PT Education; Skin Integrity; Culture; Spiritual
When assess a client who is receiving palliative care, which question regarding spiritual health is correct?
What is your source of spiritual strength during hard times? 😼Rationale: This helps the nurse undestand the client's spiritual practices, facilitating quality care.
Which medication is the first-line for acne in adolescents? Tretinoin Doxycyline Clindamycin Benzoyl peroxide
Benzoyl peroxide 😼Rationale: ➥Benzoyl peroxide is an effective first-line medication used to treat acne in asloescents; this medication is effective against inflemmatory & noninflammatory acne. ☙Tretinoin, Doxycyline, & Clindamycin are also used to treat acne, but they are no first-line agents.
A pregnant client states, "Abortion is banned in our community because it interferes with God's creative work." According to the nurse, which variable influences the client's health belief? ◘ Emotional factors ◘ Cultural background ◘ Socioeconomic factors ◘ Perception of functioning
Cultural background 😼Rationale: This statement is an example of the influence of cultural background on health beliefs.
Which action would the nurse therapist take when the father of an autistic child states that the family members wish to share their religious beliefs with the therapist? ◘ Ask father if religious beliefs relate to the child's autism. ◘ Include the mutual discussion of religious beliefs ◘ Invite the family's religious leader to a therapy session. ◘ Encourage discussion of their religion in the sessions.
Encourage discussion of their religion in the sessions 😼Rationale: ➥ If the religious beliefs are a family concern, the nurse should encourage discussion of their thoughts & feelings; ➥This would include the relationship of religious beliefs to the child's autism if this topic is important to the family. ◘ The role of the nurse is to facilitate & listen, not participate in a mutual discussion about religious beliefs. ◘ The religious leader is not part of the family unit & should not be invited only if this is requested by the family.
Which response would the nurse give to a newly delivered client who ask to take the placenta home with her upon discharge?
I need to check the hospital protocol for our policy on that practice. 😼Rationale: ➥The placenta is a part of the body & contains body fluids. It must first be assessed by the health care provider to be sure that is is not infected & to be sure that all parts of the placenta have been accounted for. ➥The nurse must follow hospital protocal regarding the release of the placenta to the family. ➥All necessary documentation must be signed & the polices must be followed before the release.
Which behavioral observation indicates normal spiritual development (according to Fowler) of a school-age child? ◘ The Child imitates the religious gestures of elders ◘ The child does not differentiate between right & wrong actions ◘ The child has spiritual disappointment & modifies religious practices. ◘ The child believes God will punish bad behavior & reward good behavior
The child believes God will punish bad behavior & reward good behavior 😼Rationale: This indicates hat teh child is in the mythical-literal stage of Fowler's spiritual development
A mother whose son has acute glomerulonephritis (AGN) is fearful that her other children may contact the disorder. What response would the nurse tell the mother about the origin of AGN?
It is a result of an autoimmune response after a streptococcal infection
Which action would the nurse take when a client is a member of a different ethic community? ◘ Ensure that the nurse's biases are understood by the family. ◘ Make plans to counteract the client's misconceptions about therapies. ◘ Offer a therapeutic regimen compatible with the lifestyle of the family. ◘ Recognize that the client's responses will be similar to other clients' responses.
Offer a therapeutic regimen compatible with the lifestyle of the family. 😼Rationale: ➥The pt cannot be expected to accept or even respond to a plan that is incompatible with the family's lifestyle. ◘ The family should not have to adjust to the nurse's biases; The nurse must self-identify biases & ensure that they do not interfere with nursing care. ◘ All individuals want good nursing care, but the perception & ideas of what constitutes good care may be different.
The school nurse works with adolescents who recently immigrated to the United States and are adjusting to life in public school.
Students who assimilate abandon all aspects of their original culture.
The preschool-age client is learning sociocultural mores. ◘ The child is developing a conscience. ◘ The child is learning about gender roles. ◘ The child is developing a sense of security. ◘ The child is learning about the political process.
The child is developing a conscience. 😼Rationale: ➥Learning the sociocultural mores of the family implies that the child is developing a conscience. ◘ This does not imply that the child is learning gender roles, developing a sense of security, or learning about the political process.
Which risk would the nurse consider when providing care for a client in the acute phase of treatment for a full-thickness burn? ◘ The risk of septicemia and its potential complications from treatment ◘ The risk of psychosocial adjustments and resuming previous roles ◘ The risk of oral mucous membrane injury and its associated risks ◘ The risk of insufficient community resources and emotional support
The risk of septicemia and its potential complications from treatment 😼Rationale: ➥Skin is the first line of defense against infection. When much of it is destroyed, the client is vulnerable to infection. ☙Complications, such as infection and contractures, still may occur during the acute phase and as the client is healing. ☙Psychosocial adjustments, previous roles, and insufficient community resources are priorities in the rehabilitative phase. ☙Risk of oral mucous membrane injury is in the emergent (resuscitation) stage. Emotional support is provided in all three phases.
