Community Nursing Week 2 NCLEX
A clinic nurse is performing an admission assessment on an African American client scheduled for cataract removal with intraocular lens implantation. Which question should the nurse avoid asking on the initial assessment? 1. "Do you have any family problems?" 2. "Do you ever experience chest pain?" 3. "Do you have any problems urinating?" 4. "Do you frequently have episodes of constipation?"
1. "Do you have any family problems?" Rationale: In the African American culture, it is considered to be intrusive to ask personal questions on the initial contact or meeting. African Americans are highly verbal and express feelings openly to family or friends, but what transpires within the family is viewed as private. The psychosocial assessment would be of lowest priority during the initial admission assessment. Additionally, because cardiovascular, renal, and gastrointestinal assessments are physiological, they are the priority assessments.
Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? 1. Arranging for home health care 2. Focusing on managing a single illness at a time 3. Communicating with one provider only to avoid confusion for the client 4. Allowing the client to teach a support person about their treatment regimen
1. Arranging for home health care Rationale: Nursing follow-up visits are important in promoting health for individuals with chronic illness; therefore, arranging for home health care is an important strategy. Focusing on a single illness does not effectively manage an individual with multiple chronic diseases—rather, the "big picture" needs to be understood in managing these clients. Interprofessional collaboration is important in safely managing individuals with chronic diseases, and often involves consulting with specialist providers. Nurses play a key role in facilitating communication between providers and specialists. Inclusion of the client and support person(s) in health care decisions helps increase adherence to a complex health care regimen, and the nurse should be the facilitator of this communication.
What elements are essential for the nurse to address to be able to deliver culturally competent care? Select all that apply. 1. Assessing the client's health preferences 2. Having knowledge of various racial and ethnic groups 3. Acknowledging personal misconceptions of various ethnic groups 4. Diagnosing health conditions commonly seen within the ethnic group 5. Recognizing that subcultures exist and not every characteristic of the cultural group is present
1. Assessing the client's health preferences 2. Having knowledge of various racial and ethnic groups 3. Acknowledging personal misconceptions of various ethnic groups 5. Recognizing that subcultures exist and not every characteristic of the cultural group is present Rationale: The nurse always determines the client's health preferences in order to create an individualized plan of care. Health care providers must have awareness of their own beliefs and values, as well as being aware that others hold different values and beliefs based on personal preferences or ethnic, cultural, and racial backgrounds. Recognizing one's own biases and respecting all people despite differences can influence satisfaction in care. It is imperative for health care providers to understand that cultural groups share dominant characteristics; however, subcultures exist and stereotyping must be avoided. It is not within the nurse's role to diagnose health conditions.
A homeless mother brings her 1-year-old child to an emergency clinic. The nurse caring for this child understands that children affected by homelessness are most at risk for which problems? Select all that apply. 1. Asthma 2. Anemia 3. Obesity 4. Ear infections 5. Lead poisoning 6. Diabetes mellitus
1. Asthma 2. Anemia 4. Ear infections 5. Lead poisoning Rationale: Homeless children will often be victims of malnourishment leading to anemia, and while they may be diabetic, being homeless does not put them at greater risk for having diabetes. Typically, homeless children are underweight, not obese. Environmental exposures increase their risk of being asthmatics or getting ear infections. This pediatric population is sick more often and will have an increased incidence of mental health and behavioral problems.
What health effects best describe a client who is the victim of abuse or negligence? Select all that apply. 1. Depression 2. Chronic fatigue 3. Involuntary shaking 4. Motivation to persevere 5. Interrupted sleeping patterns
1. Depression 2. Chronic fatigue 3. Involuntary shaking 5. Interrupted sleeping patterns Rationale: Clients who are victims of abuse or neglect are prone to certain health effects; these effects may be physical, such as bruises, broken bones, chronic fatigue, or involuntary shaking. The victim may also experience mental effects, such as nightmares, anxiety, post-traumatic stress disorder (PTSD), depression, interrupted sleep patterns, and low self-esteem. Motivation to persevere is not a direct effect and can be a positive characteristic.
