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When assessing the health beliefs and practices of an older Hispanic adult, the nurse observes that the client uses a traditional folk healer to manage health problems. How would you respond?
- A. Respectfully acknowledge the practice and integrate it where possible.
- B. Discredit the folk healer's methods.
- C. Insist on conventional medical treatment only.
- D. Ignore the client's preference.
Correct Answer: A
Rationale: Respecting and integrating traditional practices fosters trust and collaboration in care delivery.
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In assigning patients with alterations related to gastrointestinal (GI) cancer, which would be the most appropriate nursing care tasks to assign to the LPN/LVN, under supervision of the team leader RN?
- A. A patient with severe anemia secondary to GI bleeding.
- B. A patient who needs enemas and antibiotics to control GI bacteria.
- C. A patient who needs pre-op teaching for bowel resection surgery.
- D. A patient who needs central line insertion for chemotherapy.
Correct Answer: B
Rationale: Administering enemas and antibiotics involves routine tasks that LPNs/LVNs are trained to perform, whereas the other options require advanced skills or supervision.
What piece of equipment should the nurse advise Mrs. Singer to have ready when her husband returns home?
- A. An electronic artificial larynx
- B. A humidifier
- C. A television
- D. A high-low bed
Correct Answer: B
Rationale: Humidifiers maintain moisture in the air, aiding breathing through the stoma.
What evaluation would help Mr. Jones control his chest pain on inspiration?
- A. Evaluate the intensity and quality of his pain
- B. Explain the cause of his pain
- C. Encourage him to lie on his affected side
- D. Reassure him that the pain will subside
Correct Answer: C
Rationale: Lying on the affected side stabilizes the chest wall, reducing pain during inspiration.
Which of the following would be appropriate to delegate to the nursing assistant?
- A. Assist the child to remove outer clothing
- B. Advise the parent to use acetaminophen instead of aspirin
- C. Explain the need for cool fluids
- D. Prepare and administer a tepid bath
Correct Answer: A
Rationale: Removing outer clothing is a simple task that does not require clinical judgment.
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as:
- A. Autistic.
- B. Ecopraxic.
- C. Echolalic.
- D. Catatonic.
Correct Answer: C
Rationale: Echolalia is the repetition of words or phrases heard from others.