BAH 13
An international nurse has noted that a trend in developing countries is a decrease in mortality from some acute conditions. This has corresponded with an increase in the incidence and prevalence of chronic diseases. What has contributed to this decrease in mortality from some acute conditions?
A) Improved nutrition
You are planning an educational inservice for your nursing colleagues with the goal of fostering culturally competent care. What outcome should you prioritize when planning this education?
A) Participants will acknowledge and adapt to diversity among their colleagues.
After working with a patient who has human immunodeficiency (HIV) for several weeks, the nurse has become more aware of the role of health disparities. Which of the following variables are known to underlie health disparities? Select all that apply.
A) Poverty B) Isolated geographic location C) Overdependence on publicly funded facilities
A home care nurse is making an initial visit to a 68-year-old man. The nurse finds the man tearful and emotionally withdrawn. Even though the man lives alone and has no family, he has been managing well at home until now. What would be the most appropriate action for the nurse to take?
A) Reassess the patients psychosocial status and make the necessary referrals
You are assessing an older adult patient post-myocardial infarction. You attempt to identify your patients health patterns and to assess if these health patterns are achieving the patients goals. How should you best respond if it is found that the patients health patterns are not achieving their goals?
A) Seek ways to promote balance in the patient.
You are auditing the electronic health record of a 33-year-old patient who was treated for a postpartum hemorrhage. When reviewing the patients records, you can see various demonstrations of negative feedback loops. Which of the following constitute negative feedback loops? Select all that apply.
A) Serum glucose levels B) Acid-base balance C) Temperature
The nurse is admitting a 51-year-old patient to the medical-surgical unit after a diagnosis of cellulitis of the calf. What factors does the nurse know impact the processes of inflammation, repair, and replacement? Select all that apply.
A) Severity of the injury C) Condition of the host E) Nature of the injury
You are caring for a patient with a history of chronic angina. The patient tells you that after breakfast he usually takes a shower and shaves. It is at this time, the patient says, that he tends to experience chest pain. What might you counsel the patient to do to decrease the likelihood of angina in the morning?
A) Shower in the evening and shave before breakfast.
A 56-year-old woman who emigrated from Vietnam as an adult was admitted with a urinary tract infection, but has now developed urosepsis. The nurse is in the process of changing the patients plan of care accordingly. The nurse should consider what phenomenon that tends to occur in patients of all ages when they are ill?
A) Tendency to regress in language skills
A nurse is providing care for a female patient who is Hispanic. The care team is discussing the patients nutritional status and one of the nurses colleagues states, I suppose we should try to get her some tacos or burritos since thats what shes probably used to. How should the nurse best interpret the colleagues statement?
A) The colleague may have stereotypical views of Hispanics.
A patient with a spinal cord injury is being assessed by the nurse prior to his discharge home from the rehabilitation facility. The nurse is planning care through the lens of the interface model of disability. Within this model, the nurse will plan care based on what belief?
A) The patient has the potential to function effectively despite his disability.
An elderly patient has presented to the clinic with a new diagnosis of osteoarthritis. The patients daughter is accompanying him and you have explained why the incidence of chronic diseases tends to increase with age. What rationale for this phenomenon should you describe?
A) With age, biologic changes reduce the efficiency of body systems.
The nurse is assessing a newly admitted patient who is an 84-year-old woman. The nurse learns that the patient has simultaneously experienced a hip fracture and the exacerbation of her chronic heart failure. What is an example of a bodily function that restores homeostasis by negative feedback when conditions shift out of normal range?
Body temperature
A nurse practitioners assessment of a new patient includes each of the four basic assessment techniques. When using percussion, which of the following is the nurse able to assess?
Borders of the patients heart
A group of nurses are planning the care of an older adult who is being rehabilitated following a stroke. A nurse notes that hypertension and cardiovascular disease could have occurred over time if the patient previously experienced a state of chronic arousal. In a state of chronic arousal, what can happen within the body?
Arteriosclerosis may develop.
A team of community health nurses has partnered with the staff at a youth drop-in center to address some of the health promotion needs of teenagers. The nurses have identified a need to address nutritional assessment and intervention. Which of the following most often occurs during the teen years?
Lifelong eating habits are acquired.
The nurse is assessing a patient and learns that the patient and his wife were married just 3 weeks earlier. Which of the following statements should underlie the nurses care planning for this patient?
Marriage causes transition, which has the potential to cause stress.
The nurse is caring for a patient who was widowed 2 years prior to this current hospitalization, her fifth since the death of her husband. The woman says to the nurse, The doctor says my blood pressure is dangerously high. What is making my blood pressure so high? What does the nurse know about the probable cause of this patients hypertension?
Prolonged or unrelenting suffering can cause physical illness.
Imbalanced nutrition can be characterized by excessive or deficient food intake. What potential effect of imbalanced nutrition should the nurse be aware of when assessing patients?
Prolonging confinement to bed
The nurse is caring for a young adult male with a traumatic brain injury and severe disabilities caused by a motor vehicle accident when he was an adolescent. Where does the nurse often provide care for patients like this young adult?
