Gerontological Nursing 8th Edition by Charlotte Eliopoulos Test Bank
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Sample
Test
Chapter 3
Principles of Geriatrics
3.1•The health history is an important part of the comprehensive
geriatric assessment. Which of the following interventions will improve the
accuracy and efficiency of obtaining the history?
1. giving
the client a form to complete regarding past medical history as soon as the
client arrives for the appointment
2. requesting
the client bring a list of current medications, including nonprescription
medications, taken regularly
3. conducting
the assessment in an environment with comfortable seating,
handicapped-accessible furnishings, proper lighting, and limited noise
4. scheduling
30 minutes for the medical history interview
Answer: 3
Rationale: Creating a conducive environment for the older adult
will foster effective communication during the history-taking process. The form
for the past medical history should be mailed in advance with instructions for
completion. The client should bring the actual bottles of current medications
to the appointment to avoid any errors or confusion. At least 60 minutes should
be scheduled for the visit to improve quality and quantity of pertinent
information obtained from the client.
Planning
Health Promotion and Maintenance
Application
3.2•In order to deliver culturally competent healthcare, the
healthcare practitioner should
1. be
able to speak the language of the client.
2. approach
clients of a particular ethnic group in the same manner.
3. use
standardized assessment instruments in health evaluations.
4. know
prevalence, incidence, and risk factors for diseases specific to different
ethnic groups.
Answer: 4
Rationale: It is important that the health practitioner be aware
of the epidemiological factors specific to particular ethnic groups in order to
teach clients preventive interventions and screen for diseases at high risk.
Although it would be helpful for practitioners to speak the language of
clients, this is unrealistic. Interpreters, visual aides, and language boards
should be used to improve communication. Healthcare practitioners should
address clients as individuals, not from a cultural stereotype. Practitioners
should keep in mind that many of the clinical assessment instruments have not
been validated for use with ethnic minorities.
Implementation
Health Promotion and Maintenance
Application
3.3•Minimal data set (MDS)
1. is
performed only at the time of admission to a long-term care facility.
2. has
no connection to Medicare or Medicaid.
3. includes
a core set of screening, clinical, and functional measures used in client
assessment.
4. does
not address the client’s prescribed medications.
Answer: 3
Rationale: The MDS is a comprehensive assessment comprised of
screening, clinical, and functional measures to improve assessment and care in
long-term care facilities. As part of the Omnibus Budget Reconciliation Act
(1987) institutions must use MDSs to assess residents in order to collect funds
from Medicare or Medicaid. The MDS is performed at the time of admission and at
set time periods to validate the need for long-term care and to assess clinical
problems. Medications are included in the categories of data gathered.
Assessment
Health Promotion and Maintenance
Application
3.4•The leading causes of death for older adults in the United
States are
1. heart
disease, cancer, and stroke.
2. hypertension,
diabetes, and heart disease.
3. HIV/AIDS,
cancer, and heart disease.
4. unintentional
injuries, cancer, and stroke.
Answer: 1
Rationale: The leading causes of death are used to describe the
health status of a country. For older adults, the leading causes are heart
disease, cancer, and stroke. Hypertension and diabetes are risk factors for
cardiovascular disease. HIV/AIDS is a leading cause of death for African
American men aged 25 to 44. Unintentional injuries are the leading cause of
death for persons aged 1 to 44 years.
Evaluation
Health Promotion and Maintenance
Knowledge
3.5•Of the following statements, which is the most correct about
pain in the older adult?
1. Significant
undertreated pain is a frequent problem for persons in nursing homes but not
for those living in the community.
2. Significant
pain does not significantly affect vital signs in older adults.
3. The
most accurate ways to assess pain in verbal clients include client description
and self-report.
4. Acute
pain should be alleviated completely before the source of pain is identified.
Answer: 3
Rationale: The most accurate method to assess pain in verbal
clients is to ask clients to report and describe their pain. Clients can be
taught to use various measurement techniques including numerical, visual
analog, and word descriptor scales. Undertreated pain is a problem for older
adults in nursing homes as well as in the community. The assessment of vital
signs is included in the pain assessment of clients who are nonverbal.
Increased blood pressure, pulse rate, and respiratory rate may be indicative of
pain. Acute pain may signify a serious undiagnosed illness or injury and should
be aggressively reported and investigated. Treating the pain without finding
the cause may result in serious consequences.
Assessment
Physiological Integrity
Analysis
3.6•Of the following statements, which is most correct about
strategies for pain relief in older adults?
1. Non-pharmaceutical
treatments are less effective than pharmacological methods.
2. Administering
pain medication around the clock increases pain relief.
3. Opioid
analgesics should not be used to treat pain in older adults.
4. Exercise
is ineffective as a method of pain relief.
Answer: 2
Rationale: Administration of pain medication around the clock
maintains a steady level of medication in the body system promoting baseline
relief. Many factors come into play in achieving effective pain relief, which
is verified by systematic ongoing client assessment. Pharmacological
interventions, including administration of opioids; and non-pharmaceutical
interventions, such as exercise, may prove effective to relieve pain in older
adult clients.
Intervention
Physiological Integrity
Application
3.7•An ombudsman is
1. a
healthcare professional who reviews client records and offers an opinion as to
whether the client has received the appropriate standard of care in a nursing
home.