A client is visiting a new primary health care provider (PHCP) office. She is filling out the paperwork and is confused about whether she has any chronic illnesses. Which condition(s), if present, should the client markdown under that section? Select all that apply. 1. Diabetes 2. Osteoarthritis 3. Gastroenteritis 4. Cardiovascular disease 5. Vision/hearing impairment 6. Chronic obstructive pulmonary disease
1. Diabetes 2. Osteoarthritis 4. Cardiovascular disease 5. Vision/hearing impairment 6. Chronic obstructive pulmonary disease Rationale: Chronic illness is a leading cause of death and disability in the U.S.; prevalence increases with age and is a major cause of disability. Chronic illnesses include, but are not limited to, cardiovascular disease, cancer, respiratory disease, diabetes, mental disorders, vision and hearing impairment, oral diseases, bone and joint disorders, and genetic disorders. Gastroenteritis is an acute and short-term problem rather than a chronic illness.
Which essential role does the nurse play in the health care team between multiple primary health care providers and specialists? 1. Facilitates communication between the team 2. Diagnoses the client and collaborates with the team 3. Implements independent interventions and shares their effectiveness 4. Reads the client's record, including reports and specialists' consultations
1. Facilitates communication between the team Rationale: Nurses play a key role in facilitating communication between primary health care providers and specialists. The nurse is the center of collaboration for the client. It is necessary to communicate and share the client's information where and to who it is needed most. The nurse does not diagnose. Options 3 and 4 may be actions that the nurse takes, but these are not associated with the essential role the nurse plays in the health care team between multiple primary health care providers and specialists.
Which factors are most likely to affect health care access and health outcomes? Select all that apply. 1. Familial support 2. Access to education 3. Environmental safety 4. Living in a populated city 5. Access to transportation
1. Familial support 2. Access to education 3. Environmental safety 5. Access to transportation Rationale: Socioeconomic status, education level, familial and social support, community safety, and access to transportation are factors that influence health care access and health outcomes. Living in a populated city is not specifically associated with health access and outcomes.
A homeless client is being seen at a local outreach clinic. What action(s) taken by the nurse is best to help ensure the client's adherence and follow-up to the new treatment plan? Select all that apply. 1. Focusing on reported symptoms 2. Being nonjudgmental and nonthreatening 3. Setting a follow-up appointment for the client 4. Focusing on the obvious health abnormalities 5. Assisting the client to bathe first to feel presentable
1. Focusing on reported symptoms 2. Being nonjudgmental and nonthreatening 3. Setting a follow-up appointment for the client Rationale: Health visits for clients in the homeless population should be nonjudgmental and nonthreatening; this will build trust between the caregiver and the client and is more likely to promote adherence to the plan of care. Also, the nurse should focus on reported symptoms first and not what the nurse thinks is a problem, based on subjective findings. Additionally, close monitoring and follow-up may be needed, so helping set up future appointments may help the client have better adherence to the treatment plan and follow-up. Focusing on the obvious health abnormalities and expecting the client to bathe before receiving health care is demeaning.
A transgender client undergoing hormonal therapy is being seen by a primary health care provider (PHCP) in the clinic. The nurse notes new laboratory results in the client's chart. Which result has the highest priority of reporting to the PHCP? 1. Hematocrit 59% (0.59) 2. Sodium 145 mEq/L (145 mmol/L) 3. Potassium 3.5 mEq/L (3.4 mmol/L) 4. Blood urea nitrogen 10 mg/dL (3.6 mmol/L)
1. Hematocrit 59% (0.59) Rationale: Transgender persons taking hormone therapy must be monitored regularly by their PHCP due to associated complications and side effects. Polycythemia occurs from exogenous testosterone use. Normal hematocrit ranges are 37% to 52% (0.37 to 0.52 volume fraction). A hematocrit of 59% (0.59) indicates polycythemia. Normal sodium ranges are 135 to 145 mEq/L (135 to 145 mmol/L). Normal potassium ranges are 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Normal blood urea nitrogen (BUN) ranges are 10 to 20 mg/dL (3.6 to 7.1 mmol/L).