C) Medical-surgical units
The nurse is caring for a patient diagnosed with cancer of the liver who has chosen to remain in his home as long as he is able. The nurse reviews the care plan for the patient and notes that it focuses on palliative measures. The nurse also notes that over the last 3 weeks, the patients condition has continued to deteriorate. What is the nurses best response to this clinical information?
C) Recognize that the patient is in the downward phase of chronic illness and should be reassessed.
A patient who is recovering from a stroke expresses frustration about his care to the nurse, stating, It seems like everyone sees me as just a problem that needs fixing. This patients statement is suggestive of what model of disability?
C) Rehabilitation model
A nurse provides care in an inner-city hospital that serves a culturally diverse population. When attempting to foster positive and therapeutic nursepatient interactions, the nurse should recognize that these interactions are primarily dependent on what variable?
C) The ability to understand and be understood
A nurse is describing and demonstrating the technique for emptying a Vietnamese patients surgical drain, knowing that the patient will soon be discharged home with the drain in place. As the nurse is explaining, the patient laughs at times that appear unrelated to what the nurse is saying or doing. How should the nurse best understand the patients behavior?
C) The patient may be unable to fully comprehend the information the nurse is trying to convey.
25. You are caring for a young woman who has Down syndrome and who has just been diagnosed with type 2 diabetes. What consideration should you prioritize when planning this patients nursing care?
C) The same information you would provide to a patient without a chronic condition
During an orientation class, the medical units nursing educator is presenting education on transcultural nursing to a group of new nursing graduates. What should the staff educator identify as the underlying focus of transcultural nursing?
C) The underlying focus of transcultural nursing is to provide culture-specific and culture-universal care.
You are presenting patient teaching to a 48-year-old man who was just diagnosed with type 2 diabetes. The patient has a BMI of 35 and leads a sedentary lifestyle. You give the patient information on the risk factors for his diagnosis and begin talking with him about changing behaviors around diet and exercise. You know that further patient teaching is necessary when your patient tells you what?
C) There is nothing that can be done anyway, because chronic diseases like diabetes cannot be prevented.
7. The nurse is preparing a discharge teaching session with an Asian patient to evaluate the patients ability to change a dressing. The patient speaks and understands minimal English. What would be the best way to promote understanding during the teaching session?
C) Use an interpreter during the teaching session.
A man and woman are in their early eighties and have provided constant care for their 44-year-old son who has Down syndrome. When planning this familys care, the nurse should be aware that the parents most likely have what concerns around what question?
C) Who will care for our son once were unable?
You are the nurse performing a health assessment of an adult male patient. The man states, The doctor has already asked me all these questions. Why are you asking them all over again? What is your best response?
This history helps us determine what your needs may be for nursing care.
You are admitting an elderly woman who is accompanied by her husband. The husband wants to know where the information you are obtaining is going to be kept and you follow up by describing the system of electronic health records. The husband states, I sure am not comfortable with that. It is too easy for someone to break into computer records these days. What is your best response?
This hospital is as concerned as you are about keeping our patients records private. So we take special precautions to make sure no one can break into our patients medical records.
You are discharging a 4-year-old boy from the emergency department. The boy was seen for an insect bite that became swollen and reddened and warm and painful to touch. The patients vital signs are all within normal range for age. While giving discharge instructions to the patients father, he asks why the child is not going to get antibiotics for the infected insect bite. What would be your best response?
This is a local inflammatory response to the insect bite; it is not an infection so antibiotics will not help.
A nurse on a medical unit is conducting a spiritual assessment of a patient who is newly admitted. In the course of this assessment, the patient indicates that she does not eat meat. Which of the following is the most likely significance of this patients statement?
This is an aspect of the patients religious practice.
During a comprehensive health assessment, which of the following structures can the nurse best assess by palpation?
Thyroid gland
Your patient tells you that he has just been told that his computed tomography results were abnormal. You can expect that his sympathetic nervous system has stimulated his adrenal gland to release what?
Epinephrine
A school nurse at a middle school is planning a health promotion initiative for girls. The nurse has identified a need for nutritional teaching. What problem is most likely to relate to nutritional problems in girls of this age?
Folate intake is below the recommended levels in this age group.
An initiative has been launched in a large hospital to promote the use of people-first language in formal and informal communication. What is the significance to the patient when the nurse uses people-first language?
B) The person is of more importance to the nurse than the disability.
During the care conference for a patient who has multiple chronic conditions, the case manager has alluded to the principles of the interface model of disability. What statement is most characteristic of this model?
B) This patient can be empowered and doesnt have to be dependent
The quality improvement team at a large, urban hospital has recognized the need to better integrate the principles of transcultural nursing into patient care. When explaining the concept of transcultural nursing to uninitiated nurses, how should the team members describe it?
B) Transcultural nursing refers to research-focused practice that focuses on patient-centered, culturally, competent nursing.
