervention at this point?

Conduct a forensic interview

The nurse is assessing a client with a history of Korsakoff syndrome. What would the nurse expect this client might demonstrate?

Confabulation

While conducting an assessment the nurse suspects that a client is making up things in response to specific questions. What behavior is this client demonstrating?

Confabulation

The nurse is caring for a married female client who defers to her husband to answer all assessment questions. The nurse understands that it is common in some cultures for the male to hold a dominant role in the relationship. What stage of cultural awareness does the nurse display?

Conscious competence

The nurse is caring for a married female patient from the Middle East who defers to her husband to answer all assessment questions. The nurse understands that it is common in this culture for the male to hold a dominant role in the relationship. What stage of cultural awareness does the nurse display?

Conscious competence

A nurse is assigned to care for a client who practices Orthodox Judaism. After reading the client's medical record, the nurse takes time to talk with the client about how to make his hospital stay more comfortable. The nurse admits to the client that she is not familiar with Orthodox Judaism but would like to learn more. The nurse is in which stage of cultural awareness?

Conscious incompetence

The nurse is caring for a patient who is from another country, and states to the charge nurse, "I just don't know if the patient really understands what I am saying, and I am not understanding the patient either, even though he speaks English." What stage of cultural awareness is the nurse experiencing?

Conscious incompetence

The nurse asks the client to draw the face of a clock with numbers and hands and to make it read 3 o'clock. What is tested by the completion of this task?

Constructional ability

When interviewing a client who is abused by the partner, the nurse should attempt to display which type of behavior towards the client?

Convey a concerned and nonjudgmental attitude

During a group session a victim of intimate partner violence describes the events that led up to the most recent episode of abuse. If using the Tension Building/Explosion Model, what should the nurse expect the victim to describe? Select all that apply.

Criticism Battering Honeymoon

A nurse is participating in an educational exercise in which she is conducting a self-examination of her own biases. This activity addresses what construct of cultural competence?

Cultural awareness

A new graduate nurse from a small community college is going to work in an urban setting. She embraces the thought of working in a more diverse setting and wants to learn about different cultures. What behavior is this nurse exhibiting?

Cultural desire

A male nurse is caring for an elderly woman from Iran who has become withdrawn and somewhat confused since the nurse has come on duty. When the nurse goes into the room to bathe the patient, she refuses to allow it. The best explanation for her actions would be which of the following?

Cultural differences

The nurse knows that she will be caring for a patient from Southern Korea who has been visiting with a family member. The nurse obtains some information about the Korean culture so that she will be able to meet the patients needs. What is the nurse demonstrating?

Cultural knowledge

A shared, learned, and symbolic system of values, beliefs, and attitudes that shape and influence how people see and behave in the world is a definition of what?

Culture

A nurse is gathering information about the history of the community in which she works. Which of the following should she include in this study?

Ethnic groups who settled in the area, based on information from the local library

A client requests to be cared for by a nurse who is a member of his own culture. The nurse recognizes that which barrier exists in regards to this client's nursing care?

Ethnocentrism

A nurse recognizes that the belief that one's worldview is the only acceptable truth and that one's beliefs, values, and sanctioned behaviors are superior to all others is called what?

Ethnocentrism

Many factors put older adults at risk for abuse. Which of the following are possible factors? Select all that apply.

Decline in physical health of caregivers Strained mental health of caregivers Cognitive decline Dependency

A client known to a health clinic arrives wearing soiled clothing with matted hair and streaks of dirt on the face and hands. What should this client's appearance suggest to the nurse?

Depression

A nurse is assessing a client from India who complains of panic, sexual dysfunction, fatigue, weakness, and loss of appetite. Which culture-bound syndrome should the nurse suspect in this client?

Dhat

Which of the following are cues that a person may have dementia? Select all that apply.

Disorientation Looking to a family member to answer questions directed to the client Repeatedly failing to follow instructions

The nurse is admitting a client to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?

Do you have any thoughts of wanting to harm or kill yourself?

The nurse is admitting a patient to the mental health unit with a diagnosis of attempted suicide. Which is the best question for the nurse to ask first?

Do you have any thoughts of wanting to harm or kill yourself?

A nurse is working with a 25-year-old woman who has struggled with anger, depression, and anxiety since her mother stole her identity and opened up seven different credit cards in her name. The nurse recognizes this as which type of abuse?

Economic abuse

What should a nurse be aware of before effectively assessing for the presence of family violence?

