Nokea
A nurse is providing care to a patient from adifferent culture. Which action by the nurse indicates cultural competence?
- A. Communicates effectively in a multicultural context
- B. Functions effectively in a multicultural context
- C. Visits a foreign country
- D. Speaks a different language
Correct Answer: A
Rationale: The correct answer is A because effective communication in a multicultural context is essential for cultural competence. By communicating effectively, the nurse can understand and respect the patient's cultural beliefs, values, and practices. This helps in providing appropriate care tailored to the patient's cultural needs. Choice B is too vague and does not specifically address communication skills. Choice C, visiting a foreign country, does not directly demonstrate cultural competence in patient care. Choice D, speaking a different language, is important but not sufficient on its own to indicate cultural competence without effective communication skills.
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A patient has returned to the post-surgical unit after vulvar surgery. What intervention should the nurse prioritize during the initial postoperative period?
- A. Placing the patient in high Fowlers position
- B. Administering sitz baths every 4 hours
- C. Monitoring the integrity of the surgical site
- D. Avoiding analgesics unless the patients pain is unbearable
Correct Answer: C
Rationale: The correct answer is C: Monitoring the integrity of the surgical site. This is the priority intervention as it ensures early detection of any complications like infection or bleeding. The nurse should assess for signs of infection, such as redness, swelling, or drainage, and monitor for any changes in the wound appearance. Placing the patient in high Fowler's position (A) may be beneficial for comfort but is not the priority. Administering sitz baths (B) may be helpful for comfort but should not be the priority over monitoring the surgical site. Avoiding analgesics (D) unless the pain is unbearable is not appropriate as pain management is essential for the patient's comfort and recovery.
The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?
- A. These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies.
- B. These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer.
- C. Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy.
- D. Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying.
Correct Answer: A
Rationale: The correct answer is A because it acknowledges the patient's symptoms, reassures monitoring, and addresses the cause. It validates his experience while offering a proactive approach. Choice B is incorrect as it dismisses the patient's symptoms and can cause distress. Choice C is incorrect because it generalizes the patient's experience and lacks individualized care. Choice D is incorrect as it may give false hope and oversimplifies the situation. A provides the best balance of empathy and information for the patient's well-being.
A woman aged 48 years comes to the clinic because she has discovered a lump in her breast. After diagnostic testing, the woman receives a diagnosis of breast cancer. The woman asks the nurse when her teenage daughters should begin mammography. What is the nurses best advice?
- A. Age 28
- B. Age 35
- C. Age 38
- D. Age 48
Correct Answer: D
Rationale: The correct answer is D: Age 48. This recommendation aligns with the current guidelines from major health organizations, such as the American Cancer Society, which suggest that women at average risk should start regular mammograms at age 45 to 54. Screening before age 45 may lead to unnecessary procedures due to false positives. Beginning at age 48 allows for early detection without subjecting the daughters to unnecessary testing at a younger age. Choices A, B, and C are incorrect as they suggest starting mammography at younger ages than recommended, which can increase the likelihood of false positives and unnecessary interventions.
A patient has been diagnosed with serous otitis media for the third time in the past year. How should the nurse best interpret this patients health status?
- A. For some patients, these recurrent infections constitute an age-related physiologic change.
- B. The patient would benefit from a temporary mobility restriction to facilitate healing.
- C. The patient needs to be assessed for nasopharyngeal cancer.
- D. Blood cultures should be drawn to rule out a systemic infection.
Correct Answer: A
Rationale: Step 1: Serous otitis media is common in children due to eustachian tube dysfunction, not usually related to systemic infections.
Step 2: Recurrent infections may indicate age-related changes like decreased eustachian tube function.
Step 3: Age-related physiologic changes can lead to poor drainage, causing recurrent otitis media.
Step 4: Therefore, choice A is correct as it aligns with the typical presentation of serous otitis media in the context of age.
Summary: Choice B is incorrect as there is no indication for temporary mobility restriction. Choice C is incorrect as serous otitis media does not typically warrant assessment for nasopharyngeal cancer. Choice D is incorrect as blood cultures are not typically indicated for serous otitis media.
A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?
- A. Metastasis
- B. Risk for stroke
- C. Emotional and personality changes
- D. Pathologic bone fractures
Correct Answer: C
Rationale: The correct answer is C: Emotional and personality changes. In Huntington disease, neurodegeneration affects the brain, leading to changes in behavior, emotions, and personality. These changes are characteristic of the disease progression. Metastasis (A) refers to the spread of cancer, which is not associated with Huntington disease. Risk for stroke (B) is not a typical manifestation of Huntington disease. Pathologic bone fractures (D) are not directly related to the primary symptoms of Huntington disease. Thus, addressing emotional and personality changes is crucial in providing anticipatory guidance for individuals with Huntington disease.