A nurse is planning the care of a woman who has been admitted to the medical unit following an ischemic cerebrovascular accident. What would the nurse recognize as the longest-acting phase of the womans physiologic response to stress and its cause?
Hypothalamic-pituitary response caused by persistent stress
A teenage boy who was the victim of a near drowning has been admitted to the emergency department. The patient was submerged for several minutes and remains unconscious. What pathophysiological process has occurred as a result of the submersion?
Hypoxia to the brain
You are the nurse assessing a 28-year-old woman who has presented to the emergency department with vague complaints of malaise. You note bruising to the patients upper arm that correspond to the outline of fingers as well as yellow bruising around her left eye. The patient makes minimal eye contact during the assessment. How might you best inquire about the bruising?
Is anyone physically hurting you?
An older adults unexplained weight loss of 15 pounds over the past 3 months has prompted a thorough diagnostic workup. What is the nurses rationale for prioritizing biochemical assessment when appraising a persons nutritional status?
It reflects the tissue level of a given nutrient.
A family whose religion limits the use of some forms of technology is admitting their grandfather to your unit. They express skepticism about the fact that you are recording the admission data on a laptop computer. What would be your best response to their concerns?
Its been found that using computers improves our patients care and reduces their health care costs.
A patient who has a 40 pack-year history of smoking may have dysplasia of the epithelial cells in her bronchi. What would the nurse tell the patient about dysplastic cells in the bronchi?
Dysplastic cells have a high potential to become malignant.
You are caring for an older female patient who is being treated for acute anxiety. She has a nursing diagnosis of Ineffective Coping related to a feeling of helplessness. What would be the most appropriate nursing intervention?
Encourage an attitude of realistic hope to help her deal with helpless feelings.
The staff development nurse is presenting a class on the importance of incorporating people-first language into daily practice as well as documentation. What is an example of the use of people-first language when giving a verbal report?
B) The patient with schizophrenia
6. The nurse is helping a patient choose her menu options for the following day. The nurse reads out the option of ham with scalloped potatoes and the patient states that her religion does not allow this. Which of the following is most likely the patients religion?
C) Islam
In your role as a community health nurse, you are focusing your current health promotion efforts on diseases that are disproportionately represented among ethnic and racial minorities. Which of the following diseases would you likely address? Select all that apply.
A) Human immunodeficiency virus (HIV) B) Cancer C) Heart disease
. In your role as a school nurse, you are presenting at a high school health fair and are promoting the benefits of maintaining a healthy body weight. You should refer to reductions in the risks of what diseases? Select all that apply.
A) Heart disease B) Stroke D) Diabetes E) Hypertension
A 30-year-old man is in the clinic for a yearly physical. He states, I found out that two of my uncles had heart attacks when they were young. This alerts the nurse to complete a genetic-specific assessment. What component should the nurse include in this assessment?
A complete health history, including genogram along with any history of cholesterol testing or screening and a complete physical exam
A nurse who has practiced in the hospital setting for several years will now transition to a new role in the community. How does a physical assessment in the community vary in technique from physical assessment in the hospital?
A physical assessment in the community consists of largely the same techniques as are used in the hospital.
. A case manager is responsible for ensuring that patients meet the criteria for diagnoses of chronic conditions in order to ensure their eligibility for federal programs. Which of these definitions may not apply for legal purposes?
A) A person who is temporarily disabled but later return to full functioning.
A hospitals written policies and procedures are being reviewed as part of an accreditation process. Which of the following policies are congruent with the principles of culturally competent nursing care? Mark all that apply.
A) A policy that outlines the appropriate use of translation services B) A policy guiding staff in the care of patients with different values D) A policy that establishes flexible regulations pertaining to visitors
Prior to planning health promotion interventions in your local community, you are appraising the key health care indicators in your region and comparing them with those in the nation as a whole. What do these key indicators reveal about the United States?
A) A significant gap in health status between the overall population and people of specific ethnic Backgrounds
A man with a physical disability uses a wheelchair. The individual wants to attend a support group for the parents of autistic children, which is being held in the basement of a church. When the individual arrives at the church, he realizes there are no ramps or elevators to the basement so he will not be able to attend the support group. What type of barrier did this patient encounter?
A) A structural barrier
The nurse is completing a family history for a patient who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems? Select all that apply.
A) Allergies B) Alcoholism E) Obesity
Personal space and distance is culturally dependent and can impact nursepatient interactions significantly. What is the best way for the nurse to interact with a patient who has a different cultural perspective on space and distance?
A) Allow the patient to adopt a position that is comfortable for him or her.
A patient who is legally blind is being admitted to the hospital. The patient informs the nurse that she needs to have her guide dog present during her hospitalization. What is the nurses best response to the patient?
A) Arrangements can be made for your guide dog to be at the hospital with you during your stay.
The community nurse is caring for a patient who has paraplegia following a farm accident when he was an adolescent. This patient is now 64 years old and has just been diagnosed with congestive heart failure. The patient states, Im so afraid about what is going to happen to me. What would be the best nursing intervention for this patient?