Examine feelings, beliefs, and biases about violence (Before starting an assessment of family violence, the nurse must examine his or her own feelings, beliefs, and biases about violence. Creating a safe and confidential environment, discussing any legal, mandatory reporting requirements, and demonstrating a concerned and nonjudgmental attitude are interview techniques the nurse should implement.)

A nurse is conducting a mental status assessment of a 70-year-old male client who is being treated for depression. When assessing the client's facial expression and eye contact, the nurse should consider which of the following?

Eye contact is strongly influenced by cultural norms.

The nurse assesses a client using the Glasgow Coma Scale. Which of the following indicators will be used to determine the score?

Eye opening, and appropriateness of verbal and motor responses.

People of all cultures believe that autonomy is a universal right of health care consumers. (T/F)

False

The nurse is concerned that an older community member is being abused by an adult son however will not report the abuse or seek help. What could be a reason for this older adult to refrain from reporting the abuse?

Fear of being institutionalized

A 29-year-old woman comes to the office. During history taking, the nurse notices that the client is speaking very quickly and jumping from topic to topic so rapidly that it is difficult to follow her. The nurse can find some connections between ideas, but it is difficult. Which word best describes this thought process?

Flight of ideas

A nurse is assessing an elderly client who may be a victim of elder mistreatment. Which of following are examples of elder mistreatment? Select all that apply.

Forcing an elder to perform a sexual act Having an elder sign financial documents without an understanding of what is being signed Failure to provide adequate nutrition to an elder Shoving an elder into a wheelchair

The nurse suspects that a client is experiencing normal age-related changes in mental functioning. What assessment finding caused the nurse to come to this conclusion?

Forgot the word to describe indigestion

When performing a spiritual assessment, what may help the nurse to identify related nursing diagnoses, needed interventions, and improve patient care?

Gaining relevant information about the patient's spirituality.

The nurse is conducting a health history with an older adult who recently lost a spouse. The client reports difficulty sleeping, a lack of appetite, and having one glass of wine each week. The client states, "I don't know how I can go on. Why did God have to take him? I feel so lost without my husband." Which tool should the use to further assess the client?

Geriatric Depression Scale

A nurse is assessing a Navajo client, who has presented to the health clinic with complaints of feeling endangered, confusion, bad dreams, and hallucinations. Which culture-bound syndrome should the nurse suspect in this client?

Ghost sickness

A 22-year-old man is brought to the office by his father. The client was diagnosed with schizophrenia 6 months ago and has been taking medication since. The father states that his son's dose isn't high enough and needs to be increased. He states that his son has been hearing things that don't exist. The nurse asks the young man what is going on. He says that his father is just jealous because his sister only talks to him. His father turns to him and says, "Son, you know your sister died 2 years ago!" His son replies "Well, she still talks to me in my head all the time!" Which best describes this client's abnormality of perception?

Hallucination

A Hispanic mother brings her 2-year-old child to the clinic for a well-child checkup and age-appropriate vaccinations. Which of the following observations indicate potential abuse at home?

Hand or finger-patterned bruising around upper arm and leg.

You are admitting a patient to your unit for surgery the next morning. You note that the patient speaks at an accelerated pace and jumps from topic to topic, none of which progresses to sensible conversation. What would you document about this patient?

Patient demonstrates flight of ideas

As a novice nurse caring for a patient from a different culture, what may the nurse find confusing or upsetting?

Patient's nonverbal communication

A nurse rA nurse performs an admission assessment and notices that a client's speech is slow and the client has difficulty answering some of the questions. How can the nurse differentiate the cause of the client's slow speech?

Have the patient read a few sentences out loud.

A nurse is assigned to care for a client who has been physically abused by her stepfather. The nurse finds that client has an abuse score of 5 in her documents. Which of the following descriptions corresponds to the abuse score?

Head injury and internal injury

When assessing a community, the nurse is reviewing statistics related to adult mortality in clients who are 65 years of age and older. The nurse would assess the community for health programs to address which of the following as the major cause of death in this age group?

Heart disease

The nurse is concerned with the rising unemployment rate of the community in which she lives. How will the nurse be affected by this problem?

High unemployment rates are associated with higher morbidity and mortality rates.

A nurse is gathering health information about a community that is economically unstable. Which of the following should she expect to find?

Higher morbidity and morality

The nurse is being oriented to the oncology unit. Which is a true statement regarding the potential population of this nursing unit?

Hispanic women have higher rates of cervical cancer than white women.