What explanation would the nurse provide to a client with gastric ulcer disease who asks the nurse why the health care provider has prescribed metronidazole?
To treat Helicobacter pylori infection 😼Rationale: ➥Approximately two-thirds of clients with peptic ulcer disease are found to have Helicobacter pylori infecting the mucosa & interfering with its protective function.
Which strategy would the nurse teach the parents of a child who is being discharged from the hospital after a diagnosis of acute spasmodic laryngitis to help prevent another croup episode?
Using a cool mist vaporizer in the child's room 😼Rationale: ➥Cool mist provides humindification
Which behavior is most likely to be a cultural manifestation of the survivors' grief response immediacy after a man dies? ◘ Youngest daughter holds the children ◘ Wife weeps, moans, and calls out his name ◘ Oldest son takes charge of notifying others ◘ Oldest daughter looks stunned and shocked
Wife weeps, moans, and calls out his name 😼Rationale: The wife is fully expressing her grief, & the degree of anuish & the mode of expression is most often set or imposed by the cultural background.
Which side effects are associated with systemic antibiotic therapy for acne in adolescents? ◘ Arthralgia ◘ Nasal irritation ◘ Photosensitivity ◘ Vaginal candidiasis ◘ Decreased night vision
◘ Photosensitivity ◘ Vaginal candidiasis 😼Rationale: ➥Systemic antibiotic therapy may cause photo-sensitivity & vaginal candidiasis. ☙Arthralgia, nasal irritation, & decreased night vision are side effects of isotretinoin.
Which methods qualify as alternative therapies for pain? (Select all the apply) ◘ Prayer ◘ Hypnosis ◘ Medication ◘ Aromatherapy ◘ Guided imagery
◘ Prayer ◘ Hypnosis ◘ Aromatherapy ◘ Guided imagery 😼Rationale: ➥ Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. ➥ The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. ➥Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. ➥ Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. ◘ Analgesics, both opioid and non-opioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.
Normal vaginal pH ◘ 4.2 ◘ 6.8 ◘ 7.5 ◘ 9.3
4.2 😼Rationale: ➥Normal vaginal pH ranges from 3.5 to 5. ↬Clients with higher vaginal pH (6.8. 7.5, & 9.3) are more prone to infections.
Intravenous (IV) fluid replacement of 7200mL during the first 24hrs has been prescribed for a client with serve burns. Fifty oercent of the fluid replacement will be administered in the first 8 hours; the the remaning 50% given over the next 16hours. How many milliliters per hour will the nurse infuse during the first 8 hours? (Record using whole #)
450mL/hr 😼Rationale: ➥50% of the total volume to be infused is 3600mL The total time of the infusion is 8hrs 3600mL/8hrs = 450mL/h
A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? ◘ Prejudice ◘ Stereotyping ◘ Assimilation ◘ Ethnocentrism
Assimilation 😼Rationale: ➥Assimilation involves incorporating the behaviors of a dominant culture. ➥Maintaining eye contact is characteristic of the American or Canadian culture and not of Asian cultures. ◘ Prejudice is a negative belief about another person or group and does not characterize this behavior. ◘ Stereotyping is the perception that all members of a group are alike. ◘ Ethnocentrism is the perception that one's beliefs are better than those of others.
Which is the most appropriate approach for the school nurse to take regrading children who are to be given medications while in school? ◘ Assuring the children that their privacy will be respected ◘ Teaching each class about taking medications in the school setting ◘ Encouraging the children to tell their friends that they are taking a medication ◘ Asking teachers to answer questions when other students ask about medications given in school
Assuring the children that their privacy will be respected 😼Rationale: ➥Children's and adults' confidentiality is protected by privacy laws. ☙Although health classes may address medication as part of its curriculum, the information should be taught on a general, not a personal, level. ☙Children and their teachers should not be encouraged to divulge private information.
The nurse is assessing a Latino-Caribbean client who was brought to the hospital by family members. The family reports the client started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? ◘ Bulimia nervosa ◘ Anorexia nervosa ◘ Shenjing shuairuo ◘ Ataque de nervios
Ataque de nervios 😼Rationale: ◘ Ataque de nervios is a Latino-Caribbean culture-bound syndrome that usually happens in response to specific stressors. ➥This culture-bound syndrome is characterized by crying, uncontrollable spasms, trembling, shouting, dissociation, and trance-like states. ◘ Bulimia nervosa and anorexia nervosa are culture-bound syndromes in the form of eating disorders, but they are not characterized by crying, spasms, and shouting. ◘ Shenjing shuairuo is not associated with the Latino-Caribbean culture; instead, it is associated with Chinese culture.
