Nursing 101 5 & 14
The nurse is caring for a Mexican American who is Catholic. The nurse wishes to learn more about the culture by consulting a key informant. Which of the following religious practitioners would be most knowledgeable about the beliefs held by individuals of Mexican ethnicity? A) A church mother B) A voodoo priest C) A curandera D) A peyote leader
A curandera
Which of the following guidelines should a nursing instructor provide to nursing students who are now responsible for assessing their clients? A) "Assessment data about the client should be collected continuously." B) "Assess your client after receiving the nursing report and again before giving a report to the next shift of nurses." C) "Assess your client at least hourly if the client's vital signs are unstable, and every two hours if the vital signs are stable." D) "Assessment data should be collected prior to the physician rounding on the unit."
A) "Assessment data about the client should be collected continuously."
Which of the following examples of client data needs to be validated? Select all that apply. A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall. C) A nurse examining a client with a respiratory infection documents fever and chills. D) A client in a nursing home states that she is unable to eat the food being served. E) A pregnant client is experiencing contractions that are two minutes apart.
A) A client has trouble reading an informed consent, but states he does not need glasses. B) An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
After assessment of a client in an ambulatory clinic, the nurse records the data on the computer. The nurse recognizes which of the following as objective data? A) Auscultation of the lungs B) Complaint of nausea C) Sensation of burning in her epigastric area D) Belief that demons are in her stomach
A) Auscultation of the lungs
All of the following are factors to consider when caring for clients with limited income. Which one is the most important? A) Basic human needs may go unmet B) Limited access to reliable transportation C) Decreased access to health care services D) Risk for increased incidence of disease
A) Basic human needs may go unmet
The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next? A) Clarify discrepancies of assessment data with the client. B) Validate client data with members of the health care team. C) Document all data collected in the nursing history and physical examination. D) Seek input from family members regarding the client's breathing at home.
A) Clarify discrepancies of assessment data with the client.
A client is brought to the emergency department in an unconscious condition. The client's wife hands over the previous medical files and points out that the client had suddenly fallen unconscious after trying to get out of bed. Which of the following is a primary source of information? A) Client's wife B) Medical documents Test results D) Assessment data
A) Client's wife
Which of the following are examples of common factors in a client that may influence assessment priorities? Select all that apply. WWW.NURSINGTESTBANKSWORLD.COM A) Diet and exercise program B) Standing in the community C) Ability to pay for services D) Developmental stage E) Need for nursing
A) Diet and exercise program B) Standing in the community D) Developmental stage E) Need for nursing
A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the nurse provides an erroneous interpretation. What is a corrective action for this interpretation? A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward. B) Encourage the novice nurse to develop his or her own tool for data collection. C) Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the novice nurse arrives at the correct interpretation. D) Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek mentoring for communication skills.
A) Encourage the novice nurse to independently observe the same situation with a peer, validate the data, and discuss the situation afterward.
The nurse is using a systematic approach to the collection of assessment data. The nurse uses an assessment guide that uses a hierarchy of five life requirements universal to all persons. What model for organizing the assessment data is the nurse using? A) Human Needs (Maslow) model B) Functional Health Patterns model C) Human Response Patterns model D) Body System model
A) Human Needs (Maslow) model
The nurse observes the client as he walks into the room. What information will this provide the nurse? A) Information regarding the client's gait B) Information regarding the client's personality C) Information regarding the client's psychosocial status D) Information on the rate of recovery from surgery
A) Information regarding the client's gait
The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures
A) Measure the client's oral temperature.
The nurse has entered a client's room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference? A) Measure the client's oral temperature. B) Ask a colleague for assistance. C) Give the client a clean gown and warm blankets. D) Obtain an order for blood cultures.
A) Measure the client's oral temperature.
A nursing instructor has assigned a student to care for a client of Asian descent. The instructor reminds the student that personal space considerations vary among cultures. What personal space preferences are important for the student to consider when caring for this client? A) People of Asian descent prefer some distance between themselves and others. B) People of Asian descent commonly stand close to one another when talking. C) People of Asian descent touch one another when sitting next to a familiar person. D) People of Asian descent prefer direct eye contact when communicating
A) People of Asian descent prefer some distance between themselves and others.