A) Assist the patient in making suitable plans for his care.
. The nurse is providing care for an older adult patient who has a diagnosis of shingles. The nurse is aware that this health problem is attributable to the varicella zoster virus. This belief is an example of which paradigm explaining the cause of disease and illness?
A) Biomedical
The future of transcultural nursing care lies in finding ways to promote cultural competence in nursing students. How can this goal be best accomplished?
A) By offering multicultural health studies in nursing curricula
You are admitting a patient who is a recent immigrant from China and who has a diagnosis of adenocarcinoma. During the patients admission assessment, the patient speaks of her beliefs related to health care and indirectly references the yin/yang theory. Based on her cancer diagnosis and her yin/yang beliefs, which meal will the patient most likely order for lunch?
A) Chicken noodle soup with crackers, fruit crisp, and hot tea
A patient tells the nurse that her doctor just told her that her new diagnosis of rheumatoid arthritis is considered to be a chronic condition. She asks the nurse what chronic condition means. What would be the nurses best response?
A) Chronic conditions are defined as health problems that require management of several months or longer.
You are performing a cultural nursing assessment of a newly admitted patient of Cuban descent. What would you include in your assessment? Select all that apply.
A) Family structure C) Cultural beliefs D) Health practices E) Values
A nurse is meeting with a young woman who has recently lost her job after moving with her husband to a new city. She describes herself as being anxious and pretty depressed. What principle of stress and adaptation should be integrated into the nurses plan of care for this patient?
An accumulation of stressors can disrupt homeostasis and result in disease.
Research has corroborated an experienced nurses observation that the incidence and prevalence of chronic conditions is increasing in the United States. What health promotion initiative most directly addresses the factor that has been shown to contribute to this increase?
B) A community-based weight-loss program
A 19-year-old patient with a diagnosis of Down syndrome is being admitted to your unit for the treatment of community-acquired pneumonia. When planning this patients care, the nurse recognizes that this patients disability is categorized as what?
B) A developmental disability
An emergency department nurse is preparing to inspect and palpate the head and scalp of an older adult who experienced a fall. A member of which group would most likely consider this examination as a violation of norms?
B) Asian American
A newly admitted patient has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters are included when assessing a patients nutritional status? Select all that apply.
B) BMI C) Clinical examination findings E) Dietary data
A 54-year-old African American man has presented for a follow-up appointment shortly after being diagnosed with hypertension and being placed on an angiotensin-converting enzyme (ACE) inhibitor. The nurse takes the patients vital signs at the beginning of the appointment and obtains a blood pressure of 177/96 mm Hg. What factor should the nurse consider in light of the patients sustained high blood pressure?
B) Biologic variations may be influencing the effectiveness of the medication.
A nurse is auditing the care of a recently discharged patient and is appraising the patients care in light of Leiningers theory of Culture Care Diversity and Universality. Specifically, the nurse is looking for evidence that caregivers implemented professional actions and decisions that helped the patient achieve a beneficial or satisfying health outcome. What aspect of Leiningers theory is the nurse addressing?
B) Culture care restructuring
A nurse knows that patients with invisible disabilities like chronic pain often feel that their chronic conditions are more challenging to deal with than more visible disabilities. Why would they feel this way?
B) Despite appearances, invisible disabilities can be as disabling as visible disabilities.
A nurse is planning the care of a patient who has been diagnosed with renal failure, which the nurse recognizes as being a chronic condition. Which of the following descriptors apply to chronic conditions? Select all that apply.
B) Diseases where complete cures are rare D) Diseases that do not resolve spontaneously E) Diseases that have a prolonged course
2. A nurse is conducting a health assessment of an adult patient when the patient asks, Why do you need all this health information and who is going to see it? What is the nurses best response?
B) It is good you asked and you have a right to know; your information helps us to provide you with the best possible care, and your records are in a secure place.
. A patient with end-stage lung cancer has been admitted to hospice care. The hospice team is meeting with the patient and her family to establish goals for care. What is likely to be a first priority in goal setting for the patient?
B) Pain control
The nurse assessing health disparities in the community is focusing on disparities that exist apart from those between ethnic groups. In which of the following groups are these disparities most evident?
B) People with disabilities
A medical-surgical nurse is teaching a patient about the health implications of her recently diagnosed type 2 diabetes. The nurse should teach the patient to be proactive with her glycemic control in order to reduce her risk of what health problem?
B) Renal failure
A 39-year-old patient with paraplegia has been admitted to the hospital for the treatment of a sacral ulcer. The nurse is aware that the patient normally lives alone in an apartment and manages his ADLs independently. Before creating the patients plan of care, how should the nurse best identify the level of assistance that the patient will require in the hospital?
B) Talk with the patient about the type and level of assistance that he desires.
You are a community health nurse who provides care to a group of Hispanic people living in an area that is predominantly populated by Caucasian people. How would you characterize the Hispanic people in this community?
C) A minority
A patient who has recently been diagnosed with chronic heart failure is being taught by the nurse how to live successfully with her chronic condition. Her ability to meet this goal will primarily depend on her ability to do which of the following?