2. an
attorney who can pursue lawsuits on behalf of clients who are residents in
nursing homes.
3. a
trained person who investigates complaints from nursing home residents and
their families.
4. an
agent of the nursing home who deters clients from filing lawsuits.
Answer: 3
Rationale: All states are required to have ombudsmen programs
for long-term care facilities. The ombudsman is a person trained to investigate
complaints from residents and their families and inform clients of their
rights. An expert witness is a healthcare expert who reviews client records and
offers opinions as to whether clients have received the appropriate standard of
care. Attorneys who pursue lawsuits for nursing home clients are often in
private practice. Healthcare employees should foster proper relationships with
clients and their families and provide proper care. This will reduce the
likelihood of client litigation.
Safe, Effective Care Environment
Intervention
Application
3.8•The best way for a nurse to defend against becoming involved
in a legal suit is
1. careful
documentation of nursing care.
2. reporting
concerns about the institution to the supervisor.
3. avoiding
conflicts with clients and client families.
4. having
professional liability insurance.
Answer: 1
Rationale: Violation of the standard of care may be considered
malpractice. The legal definition of standard of care is to consider what a
reasonable nurse would do in a similar situation. The nurse can use careful
documentation, which is a legal record, to verify that she or he has met the
standard of care in a nursing situation. The nurse should report concerns to
supervisors, but this is not a defense against malpractice. It is wise to avoid
conflicts with clients and families if possible. Professional liability
insurance is a personal responsibility and is not a substitute for careful
documentation.
Safe, Effective Care Environment
Evaluation
Application
3.9•The Bill of Rights for clients who are residents of nursing
homes
1. differs
from state to state.
2. is
enforced by the ombudsman.
3. includes
the right to be free from chemical and physical restraints.
4. if
violated, results in malpractice charges.
Answer: 3
Rationale: The Bill of Rights for nursing home clients was
included in the Omnibus Budget Reconciliation Act (1987). It specifically
states that clients have the right to be free from restraints, both physical
and chemical. The ombudsman does not enforce the Bill of Rights but
investigates complaints, informs clients of their rights, and may seek
administrative or legal action in some cases. A violation of the Bill of Rights
might be considered malpractice if there is proven evidence that the standard
of care was not met.
Safe, Effective Care Environment
Intervention
Application
3.10•The legal definition of a standard of care is how a
reasonable nurse would act in a similar situation. Which of the following
scenarios describes a situation in which the performance of the nurse does not
meet the standard of care? A nurse
1. questions
a physician about an order to administer a medication that is five times the
normal dosage.
2. medicates
a client with acetaminophen when the client complains of severe chest pain and
does not notify the physician.
3. witnesses
a client fall and tries to assist the client.
4. withholds
the breakfast tray from a client who has been vomiting and remains nauseous.
Answer: 2
Rationale: The nurse who treats the client with chest pain, a
potentially serious medical problem, with acetaminophen and fails to notify the
physician of the need for medical care does not meet the standard of care.
Questioning a medication dosage outside the normal range, assisting a client
who has fallen, and not feeding a nauseous client who has recently vomited are
all situations in which a reasonable nurse would pursue a similar action.
Safe, Effective Care Environment
Intervention
Analysis
3.11•Physically restraining a client
1. is a
routine practice in hospitals but not in nursing homes.
2. is
illegal in all circumstances in hospitals and nursing homes.
3. is
allowed in emergency situations without a physician order.
4. has
been shown to increase problems associated with immobility, such as decubitus
ulcers and incontinence.
Answer: 4
Rationale: The Omnibus Budget Reconciliation Act (1987) used
nursing research that demonstrated a relationship between restrained clients
and the development of problems related to immobility. Because of the law,
restraints are seldom used in hospitals and nursing homes. Restraints may be
used only for a maximum of 2 hours, with a physician order, and in emergency
situations.
Safe, Effective Care Environment
Intervention
Application
3.12•Identify the correct statement describing the
responsibilities of healthcare institutions in handling client medical records.
1. Healthcare
facilities must maintain client medical records for at least 5 years.
2. Clients
have no legal rights to obtain copies of their medical records.
3. Clients
have the right to view their medical records and ask questions about the
information contained in the records.
4. Employees
in healthcare institutions may discuss a client situation in a public area as
long as the client is not identified.
Answer: 3
Rationale: Clients have the right to review their medical
records and ask questions regarding the information contained within the
record. Medical records must be maintained at least 7 years by healthcare
institutions. Clients have the right to obtain copies of their medical records
within a reasonable time and may be charged a fee for the copies. Healthcare
workers may not discuss client cases in public places even when the client is
unnamed because the discussion could contain identifying information and
violate confidentiality.
Safe, Effective Care Environment
Intervention
Knowledge
3.13•Of the following hospital situations, which one demonstrates
the need for further action and improved policies to maintain the
confidentiality of client medical information?
1. The
nurse logs off the computer after accessing the laboratory record of a client.
2. Reports
of client radiology tests are faxed to a fax machine that is shared by the
payroll department of the hospital.
3. Employees
who have expired passwords for computer access must contact their supervisor
for permission to obtain new passwords from the information technology
department.
