Nokea
When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because
- A. normal patterns of behavior may be labeled as deviant, immoral, or insane
- B. the meaning of the client's behavior can be derived from conventional wisdom
- C. personal values will guide the interaction between persons from 2 cultures
- D. the nurse should rely on her knowledge of different developmental mental stages
Correct Answer: A
Rationale: Normal patterns of behavior may be labeled as deviant, immoral, or insane. Culture is an important variable in the assessment of individuals. To work effectively with clients, the nurse must be aware of a cultural distinctive qualities.
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When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
- A. Biofeedback
- B. Deep breathing
- C. Distraction
- D. Imagery
Correct Answer: B
Rationale: Deep breathing. Deep breathing is a reliable and valid method for reducing stress, and can be taught and reinforced in a short period pre-operatively.
The expectant mother asks the nurse, "With all the babies in the nursery, how will I know that the nurse is bringing rue my baby?" What is the nurse's best response?
- A. "The baby has a plastic bracelet with permanent locks that must be cut for removal."
- B. "If taken from the unit, your baby's security band will set off an alarm and lock exits."
- C. "Your identification number and full name are printed on your baby's identification band."
- D. "An identification band is applied to your infant, and footprints are taken and kept on record."
Correct Answer: C
Rationale: Matching identification numbers and the mother's full name on the infant's band ensures accurate identification, which is the primary method.
The client on Floxin must be alerted to which of the following adverse effects?
- A. stunting of height in teens and young adults
- B. propensity of anovulatory uterine bleeding
- C. intractable diarrhea
- D. tendon rupture
Correct Answer: D
Rationale: Floxin is a quinolone antibiotic used in respiratory infections and pelvic and reproductive infections. Rarely, quinolones can cause tendon sheath rupture, usually of the Achilles. At the first indication of tendon pain, the antibiotic should be discontinued.
Signs of internal bleeding include all of the following except:
- A. painful or swollen extremities.
- B. a tender, rigid abdomen.
- C. vomiting bile.
- D. bruising.
Correct Answer: C
Rationale: Vomiting bile is usually not a sign of internal bleeding. Painful or swollen extremities, a tender, rigid abdomen, and bruising are indicative of internal bleeding.
The non-English-speaking hospitalized client begins to enter a room with the sign illustrated. Which intervention should the observing nurse implement?
- A. Inform the client's assigned nurse that the client is back in his or her room.
- B. Intercept the client and check the client's name band for a room number.
- C. Stop the client and ask for his or her name and the assigned room number.
- D. Ask the nearby UAP to help the client back into the room with the sign posted.
Correct Answer: B
Rationale: Intercepting and checking the name band ensures the client does not enter a radiation therapy room, accounting for the language barrier.