The nurse is caring for a non-English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply. 1. Increasing client safety 2. Using spiritual practices 3. Reducing health disparities 4. Increasing client satisfaction 5. Maintaining eye contact when conversing with clients 6. Preventing misunderstandings between the nurse and the client
1. Increasing client safety 2. Using spiritual practices 3. Reducing health disparities 4. Increasing client satisfaction 6. Preventing misunderstandings between the nurse and the client Rationale: Besides integrating cultural practices into Western medicine, other aspects of culturally competent care include the following: increasing client safety, reducing health disparities, increasing client satisfaction, and preventing misunderstandings between the nurse and the client. Incorporating spiritual practices as appropriate to the client's culture is also important. Maintaining eye contact when having a conversation with a client is not always part of culturally competent practices.
The nurse is working at an immigration clinic that provides health checks and health education for immigrants and refugees. What need(s) are essential for the nurse to focus on when caring for this population of clients? Select all that apply. 1. Offering vaccinations 2. Educating on acculturation and health promotion 3. Educating on the process of migration and what it means for the client 4. Common health conditions they will encounter now that they have migrated 5. Referring clients with a communicable health condition to appropriate specialists
1. Offering vaccinations 2. Educating on acculturation and health promotion Rationale: Immigrant and refugee clients need health care regardless of insurance status. Acculturation puts this population at risk because they begin to pick up American cultural practices that may be unhealthy in an attempt to fit in. Vaccinations should be offered to provide protection and build immunity to a new environment. Educating clients about what migration means to them does not offer any health benefits to the client. Immigrant clients do not always experience health conditions through the migration process. Finally, clients with known communicable health conditions should be treated prior to entering a new country of residence.
Which teaching method is most effective when providing instruction to members of special populations? 1. Teach-back 2. Video instruction 3. Written materials 4. Verbal explanation
1. Teach-back Rationale: When providing education to members of special populations, return explanation and demonstration (teach-back) are of particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming client understanding of the instructions. Video instruction, written materials, and verbal explanation are helpful and may be incorporated with the teach-back method.
The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete? 1. The history 2. The physical assessment 3. The nursing plan of care 4. The readmission risk assessment
1. The history Rationale: Intellectually disabled clients tend to be poor historians, and it may be necessary to take more time to ask questions in a variety of different ways when collecting the history data. The physical assessment, nursing plan of care, and readmission risk assessment portions, although they rely on the history, take less time because they require less client questioning.
The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication? Select all that apply. 1. Timing 2. Volume 3. Voice tone 4. Eye contact 5. Hand gestures 6. Ability to share thoughts and feelings
1. Timing 2. Volume 3. Voice tone 6. Ability to share thoughts and feelings Rationale: Verbal communication includes not only one's language or dialect but also voice tone, volume, timing, and ability to share thoughts and feelings. It does not include eye contact or hand gestures.
The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply. 1. Touch 2. Eye contact 3. Personal space 4. Family presence 5. Time orientation 6. Facial expression
1. Touch 2. Eye contact 3. Personal space 5. Time orientation Rationale: The most important cultural and communication considerations the nurse must be aware of are touch, eye contact, personal space, and time orientation. Family presence and facial expression are not important concepts.
The charge nurse is educating a new nurse on culturally competent communication techniques. Which response(s) made by the new nurse indicates a need for a follow-up? Select all that apply. 1. "I should identify the clients' needs to create the plan of care." 2. "I should use a language interpreter for all culturally diverse groups." 3. "I should use the client's perspective on health to help lead the conversation." 4. "I should use a communication style that promotes optimal health outcomes." 5. "I should recognize my own biases and address known stereotypes with the client."
2. "I should use a language interpreter for all culturally diverse groups." 5. "I should recognize my own biases and address known stereotypes with the client." Rationale: Knowing and understanding the client's needs and his or her beliefs about health help to guide the plan of care. Health care providers should know the client's perspectives and cultural preferences to create a treatment plan that is realistic, acceptable, and individualized for each client. Communicating in a professional and respectful manner will optimize client outcomes. A language interpreter may not be necessary for some ethnic groups that speak English. It is also important to have self-awareness about any biases or misconceptions regarding other ethnic groups. It is not appropriate to address these directly with the client.