C) Adapt her lifestyle to accommodate her symptoms.
You are caring for a patient who is terminally ill whose family has requested to hold a spiritual ceremony during which they will be using incense. What would be the best intervention you could make on behalf of this patient?
C) Arrange for the ceremony to occur after notifying all departments affected.
A parent informs the nurse that immunizations are contrary to her religious beliefs, and she does not want her child to receive immunizations. The nurse proceeds to inform the parent that the child will be in grave danger of illness all her life and will not be allowed to start school unless she is immunized. The nurse also informs the parent that she had all of her own children vaccinated with no adverse effects. The nurses behavior is an example of what?
C) Cultural imposition
A nurse is caring for a child with a diagnosis of hemophilia. The child is in need of a blood transfusion, which her familys religious beliefs forbid. What term would best describe this religions beliefs and their impact on health care for this child?
C) Cultural taboo
The segment of the population who has a BMI lower than 24 has been found to be at increased risk for poor nutritional status and its resultant problems. What else is a low BMI associated with in the community-dwelling elderly?
C) Higher mortality rate
The nurse is reviewing the importance of preventative health care with a patient who has a disability. The patient states that she will not have the money to pay for her annual gynecologic exams or mammograms due to the cost of this hospitalization. What information would be appropriate for the nurse to share with the patient?
C) Ill look into federal assistance programs that provide financial assistance for health-related expenses for people with disabling conditions.
You are the case manager who oversees the multidisciplinary care of several patients living with chronic conditions. Two of your patients are living with spina bifida. You recognize that the center of care for these two patients typically exists where?
C) In the home
A school nurse is teaching a 14-year-old girl of normal weight some of the key factors necessary to maintain good nutrition in this stage of her growth and development. What interventions should the nurse most likely prioritize?
C) Increasing calcium intake, eating a balanced diet, and discussing eating disorders
In a small, rural hospital the nurse is caring for a patient who speaks a language other than English. The nurse needs to use an interpreter to communicate but the hospital does not have access to an interpreter who speaks the patients language. When choosing another individual to interpret for this patient, what characteristic should the nurse prioritize?
C) Interpreter should be fluent in several dialects of the patients language.
The nurse is performing an admission assessment of a 72-year-old female patient who understands minimal English. An interpreter who speaks the patients language is unavailable and no members of the care team speak the language. How should the nurse best perform data collection?
Collect all possible data from the patient and have the family supplement missing details.
You are assessing an 80-year-old patient who has presented because of an unintended weight loss of 10 pounds over the past 8 weeks. During the assessment, you learn that the patient has ill-fitting dentures and a limited intake of high-fiber foods. You would be aware that the patient is at risk for what problem?
Constipation
A nursing student has presented a concept map of a medical patients health that demonstrates the maintenance of a steady state. The student has elaborated on the relationship of individual cells to compensatory mechanisms. When do compensatory mechanisms occur in the human body?
Continuously
You are the nurse caring for an adult patient who has just received a diagnosis of prostate cancer. The patient states that he will never be able to cope with this situation. How should you best understand the concept of coping when attempting to meet this patients needs?
Coping is composed of the physiologic and psychological processes that people use to adapt to change.
A 37-year-old woman with multiple sclerosis is married and has three children. The nurse has worked extensively with the woman and her family to plan appropriate care. What is the nurses most important role with this patient?
D) Help the patient develop strategies to implement treatment regimens
You are orienting a new nursing graduate to your medical unit. The new nurse has been assisting an elderly woman, who is Greek, to fill out her menu for the next day. To what resource should you refer your colleague to obtain appropriate dietary recommendations for this patient?
Culturally sensitive materials, such as the Mediterranean Pyramid
A nurse has been having a number of challenging nursepatient interactions when providing care for a patient whose surgery was complicated by a medical error. When interacting with patients and families, of what must the nurse be cognizant?
D) Her own cultural orientation
An infant with a diagnosis of pyelonephritis is receiving care on the pediatric unit and the nurses review of the childs electronic health record reveals that the infant has not received any of her scheduled immunizations. The mother informs the nurse that immunizations are against her cultural beliefs, and she does not want her child to receive immunizations. In this scenario, what do the mothers views on immunizations represent?
D) A cultural taboo
In planning the nursing care of a patient who lives with chronic pain, the nurse has included the intervention of therapeutic touch. When categorizing this particular complementary therapy, the nurse should identify it as which of the following?
D) An energy therapy
Agency policies are important to achieve culturally competent care. When reviewing a hospitals current policy framework, which of the following actions has the potential to improve the overall level of culture competence?
D) Creating greater flexibility in visiting hours
. A major cause of health-related problems is the increase in the incidence of chronic conditions. This is the case not only in developed countries like the United States but also in developing countries. What factor has contributed to the increased incidence of chronic diseases in developing countries?
D) Developing countries are simultaneously coping with emerging infectious diseases.