An unconscious patient is brought to the emergency department. Which of the following assessments should be implemented first? A) The client's airway should be assessed. B) The nurse should determine the reason for admission. C) The nurse should review the client's medications. D) The client's past medical history is assessed.
A) The client's airway should be assessed.
Which of the following data regarding a client with a diagnosis of colon cancer are subjective? Select all that apply. A) The client's chemotherapy causes him nausea and loss of appetite. B) The client became teary when his daughter from out of state came to the bedside. C) The client's ileostomy put out 125 mL of effluent in the past four hours. D) The patient is unwilling to manipulate or empty his ostomy bag. E) The patient has been experiencing fatigue in recent weeks.
A) The client's chemotherapy causes him nausea and loss of appetite. E) The patient has been experiencing fatigue in recent weeks
A nurse who collected and organized data during a client history realizes that there is not enough information to plan interventions. Which of the following would be the best remedy to prevent this from happening in the future? A) The nurse should practice interviewing strategies. B) The nurse should modify data collection tool. C) The nurse should determine specific purpose of data collection. D) The nurse should update the database.
A) The nurse should practice interviewing strategies.
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident's ability to breathe and then begins CPR. Why did the nurse assess respiratory status? A) To identify a life-threatening problem B) To establish a database for medical care C) To practice respiratory assessment skills D) To facilitate the resident's ability to breathe
A) To identify a life-threatening problem
When documenting subjective data, the nurse should do which of the following? A) Use the client's own words placed in quotation marks. B) Paraphrase the information stated by the client. C) Validate the information with the client's family prior to documentation. D) Record the information using nonspecific words.
A) Use the client's own words placed in quotation marks.
When providing nursing care to an African American individual, which of the following cultural factors should the nurse consider? A) Values and beliefs are often present oriented. B) Families are usually patriarchal. C) They possess weak religious affiliations. D) Families are highly competitive.
A) Values and beliefs are often present oriented.
A male nurse is preparing to take the vital signs of a female patient. Which ethnic group would consider this improper? A) Native American B) Arab Muslim C) White D) African American
Arab Muslim
An Asian American male client is operated on for gallstones. On the postoperative night, the nurse finds that the client is not sleeping and is tossing and turning. When asked about analgesics, the client expresses that he does not have pain. What nursing action is most appropriate? A) Believing that the client has no pain B) Assessing for non-verbal expressions of pain C) Inspecting the incision site for any abnormality D) Asking the client if he is feeling hungry
Assessing for non-verbal expressions of pain
Which of the following questions or statements would be appropriate in eliciting further information when conducting a health history interview? A) "Why didn't you go to the doctor when you began to have this pain?" B) "Are you feeling better now than you did during the night?" C) "Tell me more about what caused your pain." D) "If I were you, I would not wait to get medical help next time."
B) "Are you feeling better now than you did during the night?"
Which of the following questions or statements would be an appropriate termination of the health history interview? A) "Well, I can't think of anything else to ask you right now." B) "Can you think of anything else you would like to tell me?" C) "I wish you could have remembered more about your illness." D) "Perhaps we can talk again sometime. Goodbye."
B) "Can you think of anything else you would like to tell me?"
A Mexican immigrant who migrated to the United States and lives in a Spanish-speaking community with other relatives is taken to the ER following a fall at work. He is admitted to the hospital for observation. The nurse is aware tht this client is at risk for: A) Cultural assimilation B) Cultural shock C) Cultural imposition D) Cultural blindness
B) Cultural shock
When the nurse inspects a postoperative incision site for infection, which one of the following types of assessments is being performed? A) Complete B) Focused C) General D) Time-lapse
B) Focused
A client comes to her health care provider's office because she is having abdominal pain. She has been seen for this problem before. What type of assessment would the nurse do? A) Initial assessment B) Focused assessment C) Emergency assessment D) Time-lapsed assessment
B) Focused assessment
A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client's vital signs, pupils, and orientation every few minutes. The nurse is performing which type of assessment? A) Initial assessment B) Focused assessment C) Time-lapsed reassessment D) Emergency assessment
B) Focused assessment
The nurse caring for a Native American client plans care understanding that one belief of Native American healing practices is which of the following? A) Modern life facilitates healing agents. B) Healing takes time. C) Balancing yin and yang is important. D) Energy flows through meridians throughout the body.