4. A
physician is given a password to access computerized client records. The
information technology department keeps record logs of when and who has
accessed the client records.
Answer: 2
Rationale: The Health Insurance Portability and Accountability
Act (HIPAA) protects client health information, and establishes standards and
requirements for electronic transmission of health information. The institution
needs to improve its transfer of information so that client test results are
not transmitted via a fax machine that is accessed by persons who have no need
to see the client record. Logging off confidential files, using individual
passwords, and maintaining access record logs are proper means of maintaining
the privacy of client medical information.
Safe, Effective Care Environment
Intervention
Application
3.14•Identify the situation that constitutes a breach of privacy
according to the Health Insurance Portability and Accountability Act (HIPAA)
standards.
1. Copies
of client diagnostic test results are shredded before being discarded.
2. The
client’s chart is stored in the secured office of the radiology office while a
client is in the department having a diagnostic examination done.
3. A
physician who is not a caregiver of a client is restricted from access to the
client’s chart.
4. A
nurse discusses a client’s condition with a relative without the client’s
permission.
Answer: 4
Rationale: Caregivers must obtain a client’s permission before
discussing the client’s case with any person. Copies of client records must be rendered
unreadable before being discarded. Client records must be secure, especially
when used in departments other than the nursing unit. Persons, including
healthcare professionals, who do not legitimately need to see a client record
must be kept from accessing the record.
Safe, Effective Care Environment
Intervention
Application
3.15•A physician orders a blood transfusion for an older client
in the hospital. The nurse approaches the client to sign a consent form for the
transfusion and finds that the client is confused. The nurse should
1. explain
the benefits and burdens of the transfusion, help the client sign the consent,
and administer the blood transfusion.
2. administer
the blood transfusion; a signed consent form is not absolutely necessary.
3. explain
to the client about the ordered blood transfusion, determine the client’s
willingness to have the transfusion, and inform the client their durable power
of attorney will be contacted to sign the consent. Transfuse the blood after
the power of attorney gives consent.
4. withhold
the blood transfusion until the client’s mental status improves and then ask
the client to sign the consent.
Answer: 3
Rationale: The nurse who finds a client to lack the capacity for
consent, as in the case of a confused client, must obtain consent from a
healthcare proxy, such as the durable power of attorney. The nurse should
assent the client in the treatment decision as well. Explaining the treatment
to a confused client and then assisting the client to sign the consent does not
meet the test of capacity for consent (understanding, reasoning, problem
solving, and communicating the decision). A blood transfusion is considered a
specialized procedure and requires a separate informed consent form be signed
(Patient Self-Determination Act). Withholding the transfusion until the client
is no longer confused delays the treatment and may result in harm to the
client.
Safe, Effective Care Environment
Intervention
Application
3.16•The client voices concerns about chronic health problems.
The nurse explains the importance of participating in screening tests for
physical changes. Which of the following statements indicates
understanding by the client?
1. “I
should start having bone density studies annually once I reach menopause.”
2. “Diabetes
screening should be done every 2 years.”
3. “Annual
skin examinations should be performed to review changes and problematic areas.”
4. “I
will need to update my tetanus booster every 5 years.”
Answer: 3
Rationale: The skin should be reviewed to assess for
changes and the onset of problem areas. Skin assessments should be done
annually. A baseline density assessment should be performed at menopause
and then repeated as deemed necessary by the primary healthcare provider.
The tetanus booster should be performed every 10 years.
Evaluation; Health Promotion and Maintenance; Analysis
3.17•A client is admitted to the acute care facility from a
homeless shelter. The day after the admission, the client becomes
unresponsive and experiences cardiac arrest. The nurse caring for the
client reports there is no order to withhold resuscitative efforts. Which
of the following actions is indicated first?
1. Resuscitation
must be initiated.
2. The
homeless shelter must be notified.
3. The
admitting physician must be notified.
4. The
shift supervisor must be notified.
Answer: 1
Rationale: In the absence of a do not resuscitate order,
actions to restore life must be initiated. The homeless shelter would
have no jurisdiction over the client. The physician will require notification
but the focus is on initiating the code. The supervisor will also require
notification but it is not the first step to be taken.
Implementation; Safe, Effective Care Environment; Application
3.18•A client is admitted to the acute care facility from a
private residence where she lives with her granddaughter. The client is
81 years of age. After diagnostic testing is completed, the physician
indicates an intestinal obstruction has been located and plans are made for
surgical intervention. The nurse is charged with obtaining the surgical
consent. A review of the admission information lists the next of kin as a
daughter who lives in a neighboring community. Who will be the
responsible party to sign the surgical consent?
1. The
client’s granddaughter will sign the consent.
2. The
client’s daughter will sign the consent.
3. The
client will sign the consent.
4. Both
the client and the daughter will sign the consent.
Answer: 3
Rationale: Unless there has been some indication of a loss
of competence or legal document establishing power of attorney, the client has
the responsibility of signing surgical consents.
Planning; Safe, Effective Care Environment; Application
3.19•A nurse recently hired by an ambulatory care clinic has
attended training relating to HIPAA. Which of the following statements by
the nurse indicates understanding of the regulations associated with HIPAA?