A nurse is working with a client who confides in the nurse that her boyfriend will not let her get a job and insists on controlling all of their money. He gives her only a small allowance each month to buy food and a few necessities. When the nurse offers information on how to seek help for economic abuse, the client just shakes her head and says, "It's no use. Nothing can be done." Which of the following nursing diagnoses would be most appropriate in this situation?

Hopelessness related to remaining in a prolonged abusive relationship and inability to seek counseling and healthy supportive relationships

A nurse is working with a woman who has been abused by her husband. Which of the following is a physiological sign commonly associated with abuse?

Hypertension

A nurse is preparing to conduct a community assessment. Upon completing the assessment, which of the following should the nurse expect as the primary outcome?

Identification of health-related concerns in the community

A nurse is relying heavily on gestures and simplified language during the assessment of a client from another culture who speaks minimal English. During the lengthy assessment, the nurse asks the client if she is "okay" by making a circle with his thumb and forefinger. The nurse should be aware of which of the following?

In some cultures, this gesture is offensive.

A nurse has just learned that a community recreation league for youth has just been eliminated due to lack of funding. Which of the following results should the nurse suspect?

Increased gang activity

A nurse has just learned that a community course on water safety in a beachfront town has recently been eliminated due to a lack of funding. Which of the following results should the nurse expect?

Increased sports injuries

The client states her husband died a few months ago and she has not been the same since. Which nursing diagnosis is most appropriate?

Ineffective coping

Which of the following is not a true statement about intimate partner violence?

Intimate partner violence is caused by the "victim" refusing her husband's desire for sex.

The nurse is caring for a woman who presents to the Emergency Department with complaints of abdominal pain, as well as cuts and bruises on the arms. While observing the interaction between the husband and wife, the nurse observes the husband shaking his fist at the wife. Which type of abusive or controlling behavior did the nurse observe?

Intimidation

A nurse is working with a client who has received a terminal diagnosis. To help the nurse identify the client's possible coping responses, which of the following would be most important for the nurse to understand about spirituality?

It varies in different situations.

The nurse is explaining to the patient that the physician wrote an order to administer a blood transfusion for severe anemia. The patients emphatically refuses the blood transfusion. What religious practice should the nurse inquire about?

Jehovah's Witness

The community health nurse is reviewing recommendations from the US Preventive Services Task Force (USPSTF) to help identify risk factors for intimate partner violence. On which community factors should the nurse focus? Select all that apply.

Lack of institutions Overcrowding Neighbor unwillingness to intervene

The nurse is conducting an assessment of a rural community. Which of the following community assessment findings is most characteristic of rural communities?

Limited access to specialized health care

The nurse reviews data collected on a client who is being admitted again for treatment of injuries caused by intimate partner violence. Which diagnosis should the nurse identify as being the most appropriate for this client?

Low self-esteem

A victim of intimate partner violence tells a nurse, "I don't know how I'd live if I left my husband. And what about my children? I have no skills and haven't worked since I was a teenager." When developing the plan of care for this client, which nursing diagnosis would most likely apply?

Low self-esteem related to lack of confidence in ability

A 23-year-old ticket agent is brought in by her husband because he is concerned about her recent behavior. He states that for the last 2 weeks she has been completely out of control. She hasn't showered in days, stays awake most of the night cleaning their apartment, and has run up more than $5,000 on their credit cards. While he is talking the client interrupts him frequently, declares this is all untrue, and says she has never been so happy and fulfilled in her whole life. She speaks very quickly, changing the subject often. After a longer than normal interview, the nurse learns that the client has had no recent illnesses or injuries. Her past medical history is unremarkable. Both her parents are healthy, but the husband has heard rumours about an aunt with similar symptoms. The client and her husband have no children. She smokes one pack of cigarettes a day (although she has been chain smoking in the last 2 weeks), drinks four to six times a week, and smokes marijuana occasionally. She is very loud and outspoken. Physical examination findings are unremarkable. Which mood disorder does she most likely have?

Manic Episode

The nurse is assessing a client and notices that when being asked questions, the client does not make eye contact. The nurse should include what in the plan of care?

Minimal eye contact due to culture

When assessing the speech of an older adult client, which of the following would the nurse expect to find?

Moderately paced

A nurse realizes that when assessing beliefs about health and illness among patients from different cultures, which of the following is true?

Most patients hold a combination of beliefs when it comes to illness

A nurse is assessing a boy who appears to be undernourished. She can find no signs of physical abuse. She considers whether this may be a case of child abuse. Which of the following are included in the definition of child abuse? Select all that apply.

