Nokea
A female nurse is caring for a traditional Arab American male client. When planning effective care for this client, the nurse should be aware of which of the following cultural considerations? Select all that apply.
- A. Limited touch is acceptable only between members of the same sex.
- B. Conversing individuals of this culture stand far apart and do not make eye contact.
- C. Devout Muslim men may not shake hands with women.
- D. The man is the head of the household and women take on a subordinate role.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. In traditional Arab American culture, limited touch is acceptable only between members of the same sex due to modesty and respect for personal boundaries.
2. This cultural consideration is important for the nurse to provide appropriate care that respects the client's cultural beliefs and preferences.
3. Understanding this aspect helps the nurse establish trust and build rapport with the male client while upholding cultural sensitivity and respect.
Summary:
- Choice B is incorrect as Arab American individuals may stand close and make eye contact during conversations.
- Choice C is incorrect as devout Muslim men may opt for not shaking hands with women due to religious beliefs, not solely based on gender.
- Choice D is incorrect as gender roles in traditional Arab American culture can vary and may not always follow a strict hierarchical structure.
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An involuntarily committed client is verbally abusive to the staff and repeatedly threatening to sue. The client records the full names and phone numbers of the staff. Which nursing action is most appropriate to decrease the possibility of a lawsuit?
- A. Verbally redirect the client, and then limit one-on-one interaction.
- B. Involve the hospitals security division as soon as possible.
- C. Notify the client that documenting personal staff information is against hospital policy.
- D. Continue professional attempts to establish a positive working relationship with the client.
Correct Answer: C
Rationale: The most appropriate nursing action is to choose option C: Notify the client that documenting personal staff information is against hospital policy. This response is effective in addressing the situation because it clearly communicates boundaries to the client and informs them of the hospital's policy. By doing so, the client is made aware that their behavior is not acceptable and that there are consequences for violating the policy. This action also helps to protect the staff members' privacy and security.
Option A: Verbally redirect the client and then limit one-on-one interaction, may not effectively address the issue of the client recording personal staff information. Option B: Involve the hospital's security division as soon as possible, is a more drastic measure that may escalate the situation unnecessarily. Option D: Continue professional attempts to establish a positive working relationship with the client, is not appropriate in this scenario as the client's behavior is threatening and abusive.
Neurological tests have ruled out pathology in a clients sudden lower-extremity paralysis. Which nursing care should be included for this client?
- A. Deal with physical symptoms in a detached manner.
- B. Challenge the validity of physical symptoms.
- C. Meet dependency needs until the physical limitations subside.
- D. Encourage a discussion of feelings about the lower-extremity problem.
Correct Answer: D
Rationale: The correct answer is D because focusing on the client's emotional response is crucial when physical pathology is ruled out. By encouraging a discussion of feelings, the nurse can provide emotional support, assess coping mechanisms, and address any psychosocial factors contributing to the paralysis. This approach promotes holistic care and aids in the client's emotional well-being.
Choice A is incorrect as dealing with physical symptoms in a detached manner may neglect the client's emotional needs. Choice B is incorrect as challenging the validity of physical symptoms can invalidate the client's experience and hinder therapeutic rapport. Choice C is incorrect as meeting dependency needs may not address the emotional impact of sudden paralysis.
A client is taking chlordiazepoxide (Librium) for generalized anxiety disorder symptoms. In which situation should a nurse recognize that this client is at greatest risk for drug overdose?
- A. When the client has a knowledge deficit related to the effects of the drug
- B. When the client combines the drug with alcohol
- C. When the client takes the drug on an empty stomach
- D. When the client fails to follow dietary restrictions
Correct Answer: B
Rationale: The correct answer is B: When the client combines the drug with alcohol. Combining chlordiazepoxide with alcohol can potentiate the central nervous system depression effects, leading to respiratory depression, sedation, and potential overdose. Alcohol can enhance the sedative effects of chlordiazepoxide, increasing the risk of overdose. A, C, and D are incorrect because a knowledge deficit, taking the drug on an empty stomach, or failing to follow dietary restrictions are not directly related to increasing the risk of drug overdose in this specific scenario.
According to Eriksons developmental theory, when planning care for a 47-year-old client, which developmental task should a nurse identify as appropriate for this client?
- A. To achieve a sense of self-confidence and recognition from others
- B. To reflect back on life events to derive pleasure and meaning
- C. To achieve established life goals and consider the welfare of future generations
Correct Answer: B
Rationale: In Erikson's theory, the developmental task for a 47-year-old client aligns with the stage of Generativity vs. Stagnation. Choice B, reflecting on life events for pleasure and meaning, corresponds to this stage where individuals assess their accomplishments and seek fulfillment. This phase involves contributing to society and future generations. Choice A pertains to the earlier stage of Identity vs. Role Confusion in adolescence. Choice C aligns with the later stage of Integrity vs. Despair in older adulthood. Choice D is incomplete. Therefore, the correct answer is B as it best fits the age and developmental stage of the client in question.
A nurse moving out of state speaks to a client about the need to work with a new nurse. The client states, Im not well enough to switch to a different nurse. What does this client response indicate to the nurse?
- A. The client is using manipulation to receive secondary gain.
- B. The client is using the defense mechanism of denial.
- C. The client is having trouble terminating the relationship.
- D. The client is using splitting as a way to remain dependent on the nurse.
Correct Answer: B
Rationale: The correct answer is B because the client's statement indicates denial of the upcoming change in nurses due to their belief that they are not well enough to switch. This defense mechanism helps the client avoid the reality of the situation. Choice A is incorrect as there is no evidence of manipulation for secondary gain. Choice C is incorrect as the client is not expressing difficulty in terminating the relationship. Choice D is incorrect as splitting involves seeing people as all good or all bad, which is not evident in the client's statement.