1. “I
cannot discuss the past medical history of a client seeking care at the clinic
with her husband without permission.”
2. “Faxing
of information is prohibited by HIPAA.”
3. “Verbalization
of an understanding of the privacy notice regarding healthcare information is
sufficient.”
4. “Financial
information relating to payment for services is not subject to the HIPAA
regulations.”
Answer: 1
Rationale: Discussion of past, present, or future
healthcare, health status, or condition is not allowed without the express
permission of the client. Faxing is permitted but only with the
permission of the parties involved. Clients are required to sign receipt
and understanding of the policy of the healthcare privacy information.
Verbalization is not sufficient. Financial information is included in the
HIPAA regulations.
Evaluation; Safe, Effective Care Environment; Analysis
3.20•The nurse is working in the clinic when a client calls in
asking for a copy of her physical examination to be faxed to her
employer. She indicates her employer is awaiting the information.
What response by the nurse is indicated?
1. “You
will need to ask the employer fax a response once the information has been
safely received.”
2. “Faxing
of information is prohibited by HIPAA.”
3. “I
will need to confirm the fax number with the recipient first.”
4. “Faxing
is the least secure technological method of sending information.”
Answer: 4
Rationale: Faxing is the least secure technological method
of sending information. Faxing of health-related information is
permissible but consent must be given by the client. The fax number and
recipient must be provided by the client.
Planning; Safe, Effective Care Environment; Application
3.21•The nursing student questions the instructor about the use
of informed consent. The student asks when consents are required.
After discussing the topic with the student, which of the following statements
indicates the need for further instruction?
1. Informed
consent is required for all invasive procedures.
2. Informed
consent is implied for basic, nonspecialized procedures.
3. The
admission of a blood transfusion requires a signed consent.
4. A
client giving informed consent is legally acknowledging awareness of other
methods of treatment for the disorder/condition.
Answer: 1
Rationale: Informed consent is used to refer to an
understanding of the client of the care and procedures being performed.
Informed consent is not required for all procedures. An IV insertion is
an invasive procedure. It does not require a signed consent.
Consent is implied. The remaining statements are correct.
Evaluation; Assessment; Analysis
3.22•A nurse is caring for a client, age 70, who is preparing to
undergo surgery for a hernia. The nurse is concerned about the client’s
competency and ability to sign the surgical consent. A review of the
medical records reveals no power of attorney is in existence. The nurse
is performing an assessment to ensure the client is able to provide
consent. Which of the following criteria must be met?
1. The
client must voice knowledge of the medications that will be utilized for
anesthesia.
2. The
client must be able to verbalize the decision to undergo the surgical
procedure.
3. The
client must be able to acknowledge reasonable treatment options available.
4. The
client must understand that antibiotics may be administered after the
procedure.
Answer: 3
Rationale: The client must be able to make his or her
understanding about the procedure known to the healthcare team.
Knowledge of medications for anesthesia or infection is not a requirement for
completion of the surgical consent. Verbalization may not be possible for
some competent clients.
Diagnosis; Psychological Integrity; Analysis
3.23•The client has been admitted to the acute care facility
from the assisted living community. Upon admission, the client was in
agreement with the plan of treatment. Since admission, the client has
become increasing unhappy with the plan of care and wishes to refuse some of
the medications prescribed. Which of the following statements is most
correct?
1. The
consent for treatment obtained at admission implies acceptance of the
treatments being prescribed and should be followed by the client.
2. The
client should be discharged if she is not in agreement with the elements of the
plan of care.
3. The
client may decline options for treatment as desired.
4. The
client living in an assisted living environment is restricted in his or her
decision-making abilities and must consult with the community attorney to make
this type of care decision.
Answer: 3
Rationale: Consent that is given during hospitalization
may be withdrawn at any time. The client should speak with the healthcare
provider about areas of dissatisfaction as they arise to make mutually
acceptable decisions. The client residing in the assisted living
community has no fewer rights than any other client. The assisted living
attorney does not have a role in the planning of the care for this client.
Assessment; Psychological Integrity; Application
3.24•The daughter of a client who comes to the adult day care
service asks the nurse about the best way to select a physician for her
78-year-old father. She reveals her father has a history of hypertension
and suffered a mild stroke 30 years ago. What advice should be given in
response to the inquiry?
1. “ I
would recommend you consider Dr. Smith.”
2. “A
family practitioner would provide the best type of care for your father.”
3. “There
are several family nurse practitioners in the area who might be able to take
your father as a patient.”
4. “An
internist would be the best provider of care for your father.”
Answer: 4
Rationale: The internist is a physician for adults.
The internist has training and specialization in specific areas.
Considering the client’s history of cardiovascular problems, this would be the
best option. Recommending a specific physician would not be
prudent. A family practitioner or a nurse practitioner would be able to
provide more generalized care and does not present the wisest option for the
client, considering his age and health history.
Implementation; Safe, Effective Environment; Application
3.25•A homeless man, age 66, is admitted to the acute care
facility. He was found lying in an alley. An investigation revealed
the individual is homeless and does not have any available family
members. The client is unresponsive at the time of admission. The
prognosis is guarded. Which action by the healthcare facility is
indicated?
1. Notify
a local homeless shelter.
2. The
hospital will approach a judge to have the client become a ward of the state.