3. A nurse is caring for an elderly woman who predominantly identifies with an East Asian culture. How can the nurse best demonstrate an awareness of culturally congruent care?
D) Establish effective communication.
Giger and Davidhizar (2012) created an assessment model to guide nurses in exploring cultural phenomena that might affect nursing care. When using this model in the care of a patient who has had a transurethral prostate resection (TUPR), what area of care would be influenced most directly?
D) Explaining the rationale for continuous bladder irrigation (CBI)
The nurse is admitting a Native American patient with uncontrolled hypertension and type 1 diabetes to the unit. During the initial assessment, the patient informs the nurse that he has been seeking assistance and care from the shaman in his community. The nurse recognizes that the patients blood pressure and his blood sugar level are elevated upon admission. What is the nurses best response to the patients indication that his care provider is a shaman?
D) I understand that you value the care provided by the shaman, but we would like you to consider medications and dietary changes that may lower your blood pressure and blood sugar levels.
A patient has recently been diagnosed with type 2 diabetes. The patient is clinically obese and has a sedentary lifestyle. How can the nurse best begin to help the patient increase his activity level?
D) Identify barriers with the patient that inhibit his lifestyle change.
A nurse is aware that the number of people in the United States who are living with disabilities is expected to continue increasing. What is considered to be one of the factors contributing to this increase?
D) Increased survival rates among people who experience trauma
The interface model of disability is being used to plan the care of a patient who is living with the effects of a stroke. Why should the nurse prioritize this model?
D) It promotes the idea that patients are capable and responsible.
Touch, to a great degree, is culturally determined. When providing care for a patient who belongs to a Hispanic culture, which of the following may be considered inappropriate in a health care setting?
D) Males participating in health care activities.
Most nurses have been taught to maintain direct eye contact when communicating with patients. However, some cultural groups do not usually value direct eye contact when communicating with the nurse. Which cultural group would most likely consider the direct eye contact impolite?
D) Native Americans
A nurse who provides care on a busy medical unit is aware that his own beliefs do not always coincide with the beliefs of patients from some cultural backgrounds. What aspects of patient care may be most influenced by diverse cultural perspectives?
D) Obtaining informed consent
8. You are the nurse caring for a patient who is a recent immigrant to the United States from Mexico. Which of the following variables would you prioritize when performing an assessment of the patients cultural beliefs?
D) Patients communication style
During their prime employable years between ages 21 and 64, 77% of those with a nonsevere disability are employed. What has research shown about this employed population?
D) People with disabilities earn less money than people without disabilities.
A patient who undergoes hemodialysis three times weekly is on a fluid restriction of 1000 mL/day. The nurse sees the patient drinking a 355-mL (12 ounce) soft drink after the patient has already reached the maximum intake of fluid for the day. What action should the nurse take?
D) Reinforce the importance of the fluid restriction and document the teaching and the intake of extra Fluid
A community health nurse has drafted a program that will address the health promotion needs of members of the community who live with one or more disabilities. Which of the following areas of health promotion education is known to be neglected among adults with disabilities?
D) Sexual health
A group of nurses are attending an educational inservice on adaptive and maladaptive responses to stress. When talking about the assessment of coping strategies in patients, the nurses discuss the use of drugs and alcohol to reduce stress. What is most important for the nurses to know about these coping behaviors?
D) They increase the risk of illness.
A nurse is planning the care of a 48-year-old woman who has just received a diagnosis of breast cancer. The patient has been explicit about her desire to integrate a variety of complementary therapies into her treatment regimen. What is the nurses primary responsibility around the use of complementary therapies?
D) To assess the patients use of complementary therapies in order to promote safety
You have admitted a new patient to your unit with a diagnosis of stage IV breast cancer. This woman has a comorbidity of myasthenia gravis. While you are doing the initial assessment, the patient tells you that she felt the lump in her breast about 9 months ago. You ask the patient why she did not see her health care provider when she first found the lump in her breast. What would be a factor that is known to influence the patient in seeking health care services?
D) Unfavorable interactions with health care providers
During your integumentary assessment of an adult female patient, you note that the patient has dry, dull, brittle hair and dry, flaky skin with poor turgor. When planning this patients nursing care, you should prioritize interventions that address what problem?
Deficient nutritional status
A home care nurse is teaching meal-planning to a patients son who is caring for his mother during her recovery from hip replacement surgery. Which of the following meals indicates that the son understands the concept of nutrition, based on the U.S. Department of Agricultures MyPlate?
Ham sandwich with tomato on rye bread with peaches and yogurt
A patient presents to the health center and the nurse practitioners assessment reveals an enlarged thyroid. The nurse practitioner believes the thyroid cells may be undergoing hyperplasia. How would the nurse practitioner explain this condition to the patient?
Hyperplasia is an abnormal increase in new cells and is reversible with the stimulus for cell growth removed.
A patient has a newly diagnosed heart murmur. During the nurses subsequent health education, he asks if he can listen to it. What would be the nurses best response?
If you would like to listen to your murmur, Id be glad to help you and to show you how to use a stethoscope.