Neglect Emotional abuse Physical abuse Sexual abuse

The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding?

Nerve damage caused by repeated eye injuries

A mother brought a child in to the Emergency Department stating that she thinks her child's appendix has ruptured. Before any diagnostic tests can be done, the father comes in and says, "I don't want anything done, we will take the child to our church where prayer will heal him." What is an appropriate action by the nurse at this time?

Notify the ethics committee immediately.

After teaching a group of students about spirituality and religion, the instructor determines that the students need additional teaching when a student states which of the following?

Nursing has only recently begun to incorporate spirituality into client care.

After teaching a group of students about spirituality and religion, the instructor determines that the students need additional teaching when they state which of the following?

Nursing has only recently begun to incorporate spirituality into client care.

When performing an assessment of a patient, the nurse observes that the patient begins to cry when asked if she has a religious preference. What part of the care plan would the nurse document this assessment finding?

Objective data

An instructor is emphasizing the need for nurses to be culturally sensitive and competent for which reason?

Obtain accurate assessment data

A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates that the client will respond to stimulation in what manner?

Opens eyes to a loud voice and answers with confusion

A nurse reviews the documentation of the nurse on the previous shift and finds that the client was obtunded. The nurse anticipates the client will respond to stimulation in what manner?

Opens eyes to a loud voice and answers with confusion

The nurse is evaluating the risk for violence of a prenatal patient who has been accompanied by her partner. Which action by the nurse would be most appropriate? Select all that apply.

Perform a risk assessment for violence only when the patient is alone -Listen attentively and do not interrupt as the patient talks. -Do not judge the patient; be supportive during the interaction.

The nurse prepares an educational program on bullying for the students who attend middle- and high-school. What types of bullying should the nurse include in this presentation? Select all that apply.

Physical Relational Damage to property Verbal

A client expresses to the nurse visiting her home that her husband has threatened to kill her. The nurse understands that threats of harm and intimidation are which type of abuse?

Psychological

A client who is a victim of intimate partner violence (IVP), after undergoing a physical assessment of injuries she recently received from her husband, tells the nurse that she has had enough and is ready leave him, taking the children with her. She asks the nurse if the nurse knows of any safe places for her to go. Which of the following nursing diagnoses would be most appropriate for this client?

Readiness for enhanced self-health management related to request for information on safe locations to go after leaving her home

When assessing level of consciousness, what should a nurse do if a client does not respond appropriately to a verbal stimulus?

Repeat the command louder and in a lower tone of voice

A nurse reviews a client's past health history. Which information should cause the nurse to suspect that the possibility of abuse is present?

Repeated visits to the emergency room for injuries

While preparing a client for surgery, a nurse discovers that the client's view about spirituality is entirely different from hers. What is the most appropriate action by the nurse?

Respect the privacy of his spiritual beliefs and rituals

A nurse cares for a client who practices Hinduism. The nurse understands that Hindus believe illness is caused by which type of behavior?

Result of past and current life actions

During a thorough spiritual assessment, the nurse understands that the questions asked are designed to

Reveal beliefs that might affect client care

After assessing a patient, the nurse noted the following: he was tearful, he tried to kill himself before coming into the hospital, he had no immediate plan for another suicide attempt, he was unable to concentrate, and he reported having trouble sleeping and having little or no appetite. The nurse also noted that the patient's appearance was unkempt, that he spoke in a low monotone, and that he was unable to establish and maintain eye contact. Based on this information, which nursing diagnoses would be the most appropriate?

Risk for suicide

Police bring a client with substance abuse to the ED after being arrested for a domestic dispute in which he gave his wife a black eye. The client is out of control and verbally abusive; aggression against the staff is noted. When a nursing care plan is developed, what would be an appropriate nursing diagnosis for this client?

Risk for violence directed at others

When considering the various cultural aspects associated with death rituals, which of the following should guide a nurse's practice?

Rituals for burial and bereavement are likely to reflect original cultural practices.

A nurse provides care for a client who experiences anxiety, gastrointestinal complaints, and a fear of being poisoned or killed.The nurse recognizes this as which culture-bound syndrome?

Rootwork

The nurse is conducting a health history of a patient at the local community mental health clinic. Which assessment tool would the nurse administer to determine the suicide risk for the patient?

SAD PERSONAS

A client reports ingesting alcohol most nights of the week, smoking marijuana on weekends, and using cocaine with friends when playing poker. Which tool should the nurse use to learn more information about this client's substance use?