B) Healing takes time.
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment and records the vital signs. Which of the following data collected can be classified as subjective data? A) Blood pressure B) Nausea C) Heart rate D) Respiratory rate
B) Nausea
A nurse is collecting data from a home care client. In addition to information about the client's health status, what is another observation the nurse should make? A) Number of rooms in the house B) Safety of the immediate environment C) Frequency of home visits to be made D) Friendliness of the client and family
B) Safety of the immediate environment
A nurse is conducting a health history interview for a woman at an assisted-living facility. The woman says, "I have been so constipated lately." How should the nurse respond? A) "Do you have a family history of chest problems?" B) "Why don't you use a laxative every night?" C) "Do you take anything to help your constipation?" D) "Everyone who ages has bowel problems."
C) "Do you take anything to help your constipation?"
A nurse is collecting information from a client with dementia. The client's daughter accompanies the client. Which of the following statements by the nurse would recognize the client's value as an individual? A) "Can you tell me how long your father has been this way?" B) "Sarah, I have to go and read your father's old charts before we talk." C) "Mr. Koeppe, tell me what you do to take care of yourself." D) "Mr. Koeppe, I know you can't answer my questions, but it's okay."
C) "Mr. Koeppe, tell me what you do to take care of yourself."
The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what? A) Subjective data B) A data cue C) An inference D) Primary data
C) An inference
An older adult woman of Chinese ancestry refuses to eat at the nursing home, stating, "I'm just not hungry." What factors should the staff assess for this problem? A) The woman does not like to eat with other residents of the home. B) The woman is using this as a means of going home. C) The food served may not be culturally appropriate. D) The food served may violate religious beliefs.
C) The food served may not be culturally appropriate.
While bathing the client, the nurse observes the client grimacing. The nurse asks if the client is experiencing pain. The client nods yes and refuses to continue the bath. The nurse removes the wash basin, makes the client comfortable, and documents the event in the client's chart. Which of the following actions clearly demonstrates assessing? A) The nurse bathing the client B) The nurse documenting the incident C) The nurse asking if the client is having pain D) The nurse removing the wash basin
C) The nurse asking if the client is having pain
A nurse performs an assessment of a client in a long-term care facility and records baseline data. The nurse reassesses the client a month later and makes revisions in the plan of care. What type of assessment is the second assessment? A) Comprehensive B) Focused C) Time-lapsed D) Emergency
C) Time-lapsed
A nurse performing triage in an emergency room makes assessments of clients using critical thinking skills. Which of the following are critical thinking activities linked to assessment? Select all that apply. A) Carrying out a physician's order to intubate a client B) Educating a novice nurse on the principles of triage C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia
C) Using the nursing process to diagnose a blocked airway D) Interviewing privately a client suspected of being a victim of abuse E) Checking with the family about the data supplied by a client suffering from dementia
Of the following information collected during a nursing assessment, which are subjective data? A) vomiting, pulse 96 B) respirations 22, blood pressure 130/80 C) nausea, abdominal pain D) pale skin, thick toenails
C) nausea, abdominal pain
The nurse is admitting a client from China to the medical-surgical unit with a diagnosis of cancer. While doing the client's assessments, the client speaks of her naturalistic beliefs related to health care and the importance of the yin/yang theory. Based on her cancer diagnoses, the idea that cancer is considered a cold illness in the culture, 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 B) Turkey sandwich, small tossed salad, and iced tea C) Chef's salad, bread, and water D) Fruit smoothie and granola bar
Chicken noodle soup with crackers, fruit crisp, and hot tea
A father, mother, grandmother, and three school-aged children have immigrated to the United States from Thailand. Which member(s) of the family are likely to learn to speak English more rapidly? A) Unemployed father B) Stay-at-home mother C) Grandmother D) Children
Children
A nurse engages in professional rituals as a means to standardize practice and ensure efficiency. In doing so, the nurse integrates understanding of which of the following as a characteristic? A) Preconceived and untested belief about people B) Viewing one's own culture as the only correct standard C) Common and observable expressions of culture D) Belief system held to varying degrees as absolute truth
Common and observable expressions of culture