Which organ is responsible for causing Lyme disease in clients? ◘ Phthirus pubis ◘ Sarcoptes scabiei ◘ Borrelia burgdorferi ◘ Pediculus humanus var. corporis
Borrelia burgdorferi 😼Rationale: ➥Lyme disease is a bacterial infection caused by Borrelia burgdorferi, which is transmitted by ticks. ☙Phthirus pubis causes pediculosis ☙Scabies is caused by Sarcoptes scabiei ☙Pediculus humanus var. corporis also cuases pediculosis
Which client's report indicates acquired immunodeficiency syndrome (AIDS)? ◘ CD4+ T-cell count (750 cells/mm3); HIV disease Positive ◘ CD4+ T-cell count (550 cells/mm3); HIV disease Positive ◘ CD4+ T-cell count (175 cells/mm3); HIV disease Positive ◘ CD4+ T-cell count (450 cells/mm3); HIV disease Positive
CD4+ T-cell count (175 cells/mm3); HIV disease Positive 😼Rationale: ➥The dianosis of AINS requires that the person should be HIV positive & have either a CD4+ T-cell count of less than 200 cells/mm3 (200 cells/(L)) & HIV posistive. Having AIDS-defining illness
A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? ◘ Coin in the umbilicus ◘ Tight diaper over the umbilicus ◘ Binder that encircles the umbilicas ◘ Adhesive tape across the umbilicus
Coin in the umbilicus 😼Rationale: ➥A coin may be dislodged, allowing the infant to put it in his or her the mouth, resulting in a safety issue. ◘ A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. ◘ Cultural beliefs that do not place the infant at risk should not be discouraged.
Which medication would the nurse anticipate incorporating into the plan of care to treat the client bitten by a snake? ◘ Diazepam ◘ Epinephrine ◘ Acetaminophen ◘ Crotalidae polyvalent immune fab (CROFab)
Crotalidae polyvalent immune fab (CROFab) 😼Rationale: ➥CROFab is used for treating a victim bitten by North American pit viper as a part of hospital care. ☙Diazepam is a muscle relaxant used for the treatment of black widow spider bite. ☙Epinephrine is used as a nursing priority for bees & wasps sting ☙Acetaminophen is used for the treatment of fever related to scrpion bite
Why is it important for the nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women?
Different cultural groups favor different essential nutrients 😼Rationale: The nurse would become informed regarding the cultural eating patterns of clients so that foods containing the essential nutrients that are part of these dietary patterns may be included in the diet.
What is a primary teaching point for a pregnant adolescent at the first prenatal clinic visit?
Encouraging her to continue regularly scheduled prenatal care
Which assessment is the most important to make for a dying client and family during the developing awareness stage of grief according to Engel's 6 stages of grieving?
Family's cultural background 😼Rationale: Durig the developing awareness stage of grief, the degree of anguish experienced or expressed is influenced by the cultural background of the individual & family.
A client in the intensive care unit tells the nurse, "NO matter how much you try, I will not be able to recover. NO one can change my destiny." Which religion might the nurse expect the client to practice? ◘ Islam ◘ Judaism ◘ Buddhism ◘ Christianity
Islam 😼Rationale: ➥ The pt might be Muslims because Muslims believe that time of death is fixed & cannot be changed. ◘ Jews do not believe the time of death is fixed & cannot be changed. ◘ Buddhists accept death as the last stage of life ◘ Christians do not believe the time of death is fixed & cannot be changed.
PT asked nurse why is his skin yellow that has jaundice.
Jaundice is an abnormal condition in which the skin appears yellow or yellow-brownish in color due to increased bilirubin in the blood.
Which assessment data would be most important to obtain from Asian-American client with major depressive disorder who maintains traditional cultural beliefs and values? ◘ Dietary proctices ◘ Concept of space ◘ Immigration status ◘ Role within the Family
Role within the Family 😼Rationale: The role within the family is the most important assessment data. If the Asian-American client adheres to traditional Asian practices, the nurse must recognize that the family is the central & most important social force on the individual.
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching & would begin with which aspect of care.
The disease process and breathing exercises 😼Rationale: ➥Clients need to understand the disease process and how interventions, such as breathing exercises, can improve ventilation.
