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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.
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A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching?
- A. You'll have to remove metal objects such as watches and body jewelry.
- B. Your exposure to radiation will be minimal.
- C. You will not be able to talk to the technician during the procedure.
- D. Unlike an x-ray, the MRI allows you to move around a bit.
Correct Answer: A
Rationale: The correct answer is A: You'll have to remove metal objects such as watches and body jewelry. This is important for MRI safety as the magnetic field can interact with metal objects, causing harm or image distortion. Removing metal ensures the client's safety during the procedure. Choice B is incorrect as MRI does not involve radiation exposure but magnetic fields. Choice C is incorrect as communication with the technician is usually possible through an intercom system. Choice D is incorrect as clients must remain still during an MRI to prevent image blurring.
A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?
- A. Autonomy vs. Shame and Doubt
- B. Generativity vs. Stagnation
- C. Identity vs. Role Diffusion
- D. Integrity vs. Despair
Correct Answer: D
Rationale: The correct answer is D: Integrity vs. Despair. According to Erikson's psychosocial development theory, acceptance of death occurs during the final stage of life, which is Integrity vs. Despair. In this stage, individuals reflect on their lives and come to terms with their mortality, finding a sense of fulfillment and wisdom. Option A (Autonomy vs. Shame and Doubt) focuses on developing a sense of independence in early childhood. Option B (Generativity vs. Stagnation) pertains to middle adulthood and concerns contributing to society and future generations. Option C (Identity vs. Role Diffusion) relates to adolescence and the formation of a sense of self. These stages do not specifically address acceptance of death.
A nurse is preparing to measure a client's oxygen saturation and notes edema of the client's hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations?
- A. Finger
- B. Earlobe
- C. Toe
- D. Skin fold
Correct Answer: B
Rationale: The correct answer is B: Earlobe. The nurse should apply the pulse oximeter probe to the earlobe in this scenario because the client's hands have edema, making finger placement less reliable for accurate readings. Thickened toenails also suggest poor circulation in the toes, making toe placement less accurate. The earlobe provides a good peripheral site for accurate oxygen saturation measurement, as it has good blood flow and is less affected by edema or circulation issues. Placing the probe on the skin fold may lead to erroneous readings due to variations in skin thickness and perfusion. Therefore, the earlobe is the most suitable and reliable location for obtaining an accurate oxygen saturation measurement in this situation.
A nurse is caring for a client who has hemophilia and has developed hemarthrosis of the left knee. Which of the following actions should the nurse take?
- A. Administer low-dose aspirin.
- B. Apply heat to the knee.
- C. Administer analgesics IM.
- D. Elevate the knee.
Correct Answer: D
Rationale: The correct answer is D: Elevate the knee. Elevating the knee helps reduce swelling and promote venous return, which can help alleviate pain and prevent further bleeding in hemarthrosis. Administering low-dose aspirin (A) is contraindicated in hemophilia as it can increase the risk of bleeding. Applying heat (B) can exacerbate bleeding by increasing blood flow to the area. Administering analgesics IM (C) may provide pain relief but does not address the underlying issue of bleeding.
A client comes to the clinic reporting chronic low back pain. He asks the nurse to recommend specific exercises for him. Which of the following activities should the nurse suggest?
- A. Tennis
- B. Canoeing
- C. Swimming
- D. Archery
Correct Answer: C
Rationale: The correct answer is C: Swimming. Swimming is a low-impact exercise that helps strengthen the muscles in the back and core without putting excessive strain on the spine. It also promotes flexibility and improves cardiovascular health, which can aid in managing chronic low back pain. Other options like A (Tennis), B (Canoeing), and D (Archery) involve movements that may exacerbate back pain due to potential twisting, impact, or strain on the back muscles. Therefore, swimming is the most suitable recommendation for the client to alleviate and manage chronic low back pain effectively.