Nokea
When providing culturally competent care to a couple from the Philippines living in the United States who are expecting their first child, what should the nurse do first?
- A. review their own cultural beliefs and biases
- B. respectfully request that the couple only use medically approved health care providers
- C. understand the clients' need to learn the accepted medical practices of their new country
- D. study family dynamics to comprehend the male and female gender roles in the clients' culture
Correct Answer: A
Rationale: When providing culturally competent care, the nurse's initial step is to reflect on and understand their own cultural beliefs and biases. By doing so, the nurse can approach the care of the couple from the Philippines with sensitivity and respect. This self-awareness helps the nurse recognize potential differences in beliefs and values, fostering effective communication and care. Option B is incorrect because it does not address the nurse's need for self-reflection. Option C is incorrect as it focuses on the clients adapting to the new country's practices rather than the nurse understanding the clients' existing beliefs. Option D is incorrect as it pertains to family dynamics and gender roles rather than the nurse's self-awareness.
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How should Lasix be administered to prevent hypotension?
- A. By administering it over 1-2 minutes
- B. By hanging it IV piggyback
- C. With normal saline only
- D. By administering it through a venous access device
Correct Answer: A
Rationale: Lasix should be administered over 1-2 minutes at approximately 1mL per minute to prevent hypotension. This slow administration helps to reduce the risk of adverse effects such as sudden drops in blood pressure. Choice B is incorrect because Lasix does not need to be hung IV piggyback, choice C is incorrect as Lasix administration does not require it to be mixed with normal saline only, and choice D is incorrect as Lasix does not have to be specifically administered through a venous access device (VAD) to prevent hypotension.
An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?
- A. "I think I was a lonely child because I could not tell anyone about my abuse."?
- B. "I am now aware of how deep-seated my anger is. Before, I did not realize I was angry."?
- C. "The program has given me the courage to tell my mother how I felt about her role in my hurt."?
- D. "There are so many people just like me, who are just normal people that had bad things happen to them."?
Correct Answer: B
Rationale: The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.
A corporate executive works 60-80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions?
- A. structure
- B. relaxation technique
- C. time management
- D. regular exercise
Correct Answer: C
Rationale: The correct answer is 'relaxation technique.' Biofeedback techniques are a form of relaxation technique that can help individuals quiet the mind, release tension, and counteract responses to stress. Teaching biofeedback techniques to the client aims to promote relaxation and stress management. Choice A, 'structure,' does not directly relate to teaching biofeedback techniques. Choice C, 'time management,' focuses on organizing tasks efficiently, not on relaxation techniques. Choice D, 'regular exercise,' although beneficial for overall health, is not specifically related to the teaching of biofeedback techniques for stress relief.
A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?
- A. prosecuting the perpetrator
- B. managing symptoms of anxiety and fear
- C. determining if the memories are real
- D. collaborating with the client's story
Correct Answer: B
Rationale: The correct answer is 'managing symptoms of anxiety and fear.' When a client remembers childhood sexual abuse, the nurse's primary goal should be to help the client cope with the emotional distress and symptoms such as anxiety and fear. Prosecuting the perpetrator is not within the nurse's scope of practice and is a legal matter. Determining if the memories are real is not the nurse's role; the focus should be on providing support and care. Collaborating with the client's story is vague and does not address the immediate emotional needs of the client.
The nurse observes bilateral bruises on the arms of an elderly client in a long-term care facility. Which of the following questions should the nurse ask this client?
- A. "How did you get those bruises?"?
- B. "Did someone grab you by your arms?"?
- C. "Do you fall often?"?
- D. "What did you bump against?"?
Correct Answer: B
Rationale: When addressing suspected abuse, it is crucial to ask direct questions to determine the cause of injuries. Choice B is the most appropriate as it directly inquires about the possibility of someone grabbing the client's arms, which could indicate abuse. This question can help uncover potential abuse and provide necessary intervention. Choices A, C, and D are less direct and may not elicit the critical information needed to address abuse effectively. Clients often hesitate to report abuse due to feelings of shame and fear of retaliation, making a direct approach essential in such situations.