The nurse is working at a Veterans Affairs clinic that provides services for homeless veterans. Which client should the nurse attend to first? 1. A client with a persistent cough 2. A client with a plan to harm himself 3. An amputee with an infected wound 4. A client with a history of substance abuse
2. A client with a plan to harm himself Rationale: Mental health is common amongst veterans. Post-traumatic stress disorder (PTSD) is one of the most prevalent problems and can easily lead to suicide, which occurs commonly in this population. A client with a plan to harm himself or others is a safety risk and should be addressed first. Options 1 and 3 may or may not compete for priority, depending on other presenting factors. An infected wound can lead to a life-threatening situation, but the client with a persistent cough may have tuberculosis and this is a communicable disease. The client with a history of substance abuse can be attended to last.
Considering the primary health risks associated with a military veteran who has just been discharged from active duty, which community resources are most appropriate for the nurse to suggest? Select all that apply. 1. Tuition assistance 2. A counseling center 3. A public health clinic 4. An employment agency 5. Veterans Affairs services
2. A counseling center 4. An employment agency 5. Veterans Affairs services Rationale: Mental health is a prevalent issue in this population. Providing assistance to identify and treat mental disorders is important. Veterans who may be experiencing health issues can find management assistance through community services designed specifically for them. Resources for mental health, preparation to re-enter the civilian workforce, and a service center such as Veterans Affairs services should be specifically recommended to this population. A public health clinic is not needed because the veteran will be cared for by Veterans Affairs services. Tuition assistance is not a primary concern; in addition, the Veterans Affairs Services will address this service if the veteran expresses a desire to pursue his or her education.
Which most essential element should the nurse consider promoting client adherence to care recommendations? 1. Following the client's medication regimen 2. Adhering to the client's cultural preferences 3. Following the client's pain management goal 4. Using the client's communication preferences
2. Adhering to the client's cultural preferences Rationale: The client's care should encompass her or his perspective and beliefs about health. Understanding the client's cultural preferences will allow the nurse to create a plan of care that is realistic and acceptable to the client. Although options 1, 3, and 4 are important, they are not the most essential.
When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.
2. Arrange for an interpreter to translate. Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation.
A client is experiencing anxiety about being hospitalized. What therapeutic communication techniques should the nurse use while interacting with the client? Select all that apply. 1. Turn the client's favorite TV show on. 2. Ask the client to identify how he or she feels. 3. Help the client identify the cause of the anxiety. 4. Lean against the wall casually with arms crossed.
2. Ask the client to identify how he or she feels. 3. Help the client identify the cause of the anxiety. Rationale: If a client experiences anxiety, immediate actions are to provide a calm environment, decrease environmental stimuli, and stay with the client. Excess stimulation would escalate the anxiety. Next, ask the client to identify what and how he or she feels, and helping the client to identify the causes of the feelings increases the client's awareness of the connection between behaviors and feelings. This awareness helps to decrease anxiety. While listening to the client, the nurse observes for expressions of helplessness and hopelessness that could indicate self-harm intentions. The nurse provides follow-up care as needed, based on observations and assessments. Finally, the nurse documents the event, significant information, actions taken and follow-up actions, and the client's response. Turning the TV on ignores the client's feelings and increases stimuli. Leaning casually against the wall with the arms crossed presents a defensive stance.
The nurse should plan to take which action next after assessing a homeless pediatric client who is a victim of abuse? 1. Ask the mother who abused the child. 2. Report signs of abuse and document it. 3. Find out where the child sleeps at night. 4. Ask the child if he or she is scared of her mother or anyone else.
2. Report signs of abuse and document it. Rationale: Health care considerations for abused or neglected individuals are to treat them with compassion, respect, and dignity. Nurses are mandated reporters for domestic violence and abuse incidence, so a report should be done. Documentation of all injuries is also necessary for legal reasons. Asking the mother who abused the child and asking the child if he or she is scared of her mother or anyone else may cause fear and conflict. Finding out where the child sleeps at night may be helpful at some point of care but is not a next specific action.