Your older adult patient has been diagnosed with urosepsis and has a temperature of 103.4F. You should be aware that the oxygen demands of the patients body would change in which direction and why?
Increase due to an increase in metabolism
An elderly man tells you that his wife died 14 months ago and that he cannot stop grieving over his loss. What should you encourage the patient to consider?
Increase his interaction with his social network.
In your role as a school nurse, you are working with a female high school junior whose BMI is 31. When planning this girls care, you should identify what goal?
Increase in exercise and reduction in calorie intake
The nurse is assessing a patient and finds two enlarged supraclavicular lymph nodes. The nurse asks the patient how long these nodes have noticeably enlarged. The patient states, I cant remember. A long time I think. Do I have cancer? Which of the following is an immediate physiologic response to stress the nurse would expect this patient to experience?
Increased blood pressure
A 44-year-old woman will undergo a bilateral mastectomy later today and the nurse in surgical admitting has begun the process of patient education. What positive outcome of providing the patient with information should the nurse expect?
Increased concentration
A 35-year-old woman comes to the local health center with a large mass in her right breast. She has felt the lump for about a year, but was afraid to come to the clinic because she was sure it was cancer. What is the most appropriate nursing diagnosis for this patient?
Ineffective individual coping related to reluctance to seek care
You are admitting a patient who presents with inflammation of his right ankle. When planning this patients care, which of the following statements regarding acute inflammation should you recognize?
Inflammation is a defensive reaction intended to remove an offending agent.
You are beginning your shift on a medical unit and are performing assessments appropriate to each patients diagnosis and history. When assessing a patient who has an acute staphylococcal infection, what is the most effective technique for assessing the lymph nodes of the patients neck?
Palpation
You walk into your patients room and find her sobbing uncontrollably. When you ask what the problem is, your patient responds, I am so scared. I have never known anyone who goes into a hospital and comes out alive. On this patients care plan you note a pre-existing nursing diagnosis of Ineffective Coping related to stress. What is the best outcome you can expect for this patient?
Patient will adopt coping mechanisms to reduce stress.
The admitting nurse has just met a new patient who has been admitted from the emergency department. As the nurse introduces himself, he begins the process of inspection. What nursing action should the nurse include during this phase of assessment?
Pay attention to the details while observing.
In your role as a school nurse, you are performing a sports physical on a healthy adolescent girl who is planning to try out for the volleyball team. When it comes time to listen to the students heart and lungs, what is your best nursing action?
Perform auscultation with the diaphragm placed firmly on her skin to minimize extra noise.
As an occupational health nurse at a large industrial plant, you are planning the return to work of an employee who was exposed to a chemical spill. To what type of stressor has this patient been exposed?
Physical
You are caring for a 65-year-old widower whose wife died 4 months ago. He tells you that he is not doing well and that his friends and family seem hesitant to talk with him about his wife. What could the nurse do to help the patient?
Refer him to a support group.
A patient is experiencing intense stress during his current hospital admission for the exacerbation of chronic obstructive pulmonary disease (COPD). Which of the patients actions best demonstrates adaptively coping?
Reprioritizing needs and roles
The nurse is performing discharge planning for a patient who has numerous chronic health problems. The nurse recognizes that lifestyle changes would likely benefit the patients health status. Which factor would the nurse identify as most important in determining health status?
Social class
Computed tomography of a 72-year-old woman reveals lung cancer with metastasis to the liver. The patients son has been adamant that any bad news be withheld from his in order to protect her from stress, stating that this is a priority in his culture. How should the nurse and the other members of the care team best respond?
Speak with the son to explore his rationale and attempt to reach a consensus.
Selyes general adaptation syndrome (GAS) is a theory of adaption to biologic stress. Selye compared the GAS with the life process: childhood, adulthood, and later years. What would occur during adulthood in the GAS?
Stressful events occur and resistance or adaption occurs.
The nurse is with a patient who has learned that he has glioblastoma multiforme, a brain tumor associated with an exceptionally poor prognosis. His heart rate increases, his eyes dilate, and his blood pressure increases. The nurse recognizes these changes as being attributable to what response?
Sympathetic nervous response
You are caring for a patient in the urgent care center who presented with complaints of lethargy, malaise, aching, weakness, and loss of appetite. During the assessment, you note an area on the patients right posterior calf that is warm to touch, edematous, and tender to touch. You know the most probable cause of this patients symptoms is what?
Systemic inflammatory response
You are the nurse caring for a patient who is Native American who arrives at the clinic for treatment related to type 2 diabetes. Which question would best provide you with information about the role of food in the patients cultural practices and identify how the patients food preferences could be related to his problem?
Tell me about foods that are important in your culture and how you feel they influence your diabetes.
An 89-year-old male patient is wheelchair bound following a hemorrhagic stroke and has been living in a nursing home since leaving the hospital. He returns to the adjacent primary care clinic by wheelchair for follow-up care of hypertension and other health problems. The nurse would modify his health history to include which question?
Tell me about where you live: Do you feel your needs are being met, and do you feel safe?