3. The
hospital will assume implied consent for care for a period of 48 hours and then
move forward if there is no change to name a guardian.
4. The
client will be represented by the hospital social worker until he regains
consciousnesses or a guardian is appointed.
Answer: 2
Rationale: In the absence of capacity by the client to
communicate his or her wishes, the facility will approach the court to have the
client named a ward of the state. The court will then appoint a legal
guardian for healthcare to make decisions.
Planning; Safe, Effective Care Environment; Analysis
CHAPTER 4
Cultural Diversity
4.1•The charge nurse is making assignments for the nursing
assistants in a long-term care facility. A message was left that a 96-year-old
male client did not want an African American nurse aide caring for him.
Although care is provided to all clients consistently without bias to race or
other ethnic and cultural aspects, the charge nurse recognizes that this is a
characteristic of
1. unacceptable
racial bias.
2. life
trajectory differences.
3. complexity
of the cultural care triad.
4.
Answer: 3
Rationale: The client’s age would indicate that he was born
during a time when racial bias was acceptable. Although the nurse and the
direct caregiver may not possess the same racial bias, this circumstance
illustrates the complexity of the cultural care triad, where the nurse, client,
and caregiver come from diverse backgrounds, ethnicities, and life experiences.
Life trajectory is the experiences of an individual’s life and can differ among
individuals. Ethnicity pertains to a social group within the social system that
claims to possess variable traits.
Planning
Psychosocial Integrity
Analysis
4.2•The nurse places a patient in a treatment room of the
emergency department for treatment of abdominal pain and vaginal bleeding. The
patient is a female of the Islamic culture. The husband of the patient speaks
for the woman and asks that only a female doctor examines his wife for the
pelvic exam. To provide culturally appropriate care for this client, the nurse
would explain that
1. the
male and female doctors both respect the client’s privacy.
2. the
client will be covered with a sheet so it will not matter whether the examiner
is male or female.
3. the
request is unreasonable and cannot be honored.
4. a
female doctor is present so their request can be accommodated.
Answer: 4
Rationale: Many cultures have religious beliefs that prohibit
examination by men of reproductive areas of a female. To provide culturally
appropriate care, the nurse must recognize this as a legitimate request and
make every attempt to honor this request. Although both male and female staff
have professional and ethical responsibilities to respect a patient’s privacy,
the nurse must still make efforts to meet the request of the client. The
response of covering the patient or stating the request is unreasonable shows
insensitivity to the client’s cultural need.
Implementation
Psychosocial Integrity
Application
4.3•The nurse is conducting an assessment of a client of the
Jewish faith. While questioning the client about nutritional intake, the client
states he cannot eat certain types of foods. The client also states that he has
fasting requirements that must be followed on religious holidays. Tomorrow is a
recognized holiday. To meet the client’s request the nurse would
1. inform
the physician of the patient request and consult the dietician to obtain food
preferences for meals.
2. document
the client preferences on the assessment form.
3. explain
to the client that he must eat to maintain nutritional intake.
4. report
the client request at the end of the shift to the oncoming nurse.
Answer: 1
Rationale: Although documenting and reporting to co-workers
records the patient nutritional preferences, informing the client’s physician
and a dietician take the care further to implementation and meeting the client
needs. Trying to convince the client to not follow cultural or religious
beliefs demonstrates cultural insensitivity on the part of the nurse.
Implementation
Psychosocial Integrity
Application
4.4•The nurse is caring for an infant in the clinic who is
present for a routine wellness exam. The child is of an African ethnic origin
whose parents immigrated to America 6 months ago. The mother explains that she
has been using an herbal paste to treat the infant’s diaper rash. In providing
care to the client, the nurse would
1. tell
the mother not to use the paste because there is no way to know what the
ingredients’ scientific effect may be.
2. ask
the mother what the ingredients are in the paste.
3. give
the mother an alternate cream.
4. explain
how herbal ingredients may be harmful to the infant.
Answer: 2
Rationale: To recognize cultural practices, the nurse must
acknowledge that use of old and home remedies are part of caregiving practices.
Asking the mother what ingredients are in the paste allows the nurse to best
evaluate what the mother is using, and then a determination of the benefit or
detriment to the infant can be made in a nonjudgmental manner. Telling the
mother not to use the paste, giving an alternative, or making a judgment that
any herbal ingredient is harmful does not recognize this cultural practice and
shows insensitivity on the part of the nurse.
Implementation
Physiological Integrity
Application
4.5•The nurse is reviewing the medication record of a Latino
client who had surgery yesterday. Pain medication is documented as being
administered for the client only once in the past 24 hours. The nurse enters
the room to assess the client’s pain. There are two family members in the room.
What would be important to include in this client’s assessment? (Select all
that apply.)
1. The
client understands the language sufficiently to ask for pain medication.
2. The
client withholds his complaints of pain with the family present.
3. The
nature of the surgery was minor and pain medication may not be needed.
4. The
client views pain as punishment for past behaviors.
5. The
socially acceptable behaviors for expressing pain.
Answer: 1, 2, 4, 5
Rationale: Despite the “minor” nature of any surgery, an
individual may experience pain. Assuming that there is no pain does not
adequately assess the client needs. Given the cultural profile of this client,
the nurse would need to assess the cultural influences (language, family
presence, client view of reason for pain, and socially acceptable behaviors)
that may influence the data obtained from the client.