The nurse is preparing to provide preoperative teaching to a Spanish-speaking client and the client's family. Which nursing action would be most effective for teaching the client? 1. The nurse asks 1 of the client's English-speaking relatives to interpret. 2. The nurse secures the assistance of a professional interpreter to communicate with the client. 3. The nurse obtains a Spanish-language dictionary for help in conducting the teaching session. 4. The nurse obtains a preoperative Spanish-language teaching brochure and gives it to the client.
2. The nurse secures the assistance of a professional interpreter to communicate with the client. Rationale: Using the services of a professional interpreter is the most effective way to provide preoperative instructions. Asking a family member to interpret is not acceptable because that client may interpret different or erroneous meanings from the nurse's instructions. Non-Spanish-speaking nurses should never attempt to do the teaching themselves with only the help of a Spanish dictionary. A Spanish-language brochure may be given to the client as an adjunct to interpreted verbal instructions but would not be adequate by itself.
A transgender client is following up with the primary health care provider (PHCP). The nurse caring for this client recognizes the best way to deliver care is to employ which approach? 1. Use a same sex PHCP to assess the client. 2. Use the client's preferred pronoun to address him or her. 3. Ask if the client is more likely to choose male or female. 4. Recognize that the client is confused and therapeutically address his or her concerns.
2. Use the client's preferred pronoun to address him or her. Rationale: To build and maintain rapport, it is important for the health care provider to individualize client care and address the client as the client wishes and prefers. Transgender clients may not identify with their birth sex or birth name. It is important to ask about the client's preferences. Option 1 is unnecessary and option 3 is intrusive and personal. Option 4 is a nontherapeutic intervention.
A nurse is educating prospective foster families on health care considerations for the foster child. Which statement made by a family member indicates a need for further teaching? 1. "Community resources are important tools to utilize." 2. "A social worker will be assigned to help access community resources." 3. "All physicians will sign off on the child so medical visits will not be necessary." 4. "Some foster children have complex conditions that require a team of several doctors."
3. "All physicians will sign off on the child so medical visits will not be necessary." Rationale: A foster child can often have complex health conditions. Frequent health visits will be needed during the transition from foster care to home to ensure that the child is acclimated well without any health concerns arising. Therefore option 3 is an incorrect statement by the family member, indicating the need for further teaching. Options 1, 2, and 4 are accurate statements.
The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond? 1. "Health care is very limited in the prison setting." 2. "Living in a prison isn't different than living at home." 3. "Living in a prison can predispose a person to different health conditions." 4. "Living in a prison is similar to living in a condominium complex or dormitory."
3. "Living in a prison can predispose a person to different health conditions." Rationale: The environment of a prison can predispose a person to different health conditions, such as tuberculosis, human immunodeficiency syndrome, sexually transmitted infections, or other infectious diseases. Option 1 does not address the client's question. Options 2 and 4 convey incorrect information.
The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for a follow-up? 1. The reddened sclera of the eyes 2. Dry flaking noted on the scalp 3. A reddish-purple mark on the neck 4. A scaly rash noted on the elbows and knees
3. A reddish-purple mark on the neck Rationale: The client in this question should be screened for abuse. Battered women experience bruises, particularly around the eyes, red or purple marks on the neck, sprained or broken wrists, chronic fatigue, shortness of breath, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues. Mental health issues can also arise, including post-traumatic stress disorder, nightmares, anxiety, uncontrollable thoughts, depression, anxiety, low self-esteem, and alcohol and drug abuse. The reddened sclera, a dry rash on the elbows, and flaking of the scalp do not pose an indication of abuse.
The nurse is annoyed by a healthy Hispanic American client who had minor abdominal surgery 2 days ago. The client claims he cannot get out of bed by himself, and the nurse lectures the client and tells him to try to be tough. What type of cultural behavior is this called? 1. Cultural ignorance 2. Cultural blindness 3. Cultural imposition 4. Cultural transmission
3. Cultural imposition Rationale: Nurses and other primary health care providers who have cultural ignorance or cultural blindness about differences generally resort to cultural imposition. They use their own values and lifestyles as the absolute guide in dealing with clients and interpreting their behaviors.
