Nokea
A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?
- A. Brachial
- B. Carotid
- C. Femoral
- D. Popliteal
Correct Answer: B
Rationale: The correct answer is B: Carotid. Checking the carotid pulse bilaterally simultaneously can lead to a temporary decrease in blood flow to the brain, potentially causing dizziness or fainting. It is important to assess one carotid pulse at a time to ensure adequate blood supply to the brain. Checking the brachial, femoral, and popliteal pulses bilaterally at the same time is safe as it does not pose a risk of compromising blood flow to critical organs.
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A nurse is reinforcing preoperative teaching with a client of Chinese heritage who speaks limited English. Which of the following methods of communication by the nurse demonstrates cultural competence?
- A. Incorporate humor in the teaching with the client.
- B. Address the client by her last name.
- C. Maintain direct eye contact with the client.
- D. Place a hand on the client's head.
Correct Answer: B
Rationale: Addressing the client formally by her last name shows respect, which aligns with many cultural norms in Chinese heritage.
A nurse is supervising a newly licensed nurse who is female while she performs postmortem care on a male client who is Muslim. Which of the following actions by the newly licensed nurse should prompt the nurse to intervene?
- A. Leaves the client's dentures in his mouth
- B. Prepares to cleanse the client's body
- C. Disconnects the cardiac monitor from the client
- D. Removes soiled linens from the client
Correct Answer: B
Rationale: In Islamic practices, same-gender family members or religious personnel should perform body cleansing. A female nurse cleansing a male client would require intervention.
A client who has a femur fracture states, 'I can't stay in this bed any longer. I need to get home so I can take care of my family.' The nurse responds by saying, 'You have talked about your family. Can you tell me more about your specific concerns?' Which of the following therapeutic communication techniques is the nurse using?
- A. Summarizing
- B. Empathizing
- C. Focusing
- D. Clarifying
Correct Answer: C
Rationale: Focusing helps the client explore concerns in more detail, allowing for appropriate support and planning.
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop the coordination and balance needed to ride a tricycle around the age of 3. This activity helps improve gross motor skills and coordination. Jumping rope (A) requires more advanced motor skills and coordination. Printing letters and numbers (C) involves fine motor skills that develop later. Using scissors to cut out a picture (D) also requires more advanced fine motor skills and hand-eye coordination.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe Saturday as a holy day of rest and worship, known as the Sabbath. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and practices. This intervention promotes culturally sensitive care by acknowledging and accommodating the client's spiritual needs.
Choice B (Arrange for him to receive the sacrament of the sick) is incorrect as this intervention is specific to the Catholic faith, not Seventh-Day Adventist beliefs. Choice C (Assign same-gender caregivers) is not directly related to the client's religious preferences and may not be necessary for providing culturally sensitive care in this context. Choice D (Offer him a kosher dietary menu) is more aligned with Jewish dietary laws, which do not specifically apply to Seventh-Day Adventist beliefs.