Nokea
A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
- A. Check to see what is on the floor.
- B. Pause and wait until the client looks up.
- C. Move closer to the client.
- D. Continue the discussion while avoiding eye contact.
Correct Answer: D
Rationale: Avoiding direct eye contact is a cultural sign of respect in some Asian cultures, so the nurse should not force eye contact.
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A nurse is rehearsing assertive communication approaches to decline leadership of a nursing department committee. Which of the following statements by the nurse demonstrates assertiveness?
- A. You know this is not the right time for me to do this.
- B. Everyone knows there are others who can chair this committee better than I could.
- C. Can you tell me why you chose me?
- D. I decline the opportunity at this time.
Correct Answer: D
Rationale: Assertive communication is direct and respectful, clearly stating a decision without being passive or aggressive.
A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.
A nurse is instructing a client about postural drainage. The nurse should have the client lie on his stomach with his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: D
Rationale: Prone Trendelenburg position aids in secretion clearance from posterior lung segments.
A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the client's pain?
- A. Vital sign measurement
- B. Client's self-report of pain
- C. Visual observation for nonverbal signs of pain
- D. Nature of invasiveness of the surgical procedure
Correct Answer: B
Rationale: The correct answer is B: Client's self-report of pain. This is the most reliable source for determining the intensity of the client's pain because pain is a subjective experience and can vary greatly among individuals. The client is the best source to accurately describe their pain level, location, and quality. Vital sign measurements (A) may provide some indication of pain, but they are not as accurate as the client's self-report. Visual observation (C) may be helpful, but it can be subjective and may not always correlate with the client's actual pain level. The nature of invasiveness of the surgical procedure (D) may give some indication of potential pain level, but it does not directly measure the client's current pain intensity.
A nurse is caring for a client who is requesting information about how to enhance her immune system. The nurse should identify that which of the following complementary and alternative healing modalities uses the essential oils of plants to provide psychological and physiological benefit.
- A. Aromatherapy
- B. Biofeedback
- C. Guided imagery
- D. Yoga
Correct Answer: A
Rationale: Aromatherapy uses essential oils from plants to promote relaxation, improve mood, and support immune function.