Which is the best nursing intervention regarding complementary and alternative medicine? 1. Advising the client about "good" versus "bad" therapies 2. Discouraging the client from using any alternative therapies 3. Educating the client about therapies that he or she is using or is interested in using 4. Identifying herbal remedies that the client should request from the primary health care provider
3. Educating the client about therapies that he or she is using or is interested in using Rationale: Complementary and alternative therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role. Options 1, 2, and 4 are inappropriate actions for the nurse to take because they provide advice to the client.
An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action? 1. Advise the client to read the labels of herbal therapies closely. 2. Tell the client that herbal substances are not safe and should never be used. 3. Encourage the client to discuss the use of an herbal substance with the primary health care provider (PHCP). 4. Tell the client that if he takes the herbal substance he will need to have his blood pressure checked frequently.
3. Encourage the client to discuss the use of an herbal substance with the primary health care provider (PHCP). Rationale: Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be encouraged to avoid herbal substances because the combination may lead to an excessive reaction or to unknown interaction effects. The nurse should advise the client to discuss the use of the herbal substance with the PHCP. Therefore, options 1, 2, and 4 are inappropriate nursing actions.
The nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session, the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item is the priority? 1. Discuss the costs of food items. 2. Review the MyPlate food guide. 3. Identify the food preferences and methods of food preparation for each client. 4. Weigh each client and ask the client to document the weight on a progress chart.
3. Identify the food preferences and methods of food preparation for each client. Rationale: To determine each client's nutritional status and needs, the first priority of the nurse is to identify each client's food preferences. Cultural background and knowledge about nutrition are important factors influencing food choices and nutritional status. Although the remaining options may be a component of the sessions, the correct option is the first priority.
The nurse should recognize that some minority groups are hesitant to seek health care because of which most likely factor? 1. Low-income household 2. Lack of insurance coverage 3. Ineffective communication with the primary health care provider (PHCP) 4. Compliance with health care follow-up is not an issue for minority groups
3. Ineffective communication with the primary health care provider (PHCP) Rationale: Some ethnic minorities report hesitancy in seeking health care due to a language barrier. Effective communication is essential to understand and treat the client. Ineffective communication affects the client's safety or willingness to comply with treatment or follow-up care. Low-income households and lack of insurance coverage may be factors but are less likely than the communication problem.
The nurse is caring for a minority client. When assessing for social inequities, which social determinants would be most appropriate for the nurse to consider? Select all that apply. 1. Age 2. Gender 3. Living condition 4. Work condition 5. Access to health care
3. Living condition 4. Work condition 5. Access to health care Rationale: Age and gender are not social determinants; they are biological. Where minority clients live, work and their access to health care play a major role in managing health care maintenance. Without adequate living or work conditions, or little to no access to health care, then health inequities and disparities are created.
The nurse working in a community health clinic for refugees plans care knowing which health condition(s) are common in this population? Select all that apply. 1. Obesity 2. Asthma 3. Measles 4. Tuberculosis 5. Poor nutrition 6. Pregnancy complications
3. Measles 4. Tuberculosis 5. Poor nutrition 6. Pregnancy complications Rationale: Refugees and immigrants are at risk for many health conditions that are associated with acculturation, the process of migration, and little to no access to health care. Communicable diseases, poor nutrition, and pregnancy complications are some associated risks. Obesity and asthma are not directly associated with refugees or immigrants.
A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take? 1. Have one of the client's family members interpret. 2. Have the Spanish-speaking triage receptionist interpret. 3. Page an interpreter from the hospital's interpreter services. 4. Obtain a Spanish-English dictionary and attempt to triage the client.
3. Page an interpreter from the hospital's interpreter services. Rationale: The best action is to have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality as well as accurate information may be compromised when a family member or a non-health care provider acts as interpreter.