Despite the presence of a large number of elderly residents of Asian heritage, a long-term care facility has not integrated the Asian concepts of hot and cold into meal planning. Which of the following should the nurses at the facility recognize this as an example of? A) Cultural blindness B) Stereotyping C) Cultural assimilation D) Cultural imposition
Cultural blindness
What is the term that describes the inability of a person to recognize his or her own values, beliefs, and practices as well as those of others, because of strong ethnocentric tendencies? A) Acculturation B) Cultural blindness C) Cultural imposition D) Stereotyping
Cultural blindness
A nurse is providing care for a Cambodian client. The nurse says, "You have to get up and walk whether you want to or not." What is this statement an example of? A) Culture shock B) Stereotyping C) Cultural imposition D) Cultural competence
Cultural imposition
A nurse walks by a client's room and observes a Shaman performing a healing ritual for the client. The nurse then remarks to a coworker that the ritual is a waste of time and disruptive to the other clients on the floor. What feelings is this nurse displaying? A) Culture conflict B) Cultural blindness C) Stereotyping D) Cultural shock
Culture conflict
A nurse in the emergency department is completing an emergency assessment for a teenager just admitted from a car crash. Which of the following is objective data? A) "My leg hurts so bad. I can't stand it." B) "Appears anxious and frightened." C) "I am so sick; I am about to throw up." D) "Unable to palpate femoral pulse in left leg."
D) "Unable to palpate femoral pulse in left leg.
A nurse is caring for a client from Taiwan who constantly requests pain medication. What should the nurse consider when assessing the client's pain? A) Most people react to pain in the same way. B) Pain in adults in less intense than pain in children. C) The client has a low pain tolerance. D) Pain is what the client says it is.
D) Pain is what the client says it is.
The nurse completes a health history and physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment? A) To gather data about a specific and current health problem B) To identify life-threatening problems that require immediate attention C) To compare and contrast current health status to baseline data D) To establish a database to identify problems and strengths
D) To establish a database to identify problems and strengths
What is the primary purpose of validation as a part of assessment? A) To identify data to be validated B) To establish an effective nurse-client communication C) To maintain effective relationships with coworkers D) To plan appropriate nursing care
D) To plan appropriate nursing care
A nurse is preparing to conduct a health history for a client who is confined to bed. How should the nurse position herself? A) Standing at the end of the bed B) Standing at the side of the bed C) Sitting at least six feet from the beside D) sitting at a 45-degree angle to the bed
D) sitting at a 45-degree angle to the bed
A nurse is caring for an elderly woman from a far eastern culture. How does the nurse demonstrate awareness of culturally competent care? A) Maintaining eye contact at all times. B) Trying to speak louder than usual. C) Using touch when communicating. D) Establishing effective communication.
Establishing effective communication.
A client who has difficulty sleeping expresses to the nurse that watching television may help him relax and get sleep. The nurse disregards the client's concern and suggests drinking warm milk before going to bed. Which cultural characteristic is the nurse demonstrating? A) Stereotype B) Ethnocentrism C) Racism D) Relativity
Ethnocentrism
The nurse is admitting a new client to the unit. The nurse notes that this client would need an alternate meal choice when the menu specified pork for a meal. What cultural group would require an alternative meal choice? A) Christian B) Protestant C) Muslim D) Mormon
Muslim
Personal space and distance is a cultural perspective that can impact nurse-client interactions. What is the best way for the nurse to interact physically with a client who has a different cultural perspective on space and distance? A) Know the client's cultural personal space preferences. B) Realize that sitting close to the client is an indication of warmth and caring. C) Sit three to six feet away from the patient in an attempt to not offend. D) Remember not to intrude into the personal space of the elderly.
Know the client's cultural personal space preferences.
The nurse is obtaining a health history from a patient of Puerto Rican descent. Which of the following is most likely to be a health problem that has a cultural connection for this patient? A) Lactose enzyme deficiency B) Tuberculosis C) Sickle cell anemia D) Suicide
Lactose enzyme deficiency
The nurse is providing home care for a client who traditionally drinks herbal tea to treat an illness. How should the nurse respond to a request for the herbal tea? A) We do not allow our clients to drink herbal tea. B) Why in the world would you want to drink that stuff? C) Let me check with the doctor to make sure it is okay to drink the tea with your medicines. D) I have to fill out a lot of forms that you will have to sign before I can do that.
