PrepU - Exam 2
A new graduate nurse from a small community college is going to work in an urban setting. She embraces the thought of working in a more diverse setting and wants to learn about different cultures. What behavior is this nurse exhibiting?
Cultural desire
A male nurse is caring for an elderly woman who has become withdrawn and somewhat confused since the nurse has come on duty. When the nurse goes into the room to bathe the client, she refuses to allow it. The best explanation for her actions would be which of the following?
Cultural differences
Based on findings during assessment, a nurse asks a client to fill out a danger assessment questionnaire. Which of the following is the best rationale for this intervention?
Determine the client's risk for becoming a victim of homicide
The nurse assesses a client for exposure to violence. Which question that is answered affirmative indicates that the client has been abused? Select all that apply.
Do you feel unsafe in your home? Are you afraid of anyone in your home? Has anyone in your home ever hurt you? Has anyone ever threatened you in public?
During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?
Either side of the frenulum on the floor of the mouth
The nurse is caring for a woman in the prenatal clinic who comments that she just cannot seem to get things "right" anymore at home and that her husband says she knows so little about life. Which type of abusive or controlling behavior is the woman describing?
Emotional abuse
The spouse of a client believed to be a victim of intimate partner violence refuses to leave the room for the nurse to complete an assessment. What should the nurse do first?
Ensure for personal safety
The frontal sinuses are the only ones readily accessible to clinical examination.
False
The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the
Frenulum
When the nurse tells the client that she will return in 1 hour to administer an intravenous antibiotic, the nurse is showing that she values time in which of the following orientations?
Future
A client presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The client describes these as painful. The nurse suspects what condition?
Herpes Simplex
A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?
How to reduce periodontal disease
Because the nurse realizes that spirituality varies, information gained will assist the nurse in
Individualizing interventions to meet specific needs
Johnny is a 5-year-old boy who comes to the clinic for his scheduled injections. Which physical indications would lead you to suspect child abuse?
Irregular pattern of small circular reddened areas with healing blisters on various parts of the body
A client arrives at the clinic accompanied by her husband. When the client is in the examination room she says to the nurse, "He loves me so much. He only lets me go out when he is with me because he says other men look at me." What type of behavior is this husband exhibiting?
Isolation
The emergency department nurse is assessing a female client with traumatic injuries. To assess whether or not the client's injuries have resulted from abuse, which question would be most appropriate for the nurse to ask the client?
It looks like someone has hurt you. Tell me about it
A client who followed Judaism has died. What should the nurse do to ensure for this client's end-of-life care and burial?
Keep all bandages with the clients blood
The nurse wants to support a client's spirituality. To do so, what must the nurse do first?
Keep an objective perspective and meet the client at his or her level
A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?
Kiesselbach's plexus
After completing a spiritual assessment, a nurse determines that the client has signs and symptoms requiring medical diagnosis and treatment. What should the nurse do?
Make a referral to a primary care provider
A nurse is performing a spiritual assessment on a client that is diagnosed with aggressive form of lymphoma. What is the best intervention by the nurse to address the client's spiritual end of life issues if she is unable to?
Make a referral to the appropriate professional.
The nurse is interviewing Mr. Jenkins and, due particularly to his nervous affect and his reaction when his son is mentioned, suspects potential elder abuse. In assessing Mr. Jenkins, the nurse should
Make sure that the assessment includes questions to ensure that Mr. Jenkins has access to food and needed medication
Sickle cell disease and other hemoglobinopathies such as thalassemia are often found in persons originating from which geographical regions?
Mediterranean and Africa
The nurse notes that an adolescent male has ptosis of the left eye. What should the nurse suspect as the reason for this finding?
Nerve damage caused by repeated eye injuries
During a client interview, the nurse is focusing on cultural influences particularly when assessing: (Select all that apply.)
Nutrition Health care beliefs and practices High-risk behaviors
A client of a different culture than the nurse is enjoying the afternoon in the park playing with her daughter. She later arrives 30 minutes late to her doctor's appointment and does not understand the problem when the receptionist tells the client that she will have to reschedule. This client views time in which context?
Present
After completing an admission assessment the client asks if the room door can be closed so that the client can have silence when reading the Bible. What does this indicate to the nurse about the client's spirituality?
Reading the Bible provides comfort to the client
The nurse is preparing to do a spiritual assessment for a newly admitted client with a diagnosis of pancreatic cancer. Prior to performing the assessment, what defining characteristic of the spiritual assessment should the nurse understand? (Select all that apply)
Respectful Non-biased
When the nurse asks a client of African origin for the reason for coming to the health clinic, the client responds by saying, "Bad blood." The nurse recognizes that the client is most likely referring to which of the following?