The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply. 1. Asthma 2. Claustrophobia 3. Sleep problems 4. Bipolar disorder 5. Aggressive behavior 6. Attention-deficit hyperactivity disorder (ADHD)
3. Sleep problems 4. Bipolar disorder 5. Aggressive behavior 6. Attention-deficit hyperactivity disorder (ADHD) Rationale: Foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, post-traumatic stress disorder, reactive detachment disorder, sleep problems, prenatal drug and alcohol exposure, and personality disorder. Claustrophobia and asthma are not specifically associated with foster children.
A client with a history of mental illness and is taking psychotropic medications is visiting the primary health care provider (PHCP) office. He complains to the nurse that he is consistently dealing with xerostomia. The nurse knows that which factor is the most likely cause? 1. The client's diet 2. The client's dehydration 3. The client's medications 4. The client's history of substance abuse
3. The client's medications Rationale: There are many side effects from psychotropic medications. Xerostomia, which is dry mouth, is caused from a reduction in salivary gland flow, and in this case is most likely due to medications. Proper education should be done so the client knows the potential side effects that are most common. Diet is not a likely cause. Although dehydration can cause a dry mouth, there is no data in the question that supports this as a cause. A history of substance abuse is also an unlikely cause of xerostomia.
The nurse is working in a very busy outpatient clinic that cares primarily for uninsured clients. The nurse plans care knowing that the most likely reason for this clinic being so busy is which factor? 1. The clients are unemployed. 2. The clinic has payment options. 3. The clients lack access to preventive health care. 4. The clinic can qualify them for Medicaid coverage.
3. The clients lack access to preventive health care. Rationale: The underinsured or uninsured client is at increased risk for health disorders due to a lack of access to care. Additionally, preventive care or treatment for chronic diseases is decreased amongst this population as well. A client can be employed and still be uninsured. There is no data to indicate that the clinic has payment options or that the clinic can qualify clients for Medicaid.
The nurse is preparing a plan of care for a client and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? 1."I cannot have surgery." 2. "I cannot have any medicine." 3. "I believe the soul lives on after death." 4. "I cannot have any food containing or prepared with blood."
4. "I cannot have any food containing or prepared with blood." Rationale: Among Jehovah's Witnesses, surgery is not prohibited, but the administration of blood and blood products is forbidden. For a Jehovah's Witness, administration of medication is an acceptable practice except if the medication is derived from blood products. This religious group believes that the soul cannot live after death. Jehovah's Witnesses avoid foods prepared with or containing blood.
The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories? 1. "CAM includes biologically based practices." 2. "Whole medical systems are a component of CAM." 3. "Mind-body medicine is part of the CAM approach." 4. "Magnetic therapy and massage therapy are a focus of CAM."
4. "Magnetic therapy and massage therapy are a focus of CAM." Rationale: The 5 main categories of CAM include whole medical systems, mind-body medicine, biologically based practices, manipulative and body-based practices, and energy medicine. Magnetic therapy and massage therapy are therapies within specific categories of CAM.
The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first? 1. Blood pressure 154/72 mm Hg 2. Visual acuity of 20/200 in both eyes 3. Random blood glucose level of 206 mg/dL (11.47 mmol/L) 4. Complaints of pain associated with numbness and tingling in both feet
4. Complaints of pain associated with numbness and tingling in both feet Rationale: The nurse should address the complaints of pain and numbness and tingling in both feet first with this population. If the client perceives value to the service provided, they will be more likely to return for follow-up care. While the blood pressure, blood glucose, and vision results are concerning, the client's stated concern should be addressed first.
The nurse is caring for a pediatric client who is recovering from abuse and neglect. Place in order of priority the interventions that the nurse performs. All options must be used. 1. Clean and dress wounds 2. Provide emotional support 3. Administer pain medications 4. Ensure environmental safety
4. Ensure environmental safety 2. Provide emotional support 3. Administer pain medications 1. Clean and dress wounds Rationale: Interventions that may be performed by the nurse when caring for a client who is a victim of abuse or neglect include administering pain medications, providing wound care, using assistive devices to support sprains or fractures, educating the client and family about self-care, as well as education on support programs that provide awareness and emotional support. Also, ensuring that the victim is in a safe environment both in the hospital and when the victim is discharged is a priority. Administering pain medications, and cleaning and dressing wounds should be done first, followed by ensuring environmental safety and providing emotional support.