Assessment
Physiological Integrity
Application
4.6•The nurse is meeting with the family of a 95-year-old
Chinese client. The client’s family insists that they will care for the client
in their home on discharge, stating that it is their tradition and
responsibility. The nurse can meet the client’s need by
1. insisting
that the family reconsider their decision and look at other treatment care
options.
2. explaining
to the family that, despite their tradition, there are resources that they can
use to help them and they should not bear all the burden.
3. exploring
the resources the family has to meet the client needs in their home.
4. discussing
how other families have approached this problem.
Answer: 3
Rationale: The nurse needs to establish respect for the cultural
beliefs and practices of individuals. Insisting the family break tradition or
comparing them to families of different cultural backgrounds does not recognize
the cultural aspects of this client and the family. Neither does expressing
personal judgment of what is a burden to the family as is stated in option b.
Helping the family explore resources to meet their needs and the client’s is
the best method to respect the tradition of the cultural background of this
client and family.
Planning
Psychosocial Integrity
Application
4.7•You are reviewing the lab reports for a Jehovah’s Witness
client. Your understanding of this religion is that they will not accept blood
transfusions even though the lab values indicate that the client needs the blood.
You decide to intervene for the patient by
1. calling
the doctor for an order for a blood transfusion.
2. consulting
pastoral care to talk to the patient.
3. asking
the client if he would reconsider the decision not to receive blood.
4. informing
the doctor of the lab values and modifying care to meet the needs of the client
since blood will not be administered.
Answer: 4
Rationale: Religious beliefs may affect the healthcare decisions
that clients make. The nurse, providing care, must respect the client’s
religious beliefs and modify care to meet the client needs. An ethical dilemma
develops when religious beliefs present a life-threatening circumstance. The
physician should be notified of the lab values to determine the long-term or
critical affect of the client’s decision. Simply calling the doctor does not
comprehensively meet the client needs. Consulting pastoral care or insisting
the patient violate religious beliefs shows lack of respect for the cultural
and religious characteristics of this client.
Implementation
Physiological Integrity
Application
4.8•The daughter of an 80-year-old Spanish client reports that
her mother seems not to understand what the doctor tells her about her disease
and the treatment plan. She asks whether an interpreter is present when he
talks to her mother. You explain that every attempt to have someone translate
information to her mother is being done, but sometimes it is not possible.
However, you acknowledge that this may not be effective care for this patient.
To meet the national standards for Culturally and Linguistically Appropriate
Services (CLAS) in healthcare, the nurse would
1. continue
to monitor the patient and offer explanations using common symbols.
2. report
the problem to the doctor.
3. revise
the plan of care to ensure an interpreter is present at all times.
4. ask
the daughter to be present whenever anyone speaks to the client.
Answer: 3
Rationale: The national standards for CLAS require that
interpreters be present for clients who have language differences from
healthcare providers. Therefore, not to provide this at all times for this
client violates the client’s rights. Monitoring the client and using symbols
can aid in communication but does not ensure that the client understands.
Reporting to the physician makes him aware of the barrier, but again does not
ensure that the client understands what is being said. And, expecting the
client’s daughter to be available for every contact may be burdensome and an
unreasonable request.
Planning
Safe, Effective Care Environment
Application
4.9•A Korean client is receiving care in a rehabilitation unit
after suffering from a stroke. The nurse notices that during the past few days
the client has eaten very little food. The client only speaks Korean and the
daughter who interprets for the client states that her mother does not like the
food. What intervention could be used to increase the client’s food intake?
1. Make
sure food is the right temperature for the client.
2. Ask
the daughter to tell her mother to eat more.
3. Add
nutritional supplements to her diet.
4. Assess
the client’s food preferences and consult dietary to include requested ethnic
dishes.
Answer: 4
Rationale: Decreased intake may be a sign that there is a
cultural barrier in a client that demonstrates heritage consistency. This
client may not be eating because the food does not meet her cultural
preferences. Therefore, to encourage her to eat food she may not like would not
meet the client’s need. Adding supplements that the client may not eat or
adjusting food temperature may not be helpful. The only intervention that meets
the cultural need is option d, which includes an assessment of both general and
cultural food preferences.
Intervention
Physiological Integrity
Analysis
4.10•The son of an 89-year-old client approaches you to discuss
his mother’s care. He is of the Arabic culture and stands very close to the
nurse when speaking. The nurse who is of the American culture steps back from
him to continue the conversation. The nurse’s action is related to which of the
following circumstances?
1. cultural
differences of personal space
2. concern
for safety
3. avoidance
of the son’s concern
4. the
need to observe body language during the conversation
Answer: 1
Rationale: It is well known that different cultures define personal
space differently. It is a natural response to step back when someone enters
personal space with which you are not comfortable. The nurse is of a culture
that speaking with an unknown person in the personal space would make the nurse
uncomfortable. There is no indication that safety is a concern and the nurse
continues to listen thus not avoiding the son’s concern. Body language is
important to observe but is not the reason for the nurse moving back during the
conversation.
