Nokea
Which approach is a priority for the nurse who works with clients from many different cultures?
- A. Speak at least 2 other languages of clients in the neighborhood
- B. Learn about the cultures of clients who are most often encountered
- C. Have a list of persons for referral when interaction with these clients occur
- D. Recognize personal attitudes about cultural differences and real or expected biases
Correct Answer: D
Rationale: The nurse must discover personal attitudes, prejudices and biases specific to different cultures. Awareness of these will prevent negative consequences for interactions with clients and families across cultures.
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A 65-year-old female is planning for retirement. Which statement indicates that the client has achieved ego integrity?
- A. After retirement, I plan to join a senior's travel club.
- B. I need to consider selling my home and moving closer to my daughter.
- C. I've worked most all my life. I'm not sure how to spend my days now.
- D. Few of my relatives live past their 70s.
Correct Answer: A
Rationale: Ego integrity, per Erikson, involves acceptance of one's life and finding meaning, as shown by planning to join a travel club . Choices B, C, and D reflect uncertainty or despair.
The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change?
- A. Anticoagulant
- B. Liquid antacid
- C. Antihistamine
- D. Cardiac glycoside
Correct Answer: C
Rationale: Antihistamine. Elderly people are susceptible to the side effect of anticholinergic drugs, such as antihistamines. Antihistamines often cause confusion in the elderly, especially at high doses.
A nurse has just started on the 7PM surgical unit shift. Which of the following patients should the nurse check on first?
- A. A 75 year-old female who is scheduled for an EGD in 10 hours.
- B. A 34 year-old male who is complaining of low back pain following back surgery and has an onset of urinary incontinence in the last hour.
- C. A 21 year-old male who had a lower extremity BKA yesterday, following a MVA and has phantom pain.
- D. A 27 year-old female who has received 1.5 units of RBC's. via transfusion the previous day.
Correct Answer: B
Rationale: The new onset of urinary incontinence may require additional medical assessment, and the physician needs to be notified.
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: Abruptio placentae causes hemorrhage due to premature placental separation, leading to fluid volume deficit, a major nursing concern. Infection (A) is unrelated, and choices B and C are incorrectly phrased nursing diagnoses.
A twenty-one year old man suffered a concussion and the MD ordered a MRI. The patient asks, 'Will they allow me to sit up during the MRI?' The correct response by the nurse should be.
- A. I will have to talk to the doctor about letting you sit upright during the test.'
- B. You will be positioned in the reverse Trendelenburg position to maximize the view of the brain.'
- C. The radiologist will let you know.'
- D. You will have to lie down on your back during the test.'
Correct Answer: D
Rationale: The MRI will require supine positioning.