The client is being seen by her primary health care provider (PHCP). During the visit, the client states that being a single parent who works is stressful, and because of this, she feels chronically fatigued. The client also states that she feels anxious because she cannot find consistent daycare for her child. The nurse wants to help the client with community resources. Which resource would be best for the client? 1. Names of food banks 2. Names of sleep study clinics 3. Names of local psychologists 4. Names of child care facilities
4. Names of child care facilities Rationale: Access to community organizations and resources can help alleviate some burdens the single parent may encounter. Services such as child care, wellness clinics for access to screenings, and employment opportunities can set single parent up for success. There is no data in the question indicating that the client needs names of food banks or names of psychologists. Although the client is chronically fatigued, there is no data indicating a sleep study is warranted.
The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch? 1. Apply heating pads to the back. 2. Vigorously massage bony prominences. 3. Position hands directly on the client's skin. 4. Position hands 2 to 4 in (5 to 10 cm) from the body.
4. Position hands 2 to 4 in (5 to 10 cm) from the body. Rationale: During therapeutic touch, nurses use their hands to assess the client's energy field. Hands are positioned 2 to 4 in (5 to 10 cm) from the body. The energy field is assessed for bilateral similarities or differences in the flow of energy. The next step is clearing and balancing the energy field. Nurses then redirect energy through their own intentionality. The session ends with a smoothing of the energy. Therefore, the remaining options are incorrect.
The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? 1. Hypertension 2. Hyperlipidemia 3. Substance abuse disorder 4. Post-traumatic stress disorder
4. Post-traumatic stress disorder Rationale: Post-traumatic stress disorder (PTSD) is extremely common in this population. Identifying and treating mental health disorders assists in mitigating suicide risk. Treatment of comorbid conditions such as PTSD may also help address any substance use disorder. Use of screening tools in identifying substance use disorder is helpful. Treatment of PTSD includes exposure therapy, psychotherapy, and family/group therapy. Hypertension and hyperlipidemia are important but not the priority; the risk of suicide and other safety concerns associated with PTSD are the priority for this population.
The nurse is providing care to a Hispanic client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the appropriate action? 1. Restrict the number of family members visiting at 1 time. 2. Inform the family that emotional outbursts are to be avoided. 3. Contact the primary health care provider to speak to the family regarding their behavior. 4. Request permission to move the client to a private room and allow the family members to visit.
4. Request permission to move the client to a private room and allow the family members to visit. Rationale: In Hispanic cultures, loud crying and other physical manifestations of grief are considered socially acceptable. Of the options provided, the correct choice is the only one that identifies a culturally sensitive approach on the part of the nurse. The remaining options are inappropriate nursing interventions.
The nurse is caring for a client in the emergency department who states that he or she is homeless. Which statement, if made by the nurse, requires the need for further teaching? 1. The homeless population can be victims of physical and emotional trauma. 2. The homeless population is at risk for prolonged environmental exposures. 3. The homeless population has an increased risk for mental health-related issues. 4. The homeless population is comprised primarily of physically and mentally disabled persons.
4. The homeless population is comprised primarily of physically and mentally disabled persons. Rationale: Individuals affected by homelessness are at increased risk for death related to chronic illness, environmental exposures, communicable diseases, mental illnesses, and many other conditions. Homeless individuals can also experience violence and physical and emotional trauma. There are many reasons leading to homelessness, and disability is one factor but not necessarily the primary factor.
The charge nurse is assessing the nurse's knowledge about the use of an interpreter. Which statement made by the nurse requires a need for further teaching? 1. Using friends to interpret is a conflict of interest 2. Family members should not be used due to confidentiality 3. The use of an interpreter decreases the risk of relaying inaccurate information 4. The use of an interpreter does not need to occur until the client requests one
4. The use of an interpreter does not need to occur until the client requests one Rationale: The use of an interpreter should occur regularly and frequently while interacting with the client. Family members and friends should not be asked by a health care professional to be an interpreter. Confidentiality, conflict of interest, and the risk of relaying inaccurate information are all barriers to not using a designated health care agency interpreter.