Sexually transmitted infection
A nursing student realizes that which of the following is an important variation of communication?
Silence
When the nurse is attempting to demonstrate nursing presence, which intervention would be most therapeutic?
Sitting with the client as he or she shares feeling about being ill
The nurse reviews data collected while completing a spiritual assessment with a client. Which data should the nurse focus as the primary source of information for this assessment?
Subjective
The nurse observes the spouse of a client pinch the client's arm when someone talks with the client in the waiting room of the community clinic. What should this observation indicate to the nurse?
The client is not permitted to have contact with others
The nurse is caring for a first-time mother and newborn in the postpartum unit. The nurse overhears the new mother ask family members to prepare the nursery and purchase clothing for the baby. What would the culturally sensitive nurse suspect?
The new mother may believe buying infant clothing before the delivery is bad luck.
What must occur before a client will be willing to teach the nurse about her culture?
The nurse needs to establish rapport and trust
The nurse is evaluating the older adult at risk for post-trauma syndrome. Which outcome would be expected?
The older adult denies problems with sleeping?
The nurse prepares to complete a spiritual assessment with a client. What should the nurse keep in mind when completing this assessment?
The reason is to better understand the client's spiritual perspective related to health
A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis?
Torus palatinus
An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are
Touching each other
A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely?
acute bacterial sinusitis
On examining a client, the nurse detects a sulfur odor to the breath. The nurse recognizes this finding as a characteristic of which disease process?
end stage liver disease
A nurse is aware that religion can sometimes negatively affect health. Which of the following is an example?
failure to seek timely and proper medical care
The nurse reviews data collected on a client who is being admitted again for treatment of injuries caused by intimate partner violence. Which diagnosis should the nurse identify as being the most appropriate for this client?
low self-esteem
The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the
maxillary sinuses
The nurse and a client are developing a transcultural nursing care plan related to hypertension. The nurse will include in the plan
nutritional information specifically for the client's culture
What is the common channel for the respiratory and digestive systems?
oropharynx
The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion?
overuse of nasal spray may cause rebound congestion
Which characteristic demonstrates the nurse's understanding and practice of cultural competent nursing? Select all that apply.
states, "I'm really interested in learning about the dietary practices of the Hasidic Jews." recognizes the need to provide all clients holistic care
What aspects of culture are relevant when conducting a health assessment on a foreign-born client admitted for surgery? Select all that apply.
whether there are any existing language barriers nutritional or dietary considerations alternative medicine practices
Which statement by the nurse demonstrates a cultural bias?
"American healthcare is really so much better than that provided by any other country."
Which statement by the nurse demonstrates an understanding of the importance that a client's culture plays in the client's health and wellness?
"I need to understand the clients cultural background to best interpret the client's needs
The client states his pain is "intolerable" and requests pain medication. The nurse observes the client to be talking and laughing with visitors. How should the nurse best respond?
"I will be back with your pain medication."
A 4-year-old has been sexually abused. As you watch her play with anatomically correct dolls, she inserts the male doll's penis into the female doll's mouth. What is your best response to this action?
"What are the dolls doing?"
What open-ended question might be helpful when assessing abuse with a client demonstrating discomfort discussion the issue?
"What would you like me to know"
A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase 3 of the cycle of violence?
'He tells me that he is sorry and that he will never hit me again."
A nurse has a regular client who is an immigrant from China and who follows the traditional medical system of that culture. To improve the ability to understand and work with this client, the nurse researches this client's cultural view of health. Which of the following would the nurse most likely discover?
A focus on maintaining balance between yin and yang
A client with cancer is talking to the primary nurse about the diagnosis and states, "I feel like it is God's will that I have this cancer. If I get out of the hospital, I want to take nature walks like I used to before I got so sick. I feel so close to God when I do this." The nurse understands that this client is demonstrating which of the following?
Acceptance of the diagnosis
Which approach would be most appropriate when counseling a woman who is a suspected victim of violence?
Ask, "Have you ever been physically hurt by your partner?"
A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?
B12
What are some basic rules for nurses to follow when assessing for violence? Select all that apply
Be very patient when the client talks Demonstrate compassion, not judgement Perform assessment and screening only when the client is alone in a safe, private environment
Which of the following statements is true about biologic variation?
Both genetics and environment produce biologic variation