SBIRT

A 19-year-old college student, Todd, comes to the clinic with his mother, who is concerned that there is something seriously wrong with him. She states that for the past 6 months, her son's behaviour has become peculiar, and that he has flunked out of college. Todd denies any recent illness or injuries. His past medical history is remarkable only for a broken foot. His parents are healthy. He has a paternal uncle who had similar symptoms in college. The client admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but not in the last week. He denies use of any other substances and feelings of depression or anxiety. The nurse does a complete physical examination, which is essentially normal. When the nurse questions the client about how he is feeling, he says that he is worried that his software for creating a better browser has been stolen. He says that he has seen a black van in his neighborhood at night, and he is sure that it is full of computer programmers stealing his work through special gamma waves. The nurse asks why Todd believes they are trying to steal his programs. He replies that the programmers have been telepathing their intents directly into his head. He says he hears these conversations at night, so he knows this is happening. What psychotic disorder is most consistent with Todd's history and physical examination findings?

Schizophrenia

A 19-year-old college student, Todd, comes to the clinic with his mother, who is concerned that there is something seriously wrong with him. She states that for the past 6 months, her son's behaviour has become peculiar, and that he has flunked out of college. Todd denies any recent illness or injuries. His past medical history is remarkable only for a broken foot. His parents are healthy. He has a paternal uncle who had similar symptoms in college. The client admits to smoking cigarettes and drinking alcohol. He also admits to marijuana use but not in the last week. He denies use of any other substances and feelings of depression or anxiety. The nurse does a complete physical examination, which is essentially normal. When the nurse questions the client about how he is feeling, he says that he is worried that his software for creating a better browser has been stolen. He says that he has seen a black van in his neighbourhood at night, and he is sure that it is full of computer programmers stealing his work through special gamma waves. The nurse asks why Todd believes they are trying to steal his programs. He replies that the programmers have been telepathing their intents directly into his head. He says he hears these conversations at night, so he knows this is happening. What psychotic disorder is most consistent with Todd's history and physical examination findings?

Schizophrenia

The nursing instructor talks with the student nurse on the adult psychiatric unit. The student tells the instructor that cradle cap appears to be around a specific client's face. The instructor explains that this may be an indication of long-term lack of care as a consequence of what disorder?

Schizophrenia

The nursing instructor talks with the student nurse on the adult psychiatric unit. The student tells the instructor that cradle cap appears to be around a specific client's face. The instructor explains that this may be an indication of long-term lack of care because of what disorder?

Schizophrenia

When evaluating a community's education, which of the following would the nurse use to identify the effectiveness of the community's school system?

Scores on standardized tests

The nurse chooses to use a formal assessment technique when doing a client's spiritual assessment. Which of the following techniques would be most appropriate?

Self-response assessment instrument

A nurse is assessing a community's environmental protection. The nurse should address which of the following?

Sewage treatment facilities

A nurse is making rounds and checking on clients in an inpatient mental-health facility. As she walks into a client's room, she finda another nurse engaged in sexual relations with the client. What type of violence has this nurse observed?

Sexual violence

A nurse is assessing a client who recently immigrated to the United States from Kenya. When the nurse asks the client her reason for coming to the health clinic, the client responds by saying, "bad blood." The nurse recognizes that the client is most likely referring to which of the following?

Sexually transmitted infection

An adult female client is being assessed for intimate partner violence (IPV). She acts as if the abuse she has suffered is normal. What could be a reason for her actions?

She has a history of violence in her family

When performing a cultural assessment on a client from another country, what can a nurse do to ensure the client receives culturally sensitive care?

Show genuine interest in the client's culture and personal life experiences.

The nurse is conducting a health history of the patient who presents to the urgent care with complaints of shortness of breath. The nurse asks, "Who lives with you?" Which type of assessment is the nurse conducting?

Social assessment

The intensive care nurse is working with a client who has increased intracranial pressure secondary to a traumatic brain injury. The nurse is performing the hourly assessment of the client's level of consciousness and observes that the client's eyes are closed. How should the nurse first stimulate the client to assess for arousability?

Speak to the client clearly from a close distance.

While conducting a mental status history, the nurse notes that the patient is articulate, makes spontaneous comments, and speaks at a normal rate. For which section of the history is this information important?

Speech and Language

The nurse is assessing a patient's ability to employ coping mechanisms when given a diagnosis of cancer. What type of assessment would be beneficial for the nurse to use?