Intervention
Psychosocial Integrity
Analysis
4.11•A nurse practitioner (NP) who specializes in serving the
elderly population is learning Spanish to help increase her ability to
communicate with the clients in her practice. The NP is aware that:
1. the
elderly Hispanic population is the fastest growing elderly population in the
United States.
2. it is
not important to learn the language that your clients speak.
3. the
elderly population is steadily moving toward the southern states, and learning
Spanish will help the NP teach patients in the future.
4. the
Hispanic population has large families, so most elderly Hispanics will have a
family member present to help with interpretation.
Answer: 1
Rationale: The Hispanic population is the fastest growing
population in the United States. By learning Spanish, the NP will be able to
better communicate with her clients.
4.12•A nurse is providing discharge instructions to a Chinese
client regarding prescribed dietary modifications. During the teaching session,
the client continuously turns away from the nurse. Which nursing action is
appropriate?
1. Continue
with the instructions, verifying client understanding.
2. Walk
around the client so that the nurse constantly faces the client.
3. Give
the client a dietary booklet and return later to continue with the
instructions.
4. Tell
the client about the importance of the instructions for the maintenance of
health care.
Answer: 1
Rationale: Most Chinese maintain a formal distance with others,
which is a form of respect. Many Chinese are uncomfortable with face-to-face
communication. Walking around the client is in conflict with the cultural
practice. The client may consider returning later to continue the instructions
to be rude on the part of the nurse. Telling the client about the importance of
the instructions may be viewed as degrading.
Application; Physiological Integrity; Implementation
4.13•A nurse is preparing to admit an elderly client who is
deaf. The nurse is aware that ineffective communication can lead to improper or
delayed care. What intervention should the nurse include to ensure that she can
effectively communicate with the client?
1. Use
the hospital-approved interpreter program.
2. Ask
if anyone who is currently working could help communicate with the client.
3. Turn
the computer screen so that the client can read the questions the nurse needs
to ask the client.
4. Use
the client’s family members to communicate with the client.
Answer: 1
Rationale: Use of a hospital-approved interpreter program is the
intervention of choice when communicating with any client who is deaf or has
limited English proficiency. Turning the computer screen toward the client does
not ensure that the client will understand the questions that are being asked.
Use of other co-workers or family members can interfere with confidentiality
and also does not ensure that the information is being communicated correctly.
Planning, Safe, Effective Care Environment, Application
4.14•A student nurse is discussing the three areas of focus
regarding Cultural Care nursing. Which statement by the student indicates a
lack of understanding of Cultural Care nursing?
1. “A
nurse must apply the underlying background knowledge that must be possessed to
provide a given patient with the best healthcare possible.”
2. “A
nurse must possess some basic knowledge of and constructive attitudes toward
the health traditions observed among the diverse cultural groups found in the
practice setting.”
3. “A
nurse must understand and attend to the total context of the patient’s
situation. It is a complex combination of knowledge, skills, and attitudes.”
4. “A
nurse must understand the basic traditions of diverse cultural groups and be
able to explain to clients how these traditions must be changed to fit into the
plan of care.”
Answer: 4
Rationale: A nurse must have basic knowledge of diverse cultural
groups, but in Cultural Care nursing the goal is to incorporate their
traditions, not change them to meet the plan of care. Options 1, 2, and 3 are
definitions of the three areas of focus for Cultural Care nursing.
Implementation, Health Promotion and Maintenance, Application
4.15•A nurse is preparing an educational program for her peers
regarding heritage consistency. Which of the following is an example that
describes heritage consistency?
1. an
individual who attended a parochial school with a religious philosophy similar
to the family’s background
2. an
individual who does not maintain regular contact with extended family
3. an
individual who changes his or her name so that it is Americanized
4. an
individual who resides in an ethnic neighborhood different from his or her own
ethnic background
Answer: 1
Rationale: Heritage consistency is when an individual identifies
with his or her traditional heritage. Option 1 shows a situation where this is
occurring. Options 2, 3, and 4 all show situations where the individual does
not stay in contact with his or her traditional heritage.
Planning, Health Promotion and Maintenance, Application
4.16•A nurse educator working in a long-term care facility has
just finished preparing an educational program on providing culturally
competent care for several nursing assistants. Which response by a nursing
assistant would indicate a need for further education?
5. “I
will ask my clients how they would like for me to address them.”
6. “I
will address all of my clients by their last name.”
7. “I
will respect my clients’ need for privacy when they wish to pray.”
8. “I
will allow my clients to spend time with their families and not interrupt them
when it’s their scheduled time for a shower.”
Answer: 2
Rationale: Options 1, 2, and 4 show examples of how to give
culturally competent care. It is proper to ask clients how they wish to be
addressed. Some clients will prefer first names, some will prefer last names.
Evaluation, Safe, Effective Care Environment, Analysis
4.17•A graduate nurse is preparing to perform a cultural
assessment on a client recently admitted to a long-term care facility. How does
the nurse assess the client’s communication pattern? Select all that apply.
1. Does
the person do the speaking or defer to another?
2. What
is the person’s proximity to other people and objects within the environment?
3. How
does the person react to the nurse’s movement toward him or her?
4. What
nonverbal communication behaviors are exhibited?