You are the nurse caring for a 72-year-old woman who is recovering from a hemicolectomy on the postsurgical unit. The surgery was very stressful and prolonged, and you note on the chart that her blood sugars are elevated, yet diabetes does not appear in her previous medical history. To what do you attribute this elevation in blood sugars?
The blood sugars are probably a result of the fight-or-flight reaction
A nurse is conducting a home visit as part of the community health assessment of a patient who will receive scheduled wound care. During assessment, the nurse should prioritize which of the following variables?
The community and home environment, support systems or family care, and the availability of needed resources
While talking with the parents of conjoined twins who are medically unstable, you note that the father of the babies has an aggressive stance, is speaking in a loud voice, and makes several hostile statements such as, Id sure like to have words with that doctor who told us our babies would be okay. You know that this fathers cognitive appraisal has led to what?
The development of negative emotions
A patient tells the nurse that she does not like to go to the doctor and is feeling anxious about being in this place. When the nurse checks her blood pressure, it is elevated along with her heart rate. The nurse rechecks her blood pressure about 10 minutes later and it is normal. The patient asks the nurse if she should be concerned that she may have hypertension. What statement should guide the nurses response?
The first blood pressure was part of a simple stress response; our long-term blood pressure is controlled by negative feedback systems.
A group of nursing students are applying the concept of steady state to the nursing care plan of a patient who is undergoing chemotherapy and radiotherapy for the treatment of lung cancer. What would be the most complete statement by the students about the concept of steady state?
The mechanisms of steady state work to maintain balance in the body.
You are the psychiatric-mental health nurse caring for a young, recently married woman, whose sister and niece were recently killed in a motor vehicle accident. This young woman is making arrangements for the funerals, and you know that your patient has insight into her current stressors. What do you know is occurring with this young woman?
The mediating process is occurring.
The nurse at the student health center is seeing a group of students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What will be included in the nurses intervention?
The mindful use of a word, phrase, or visual, which allows oneself to be distracted and temporarily escape from stressful situations
A mother has brought her young son to the emergency department (ED). The mother tells the triage nurse that the boy was stung by a bee about an hour ago. The mother explains to the nurse, It hurts him so bad and it looks swollen, red, and infected. What can the triage nurse teach the mother?
The pain, redness, and swelling are part of the inflammatory process, but it is probably too early for an infection.
You are the nurse caring for a 51-year-old man who has just been told in a family meeting that he has stage IV colon cancer. You expect that the patient now has an increase in blood pressure, heart rate and respiratory rate. You spend time talking with this patient and his vital signs become closer to normal range. To what would you attribute this phenomenon?
The patient is adapting to noxious stressors.
A nurse who provides care in a campus medical clinic is performing an assessment of a 21-year-old student who has presented for care. After assessment, the nurse determines that the patient has a BMI of 45. What does this indicate?
The patient is extremely obese.
You are taking a health history on an adult patient who is new to the clinic. While performing your assessment, the patient informs you that her mother has type 1 diabetes. What is the primary significance of this information to the health history?
The patient may be at risk for developing diabetes.
A 51-year-old womans recent complaints of fatigue are thought to be attributable to iron-deficiency anemia. The patients subsequent diagnostic testing includes quantification of her transferrin levels. This biochemical assessment would be performed by assessing which of the following?
The patients serum
A registered nurse is performing the admission assessment of a 37-year-old man who will be treated for pancreatitis on the medical unit. During the nursing assessment, the nurse asks the patient questions related to his spirituality. What is the primary rationale for this aspect of the nurses assessment?
The patients spiritual environment can affect his response to illness.
During a health assessment of an older adult with multiple chronic health problems, the nurse practitioner is utilizing multiple assessment techniques, including percussion. What is the essential principle of percussion?
To create vibration in a body wall
In the course of performing an admission assessment, the nurse has asked questions about the patients first- and second-order relatives. What is the primary rationale for the nurses line of questioning?
To identify diseases that may be genetic
You are performing a dietary assessment with a patient who has been admitted to the medical unit with community-acquired pneumonia. The patient wants to know why the hospital needs all this information about the way he eats, asking you, Are you asking me all these questions because I am Middle Eastern? What is your best response to this patient?
We know that some cultural and religious practices include dietary guidelines, and we do not want to violate these.
You are the emergency department nurse obtaining a health history from a patient who has earlier told the triage nurse that she is experiencing intermittent abdominal pain. What question should you ask to elicit the probable reason for the visit and identify her chief complaint?
What brings you to the hospital today?
You are conducting an assessment of a patient in her home setting. Your patient is a 91-year-old woman who lives alone and has no family members living close by. What would you need to be aware of to aid in providing care to this patient?
What resources are available to the patient
You are performing the admission assessment of a patient who is being admitted to the postsurgical unit following knee arthroplasty. The patient states, Youve got more information on me now than my own family has. How do you manage to keep it all private? What is your best response to this patients concern?
Your information is maintained in a secure place and only those health care professionals directly involved in your care can see it.