Spiritual assessment

The patient states, "I cannot believe I have breast cancer. I am a good person; I don't know why God is punishing me." The nurse suspects the patient is experiencing:

Spiritual distress

The school nurse is in the talking to a group of students about sexually transmitted diseases. One of the students says, "I know that most of the 10th grade has already had sex. There's drinking and parties, and this is where a lot of it happens." What type of data is the nurse collecting?

Subjective

The nurse observes the spouse of a client pinch the client's arm when someone talks with the client in the waiting room of the community clinic. What should this observation indicate to the nurse?

The client is not permitted to have contact with others

When interviewing a client who might have been abused, what is the first and foremost thing for the nurse to consider?

The client's physical and emotional safety

An older adult client scores a 15 on a Mini-Mental Status Examination (MMSE). What does this score tell the nurse about the client?

The client's score indicates cognitive impairment

A client returns to the floor following a colon resection. The client appears to be in excruciating pain but denies it when questioned by the nurse. The client's facial expressions and gestures indicate that the opposite is true. This is an example of which of the following?

The cultural and individual differences in pain response

The nurse is caring for a first-time mother and newborn in the postpartum unit. The nurse overhears the new mother ask family members to prepare the nursery and purchase clothing for the baby. What would the culturally sensitive nurse suspect?

The new mother may believe buying infant clothing before the delivery is bad luck.

The nurse is caring for a family in which the elderly mother has been a victim of abuse and neglect by her 48-year-old son. Which of the following would be most important for the nurse to keep in mind before interviewing the family?

The nurse must allow the elderly mother to decide if she wants to leave the situation or not.

A woman has accompanied her 80-year-old husband to a scheduled clinic visit and expresses concern about subtle declines in his cognition. Which of the following principles should guide the nurse's assessment of the client's mental status?

The nurse must differentiate between age-related changes and the signs and symptoms of dementia.

Family members have brought food to the room of a woman who delivered a baby boy earlier that day. The nurse is invited to eat the food and participate in the celebration of the birth. Which action should the nurse take?

The nurse should eat food of personal liking and rejoice in the family's celebration.

While interviewing a hospitalized client, he states, "The holy days of Ramadan are coming soon. I am not to have any food or drink from sunrise to sunset during this time." Further assessment reveals that the client's request is associated with which religion?

islam

A patient of Islamic faith is being educated on a new diagnosis of diabetes mellitus. The patient asks no questions during or after the session. What does the nurse understand may be the reason for the patient not asking questions?

The patient considers asking questions of the nurse a sign of mistrust in her abilities.

Why is it important for the nurse to wait until the end of the assessment interview to ask questions about violence in the client's life?

This allows time to build rapport and to ask less sensitive questions first

A nurse wants to assess a client's orientation. The nurse recognizes that which orientation is usually lost first when the client is confused?

Time

A nursing instructor asks students to list culturally based characteristics. The students should include which of the following? (Select all that apply.)

Touch Eye contact Diet Time

A nursing student is caring for an older adult from a culture different from her own. The nurse's preceptor asks the student what would be an important assessment to make to provide quality nursing care for this client. What would be the student's most appropriate response?

Transcultural assessment

The nurse is admitting a bed-bound patient who is a practicing Muslim. Acting as an advocate for the patient and demonstrating cultural sensitivity, what arrangements should the nurse make?

Transfer the patient to a room that faces east.

The nurse is admitting a 23-year-old woman to the acute care mental health unit. Physical examination reveals vertical cuts on the patient's forearms approximately 6 inches long bilaterally. On the care plan, the nurse enters a nursing diagnosis of Risk for Self-Mutilation. What would be the most immediate

Treat medical injuries.

To determine the sources of strength for a patient, the nurse could ask, "In what ways do they help?" (T/F)

True

Which of the following is suggested for family abuse screening?

Universal screening for family and intimate partner violence is recommended.

A nurse is interviewing a child who is suspected of being abused. Which of the following would be most appropriate?

Use direct, nonleading questions

After assessing a community, the nurse plans programs to address the community's government. Which of the following would be most appropriate?

Using open forum community meetings

The nurse learns during handoff communication during end-of-shift that a client has delirium. What should the nurse expect to assess in this client? Select all that apply.

Vacillates between lucidity and confusion Experiences visual and auditory hallucinations Completely disoriented to time, place, and person

The nurse completes the mental health assessment before continuing with a head-to-toe assessment. Why did the nurse use this approach?

Validates the information the client provides during the rest of the assessment

Which nursing action is essential in caring for the victim of violence?

