Nokea
The nurse who practices culturally sensitive nursing care incorporates which concepts into client care? Select all that apply.
- A. The expression of pain is affected by learned behaviors.
- B. Physiologically, all individuals experience pain in a similar manner.
- C. Ethnic culture has an effect on the physiological response to pain medications.
- D. Clients should be assessed for pain regardless of a lack of overt symptomatology.
- E. The use of a standardized pain assessment tool ensures unbiased pain assessment.
Correct Answer: A,C,D
Rationale: Pain and its expression are often affected by an individual's ethnic culture in ways that include learned means of pain expression, the physiological response to pain medications, and attitudes regarding acceptable ways of dealing with pain. Physiologically not all individuals, even those of the same ethnic culture, will respond to pain in a similar manner, and so a standardized pain assessment tool is not effective in measuring pain in all clients.
You may also like to solve these questions
A child is admitted to the hospital with a diagnosis of nephrotic syndrome. The nurse expects to note documentation of which manifestation in the medical record? Select all that apply.
- A. Edema
- B. Proteinuria
- C. Hypertension
- D. Abdominal pain
- E. Increased weight
- F. Hypoalbuminemia
Correct Answer: A,B,D,E,F
Rationale: Nephrotic syndrome refers to a kidney disorder characterized by edema, proteinuria, and hypoalbuminemia. The child also experiences anorexia, fatigue, abdominal pain, respiratory infection, and increased weight. The child's blood pressure is usually normal or slightly below normal.
A client with a diagnosis of diabetes mellitus has a blood glucose level of 644 mg/dL (36.8 mmol/L). The nurse interprets that this client is at risk of developing which type of acid-base imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options 2, 3, and 4 are incorrect.
The nurse is assigned to give a child a tepid tub bath to treat hyperthermia. After the bath, which action should the nurse take?
- A. Leave the child uncovered for 15 minutes.
- B. Assist the child to put on a cotton sleep shirt.
- C. Take the child's axillary temperature in 2 hours.
- D. Place the child in bed and cover the child with a blanket.
Correct Answer: B
Rationale: Cotton is a lightweight material that will protect the child from becoming chilled after the bath. Option 1 is incorrect because the child should not be left uncovered. Option 3 is incorrect because the child's temperature should be reassessed a half hour after the bath. Option 4 is incorrect because a blanket is heavy and may increase the child's body temperature.
The nurse monitors a patient with acute pancreatitis. Which assessment finding indicates that paralytic ileus has developed?
- A. Inability to pass flatus
- B. Loss of anal sphincter control
- C. Severe, constant pain with rapid onset
- D. Firm, nontender mass palpable at the lower right costal margin
Correct Answer: A
Rationale: An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Option 4 is the description of the physical finding of liver enlargement.
Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.