Answer: 1, 2, 3, 4
Rationale: A nurse must answer all of these questions to help
determine a persons’ communication pattern.
Planning, Physiological Integrity, Analysis
4.18•A student nurse is preparing a presentation for her
classmates regarding the Cultural Care triad. What information does the student
need to include? Select all that apply.
1. The
triad consists of the nurse, patient, and direct caregiver.
2. Based
on recent statistics, there is a demographic parity in this triad.
3. Based
on recent statistics, there is demographic disparity in this triad.
4. The
registered nurse, in general, is a white woman between the ages of 40 and 55,
who is married and has children.
Answer: 1, 2, 3
Rationale: The average age of the registered nurse is between 30
and 49. All other information is correct.
Planning, Safe, Effective Care Environment, Application
4.19•A nurse has completed giving a presentation to her peers
regarding ethnocultural heritage. What statement by a peer would indicate a
need for further education?
1. “Heritage
consistency describes the degree to which a person’s lifestyle reflects his or
her respective tribal culture.”
2. “Culture
is the thoughts, communications, actions, beliefs, values, and institutions of
racial, ethnic, religious, or social groups.”
3. “Ethnicity
pertains to a social group within the social system that claims to possess
variable traits such as a common religion or language.”
4. “A
person can only value characteristics that are heritage consistent.”
Answer: 4
Rationale: A person can value characteristics that are both
heritage consistent (traditional) and heritage inconsistent (modern). These
values exist on a continuum. The rest of the statements are true regarding
ethnocultural heritage.
Evaluation, Psychosocial Integrity, Analysis
4.20•A long-term care nurse is completing a heritage assessment
tool with a female client. Which of the following questions would not be included in
this assessment?
9. “How
do you prefer to be addressed?”
10. “Do
you have a private place to pray?”
11. “What
medications do you currently take?”
12. “Do
you prefer to have a female caregiver assigned to you?”
Answer: 3
Rationale: Use of folk and home remedies is part of a heritage
assessment questionnaire. Prescribed medications are not. The rest of the
questions are included in the heritage assessment.
Planning, Psychosocial Integrity, Application
4.21•A nurse is has just finished giving a presentation for her
peers regarding cultural sensitivity. Which statement by a peer would indicate
a need for further education?
13. “I
will address all of my clients by their last name until they give me permission
to call them by their first name.”
14. “I
need to introduce myself and state my role to a client when I first meet the
client.”
15. “I
will never ask clients about their culture; I don’t want to offend them.”
16. “I
will show respect for the client’s support people. I understand that in some
cultures individuals don’t make their own healthcare decisions.”
Answer: 3
Rationale: If you don’t understand a particular action by a
client, it is okay to politely and respectfully seek information. This shows
you are being authentic when you are honest with others. All other statements
are correct.
Evaluation, Psychosocial Integrity, Analysis
4.22•A long-term care nurse is caring for a newly admitted
Jewish client. In reviewing the client’s records, the nurse notes that the
client has refused her meals since she was admitted 3 days ago. What would be
the most appropriate intervention for the nurse to complete first?
17. Notify
the physician.
18. Request
for the dietitian to evaluate the client.
19. Call
the client’s family and ask them to bring in food from home for the client.
20. Speak
to the client to see why she is not eating.
Answer: 4
Rationale: The nurse is aware that there may be some cultural
and/or religious beliefs that may keep the client from eating the meals. By
speaking with the client first, the nurse can assess for these issues.
Intervention, Physiologic Integrity, Analysis
4.23•A nurse is preparing a care plan for a client with limited
English skills. The nurse has identified risk for impaired verbal communication
as a nursing diagnosis. Which of the following interventions would be
appropriate for this diagnosis?
21. Using
an interpreter when communicating with the client
22. Asking
a family member to act as an interpreter
23. Writing
questions on a clip board for the client to read
24. Speaking
loud and slow when attempting to communicate with the client
Answer: 1
Rationale: Use of a competent interpreter is the most
appropriate intervention. Family members should not be used as interpreters.
Writing questions and speaking loudly does not help improve communication with
the client.
Intervention, Physiologic Integrity, Application
4.24•A student nurse is preparing a presentation regarding steps
to cultural competency. What questions does the student need to ask to become
more aware of his or her own ethnocultural heritage? Select all that apply.
25. “Where
were your parents and grandparents born?”
26. “Do
you value stoic behavior?”
27. “What
are examples of your ethnocultural life trajectories?”
28. What
do you see as seminal cultural events of your lifetime?”
Answer: 1, 2, 3, 4
Rationale: All are questions that can help a person become aware
of his or her own ethnocultural heritage.
Planning, Psychosocial Integrity, Application
4.25•A nurse has finished giving a presentation on Cultural Care
to her peers. What statement by a peer would indicate a need for further
education by the nurse?
29. “Cultural
Care describes nursing care as culturally competent.”
30. “Cultural
Care describes nursing care as culturally appropriate.”
31. “Cultural
Care describes nursing care as culturally aware.”
32. “Cultural
Care describes nursing care as culturally sensitive.”
Answer: 3
Rationale: The definition for Cultural Care is nursing care that
is culturally competent, culturally appropriate, and culturally sensitive.
Evaluation, Safe, Effective Care Environment, Application
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