Validating the abuse experience

A nurse begins the mental status exam of an older adult. Before assessing the client's thought processes and perceptions, the nurse should first obtain the results of what other assessments?

Vision and hearing

As part of a mental status assessment, the nurse asks a client to draw the face of a clock. This will allow the nurse to assess which of the following domains of mental status?

Visual perceptual and constructional ability

A nurse provides care for an African-American client who experiences tremors, muscle weakness, and nausea. The client's family believes that the client is affected by some kind of black magic. The nurse recognizes this as which culturally bound syndrome?

Voodoo

Which observation of a client should cause the nurse to suspect that the client may be physically abused?

Wears long sleeves in warm weather

If a nurse suspects that a client is depressed, asking the client about any suicidal thoughts:

is important and will not stimulate the thought of suicide

A 75-year-old homemaker brings her 76-year-old husband to the clinic. She states that 4 months ago he had a stroke; ever since she has been frustrated with his problems with communication. They were at a restaurant after church one Sunday when he suddenly became quiet. When she realized something was wrong, he was taken to the hospital by ambulance. He spent 2 weeks in the hospital with right-sided weakness and difficulty speaking. After hospitalization he was in a rehab center where he regained the ability to walk and most of the use of his right hand. He also began to speak more, but she says that much of the time "he doesn't make any sense." She gives an example that when she reminded him the car needed to be serviced he told her "I will change the Kool-Aid out of the sink myself with the ludrip." She says that these sayings are becoming frustrating. She wants the nurse to tell her what is wrong and what can be done about it. What type of aphasia does the client have?

Wernicke's aphasia

The nurse notes that an older client speaks rapidly and uses words that make no sense or communicate any clear meaning. When documenting this finding, the nurse should use which term to describe this client's speech?

Wernicke's aphasia

During an assessment the nurse becomes concerned that a client is at risk for suicide. What information in the client's health history caused the nurse to have this concern? Select all that apply.

Widower Male Caucasian

A Muslim teenager is in the hospital for surgical repair of a severe fracture in the leg during the month of Ramadan, which the client says he would like to observe during his stay. Which of the following interventions should the nurse be prepared for in caring for this client?

Withhold all food and drink between sunrise and sunset

A nurse has a regular client from China and who follows traditional medicinal system of that culture. To improve ability to understand and work, nurse researches the client's cultural view on health. Which would the nurse discover?

a focus on maintaining balance between yin and yang

During a health history, the nurse notes that an older client answers common questions inappropriately. What should the nurse now focus the assessment on to obtain more information about this finding?

aphasia

When the nurse asks the client to say "No ifs, ands, or buts," the client tries but is unable to repeat the phrase with fluency. The nurse understands that this may indicate a form of

aphasia

A nurse assesses a 4 year old who experiences gas, stomachache, and diarrhea after consuming lactose products. What type of biological variation is this?

biochemical

A nurse is assessing a Hispanic woman. Which of the following diseases is this client most at risk for due to her cultural group?

cervical cancer

What intervention should a nurse implement to become culturally competent when assessing a client from another culture?

collect relevant cultural data of the client's presenting problem

A nurse is assigned to care for patient who practices Orthodox Judaism. After reading the client's medical record, the nurse takes time to talk with the client about how to make his hospital stay more comfortable. The nurse admits to the client that she is not familiar with Orthodox Judaism but would like to learn more. The nurse is in which stage of cultural awareness?

conscious incompetence

The client's daughter asks the nurse why the nurse is asking her mother depression-related questions. The nurse explains that even though the client has symptoms of dementia, the Geriatric Depression Scale is being used because

depression often mimics signs and symptoms of dementia.

A nurse is assessing a community of Native Americans. One important piece of health-related information that the nurse should obtain is the incidence of

diabetes mellitus.

A nurse is assessing a client before administration of an antibiotic. The nurse should be aware that which of the following represents a biochemical variation that may exist between clients of different cultures?

drug metabolism

Stereotyping is defined as

expecting all members of a cultural group to hold the same beliefs and behave in the same way.