A victim of a car crash tells the nurse, "I don't believe in God anymore now that I'm paralyzed." The nurse asks the client to discuss how the condition has affected the client's ability to express what is important. Which of the spiritual assessment would this question address? ◘ Faith ◘ Vocation ◘ Connectedness ◘ Life and self-responsibility
Vocation 😼Rationale: ➥In discussing how the client's condition has affected his or her ability to express what is important to him or her, the nurse is addressing the vocation aspect of the client's spirituality. ◘ Questions about prayer, religious practices, and the meaning of life address the faith aspect of spirituality. ◘ Questions about community and feeling associated with spiritual practices address the connectedness aspect of spirituality. ◘ Questions about how the paralysis affects the client's next steps and changes in the client's life address the life and self-responsibility aspect of spirituality.
What worker would the nurse consider to be a high risk of developing dermatitis? ◘ Dry cleaners ◘ Dye workers ◘ Lathe operators ◘ Hospital workers ◘ Agricultural workers
◘ Dry cleaners ◘ Dye workers 😼Rationale: ➥Cry cleaners & Dye workers are at high risk of developing dermatitis due to exposure to subtances such as solvents & dye stuffs. ☙Lathe operators are high risk of developing cancer ☙Hospital workers are at greater risk of latex allergies ☙Agricultural workers are high risk of skin cancer
Which client conditions does the nurse associate with bluish-colored mucous membranes? ◘ Edema ◘ Diabetes mellitus ◘ Hemochromatosis ◘ Methemoglobinemia ◘ Cardiopulmonary disease
◘ Methemoglobinemia ◘ Cardiopulmonary disease 😼Rationale: ➥A bluish color of the mucous membranes may indicate methemoglobinemia (the presence of methemoglobin in the blood, which is an oxidized form of hemoglobin) and cardiopulmonary disease in the client. ☙The presence of a white color of the mucous membranes may indicate edema in the client. ☙Diabetes mellitus is associated with a yellow-orange color of the palms and soles. ☙The presence of a brown color of the distal lower extremities may indicate hemochromatosis (deposition of iron salts in the tissues).
What conditions are given a green tag according to triage disaster tag team?
◘ Strains ◘ Sprains ◘ Abrasions 😼Rationale: ➥According to the disaster triage tag system, green tags are applied to clients with strains, sprains, and abrasions. ↬Clients with shock and airway obstruction are marked with red tags according to the disaster triage tag system.
Which statements by the nurse indicates an understanding of caring for clients of various cultures.
☙I should focus on understanding the traditions, beliefs, and values of the client's culture. ☙I should be aware of my own cultural background and beliefs when attending to clients who belong to different cultures.
A nurse from the pediatric clinic who is strongly opposed to any chemical or mechanical method of birth control is asked to work in the family planning clinic. Which response from the nurse to the requesting supervisor would demonstrate professionalism? ◘ I will go, but it is against my beliefs and values. ◘ I won't do it, because I do not believe in birth control at all. ◘ I would prefer another assignment that is not contrary to my beliefs. ◘ I will have to stress that the rhythm method is the method of choice."
I would prefer another assignment that is not contrary to my beliefs. 😼Rationale: ➥ Expressing a preference for another assignment that is not contrary to the nurse's beliefs is a positive negotiation to be reassigned to an area where the nurse's personal values will not pose a problem. ◘ Fulfilling the request even though it is against the nurse's beliefs is an ineffective way to resolve value conflict; undoubtedly a client would sense this conflict. ◘ The nurse may not have the legal, ethical, or professional right to refuse this assignment if employed by the facility. ◘ Stressing that the rhythm method is the method of choice is unethical and unprofessional.
When an African American with renal failure reports the illness is a punishment for sins, which cultural health belief is the client communicating? ◘ Yin/Yang balance ◘ Biomedical belief ◘ Determinism belief ◘ Magicoreligious belief
Magicoreligious belief 😼Rationale: ➥Magicoreligious beliefs focus on hexes or supernatural forces that cause illness. (Such as the client may believe illness is a punishment for sins.) ◘ Yin/Yang belief system does not consider illness as punishment ◘ Biomedical belief system maintains that health & illness are related to physical & biochemical process with disease being a breakdown of the processes. ◘ Determinism focuses on outcomes that are externally preordained & cannot be changed.
Which equipment will the nurse prepare for a client whose burn wounds are scheduled to be debrided mechanically? ◘ Enzymatic agents ◘ Scissors and forceps ◘ Autolytic semiocclusive dressing ◘ Continuous passive-motion device
Scissors and forceps 😼Rationale: ➥Mechanical debridement means to physically remove dirt, damaged or dead tissue, and cellular debris from a wound or burn so that infection is prevented and healing is promoted. Scissors, forceps, or scalpels may be used along with hydrotherapy. ☙Enzymatic preparations are used to debride chemically by dissolving and removing necrotic tissue. ☙A mechanical device that continually moves an extremity is called continuous passive range of motion and is used for knee surgery. ☙Autolytic debridement includes semi-occlusive or occlusive dressings to soften dry eschar by autolysis.