Let me check with the doctor to make sure it is okay to drink the tea with your medicines.
An Anglo American client reports to the primary health care facility with symptoms of fever, cough, and running nose. While interviewing the client, which of the following points should the nurse keep in mind? A) Do not probe into emotional issues. B) Do not ask very personal questions. C) Sit at the other corner of the room. D) Maintain eye contact while talking.
Maintain eye contact while talking.
Most nurses have been taught to maintain direct eye contact when communicating with clients. Some cultural groups would not value direct eye contact with the nurse. Which cultural group would consider the direct eye contact impolite? A) Americans B) British C) Canadians D) Native Americans
Native Americans
When the South Asian client arrives 25 minutes late to her appointment at the clinic, the nurse recognizes this as a sign of which of the following? WWW.NURSINGTESTBANKSWORLD.COM A) Disrespect B) Laziness C) Respect D) Superiority
Respect
The client in a rehabilitation unit is having a difficult time adjusting to the scheduled activities on the unit, as well as being dependent on others for meals and medications. Which word best describes what the patient is experiencing? A) Anxiety B) Disparity C) Resolution D) Shock
Shock
When a labor and delivery nurse tells a coworker that an Asian client probably did not want any pain medication because "Asian women typically are stoic," the nurse is expressing a belief known as what? A) Stigma B) Ethnic slur C) Bias D) Stereotype
Stereotype
A nurse is caring for a client after internal fixation of a compound fracture in the tibia. The nurse finds that the client has not had his dinner, seems restless, and is tossing on the bed. Keeping in mind that the client is Latino, what is the most appropriate response by the nurse? A) Are you having pain in your leg? B) Tell me what you are feeling. C) Do you need pain medication? D) Are you feeling all right?
Tell me what you are feeling.
A home health nurse is visiting a client 60 years of age. During the initial visit, the client's husband answers all of the questions. What would the nurse assess based on this behavior? A) The client does not want the nurse to visit. B) The husband does not trust his wife to answer questions. C) The cltient is not able to answer the questions. D) The husband is the dominant member of the family.
The husband is the dominant member of the family.
When providing care on an Indian reservation, the nurse has prioritized assessments for diabetes and fetal alcohol syndrome when working with residents of the reservation. How should this nurse's practice be best understood? A) The nurse is correct in assessing for health problems that have a higher incidence and prevalence among this population. B) The nurse is stereotyping American Indians as leading unhealthy lifestyles and abusing alcohol. C) The nurse is performing cultural imposition of the majority American culture, and the accompanying beliefs around diabetes and alcohol use. D) The nurse should seek specific permission from each client before proceeding with these assessments.
The nurse is correct in assessing for health problems that have a higher incidence and prevalence among this population.
A nurse in a large metropolitan city enjoys working in a health clinic that primarily serves Hispanic clients. What does this statement imply about the nurse? A) The nurse's knowledge and skills are not adequate to care for clients with acute illnesses. B) The nurse respects and values providing culturally competent care. C) The nurse is attempting to overcome cultural blindness. D) This employment makes the nurse feel superior to a minority group of people.
The nurse respects and values providing culturally competent care.
The focal point of nursing is the nurse-client interaction. What must nurses consider when conducting the necessary assessment of their clients and significant others? A) Their health disparities B) Their societal beliefs C) The subgroup they belong to D) Their own cultural orientation.
Their own cultural orientation.
A 40-year-old nurse is taking a health history from a Hispanic man aged 20 years. The nurse notes that he looks down at the floor when he answers questions. What should the nurse understand about this behavior? A) The client is embarrassed by the questions. B) This is culturally appropriate behavior. C) The client dislikes the nurse. D) The client does not understand what is being asked.
This is culturally appropriate behavior.
A nurse in the hospital is caring for a Native American male. What person is most important to include in the care of the client? A) Family B) Physician C) Tribal medicine man D) Physical therapy aide
Tribal medicine man