When the nurse tells the patient that she will return in 1 hour to administer an intravenous antibiotic, the nurse is showing that she values time in which of the following orientations?

future

A Hindu client on hospice care tells his nurse that he is not afraid of death. He explains that this is because he believes he has lived a very good life and therefore his next life should be even better than this one, as all of his life actions will be carried into the next. The nurse recognizes this belief as which of the following?

karma

What is a culture bound syndrome of Malaysia that occurs after a traumatic episode or surprise?

latah

A nurse begins an interview with a client who is a Native American. The nurse should not be surprised to see the client display which type of behavior characteristic of this culture group when responding to questions or engaging in conversation with the nurse?

looking down

The nurse is interviewing Mr. Jenkins and, due particularly to his nervous affect and his reaction when his son is mentioned, suspects potential elder abuse. In assessing Mr. Jenkins, the nurse should

make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication.

The nurse and a Hispanic client are developing a transcultural nursing care plan related to hypertension. The nurse will include in the plan

nutritional information specifically for a Hispanic client.

The nurse and a client are developing a transcultural nursing care plan related to hypertension. The nurse will include in the plan

nutritional information specifically for the client's culture.

When assessing a rural community, the nurse will most likely identify which of the following as lacking related to health care services?

obstetric care

Nursing students are learning about human violence. The instructor is explaining key differences among various forms and how the differences affect assessment and intervention. What would the instructor explain is a key difference between violence against older adults and intimate partner violence?

perpetrator Violence against older adults is intentional or unintentional acts such as physical, sexual, psychological, and financial abuse and neglect. Intimate partner violence is between spouses or nonmarital partners, threatened or actual physical or sexual violence or psychological/emotional abuse, coercive tactics, or both when there has been prior physical and/or sexual violence. Violence against an older adult can be perpetrated by someone other than the intimate partner. The other options are distractors for the question.

Shared practices and rituals used to express one's faith can be called

religion

When interviewing a pediatric client and attempting to determine the presence of abuse, the nurse should

remain calm and accepting in response to any information the client discloses.

A nurse provides care for an African American client who experiences anxiety, gastrointestinal complaints, and a fear of being poisoned or killed. The nurse recognizes which culture-bound syndrome?

rootwork

During the assessment of a Caucasian client with wax accumulation in the ear, the nurse observes that the earwax is wet. The nurse recognizes that this is related to what physiologic variation among racial groups?

secretions produced by apocrine glands are based on genetic traits

What should a nurse do to ensure an effective face-to-face interaction with clients from different cultural backgrounds?

seek out repeated face to face encounters with members of a culture

A nurse is assessing someone that immigrated to US from Kenya. When nurses asks reason for coming to health clinic, the client responds "bad blood". Nurse recognizes the patient is referring to what?

sexually transmitted infection

A nursing student realizes that which of the following is an important variation of communication?

silence

When assessing a client, the nurse notes that he is delusional. The nurse would know that delusional thinking can lead to what?

suicide

When performing a cultural assessment, an important point to remember would be

that definitions of family differ

A client of Chinese origin enters your office to be seen. You can assume

the client may be well acculturated to your dominant culture, so don't assume.

A nurse is evaluating a client who may have Alzheimer's disease. Which of the following are warning signs of Alzheimer's disease? Select all that apply.

• Losing one's ability to pay bills • Getting lost in familiar surroundings • Neglecting to bathe • Asking the same question over and over again

A nurse is collecting both subjective and objective data in assessment of a client's mental health. Which of the following are examples of subjective data? Select all that apply.

• Onset of memory lapses • History of hospitalization for a mental health problem • History of Alzheimer's disease in a family member • Use of recreational drugs

Using Roy's adaptation model, the nurse identifies that the goal of nursing care is to assist the client to achieve what? Select all that apply.

• Optimal mental health • Physical health • Role function • Interdependence

After reviewing a client's completed danger assessment questionnaire, the nurse determines that the client is in significant danger of intimate partner violence (IPV) leading to homicide. The client says that she would prefer to return home and that she does not have a safety plan. Which of the following nursing interventions should the nurse implement at this point? Select all that apply.

• Schedule a follow-up appointment. • Have the client complete Assessment Tool 10-2: Assessing a Safety Plan. • Provide the client with contact information for shelters and groups. • Encourage the client to call with any concerns.

A nurse is determining the adequacy of long-term care services in a community. Which of the following are long-term care services that should be offered in a community? Select all that apply.

• Skilled nursing care facilities • Rehabilitation centers • Assisted-living centers

A nurse is assessing a community's formal and informal means of communication. Which of the following are examples of informal means of communication? Select all that apply.

• Word of mouth • Newsletters • Bulletin board notices • Fliers distributed door-to-door

The nurse experienced in working with different communities understands that the following groups are at higher risk for health problems and increased mortality: (Select all that apply.)

• unmarried people • elderly • immigrant farm families