Claudia Girbau

mary healthcare provider immediately b. Apply a warm, moist compress to the incision site c. Increase the intravenous fluid rate by 20 mL/hr d. Monitor vital signs more frequently b Correct answer- A nurse observes a window washer falling 25 feet (7.6 m) to the ground. The nurse rushes to the scene and determines that the person is in cardiopulmonary arrest. What should the nurse do first? a. Feel for a pulse b. Begin chest compressions c. Leave to call for assistance d. Perform the abdominal thrust maneuver d Correct answer- A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? a. Dull sound on percussion b. Vocal fremitus on palpation c. Rales with rhonchi on auscultation d. Absence of breath sounds on auscultation c Correct answer- A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which is the nurse's priority concern? a. Loss of skin integrity caused by the burns b. Potential infection as a result of the burn injury c. Inadequate gas exchange caused by smoke inhalation d. Decreased fluid volume because of the depth of the burns b Correct answer- During the first 48 hours after a client has sustained a thermal injury, which conditions should the nurse assess for? a. Hypokalemia and hyponatremia b. Hyperkalemia and hyponatremia c. Hypokalemia and hypernatremia d. Hyperkalemia and hypernatremia a Correct answer- A nurse is assessing a client's ECG reading. The client's atrial and ventricular heart rates are equal at 88 beats per min. The PR interval is 0.14 seconds, and the QRS width is 0.10 seconds. Rhythm is regular with normal P waves and QRS complexes. How will the nurse interpret this rhythm? a. Normal sinus rhythm b. Sinus tachycardia c. Sinus bradycardia d. Sinus arrhythmia b Correct answer- The nurse is caring for a client with a diagnosis of necrotizing fasciitis. Which is the priority concern of the nurse when caring for this client? a. Fluid volume b. Skin integrity c. Physical mobility d. Urinary elimination c Correct answer- A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and reports right-sided chest pain. What should the nurse do first? a. Obtain vital signs b. Initiate a cardiac arrest code c. Administer oxygen using a face mask d. Encourage the use of an incentive spirometer c Correct answer- A nurse is caring for a client with severe burns. The nurse determines that this client is at risk for hypovolemic shock. Which physiologic finding supports the nurse's conclusion? a. Decreased rate of glomerular filtration b. Excessive blood loss through the burned tissues c. Plasma proteins moving out of the intravascular compartment d. Sodium retention occurring as a result of the aldosterone mechanism a Correct answer- The nurse is caring for a client with burns and reviews the client's laboratory results: blood urea nitrogen (BUN), 30 mg/dL (10.2 mmol/L); creatinine, 2.4 mg/dL (184 mcmol/L); serum potassium, 6.3 mEq/L (6.3 mmol/L); pH, 7.1; Po 2, 90 mm Hg; and hemoglobin (Hgb), 7.4 g/dL (74 mmol/L). Which condition does the nurse suspect the client has based upon these findings? a. Azotemia b. Hypokalemia c. Metabolic alkalosis d. Respiratory alkalosis d Correct answer- A nurse is caring for a client who experienced serious burns in a fire. Which relationship between a client's burned body surface area and fluid loss should the nurse consider when evaluating fluid loss in a client with burns? a. Equal b. Unrelated c. Inversely related d. Directly proportional c Correct answer- A burn client is receiving the open method for wound treatment. Which information will the nurse explain to the client? a. Bathing will not be permitted. b. Dressings will be changed daily. c. Personal protective equipment will be worn by staff. d. Room temperature will be kept below 72° F (22.2° C). a Correct answer- A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? a. Deficient fluid volume b. Impaired skin integrity c. Inadequate nutritional intake d. Decreased participation in activities b Correct answer- A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? a. Milk b. Tea c. Orange juice d. Tomato juice a Correct answer- A woman comes to the office of her healthcare provider reporting shortness of breath and epigastric distress that is not relieved by antacids. To which question would a woman experiencing a myocardial infarction respond differently than a man? a. "Do you have chest pain?" b. "Are you feeling anxious?" c. "Do you have any palpitations?" d. "Are you feeling short of breath?" b Correct answer- During a vertex vaginal birth the nurse notes meconium-stained amniotic fluid. What is the priority nursing intervention for the newborn? a. Stimulating crying b. Suctioning the airway c. Using an Ambu bag with oxygen support d. Placing the infant in the reverse Trendelenburg position c Correct answer- While receiving a blood transfusion, the client suddenly shouts, "I feel like someone is lowering a heavy weight on my chest. I feel like I'm going to die!" Which actions are priority? a. Administer nitroglycerin and aspirin b. Slow the rate and monitor the vital signs c. Stop the transfusion and administer normal saline through new IV tubing d. Ask the client to further describe the feeling and rate the pain d Correct answer- A client who was hospitalized with partial- and full-thickness burns over 30% of the total body surface area is to be discharged. The client asks the nurse, "How will my spouse be able to care for me at home?" How should the nurse interpret this statement? a. Readiness to discuss the client's deformities b. Indication of a change in family relations c. Need for more time to think about the future d. Beginning realization of implications for the future b Correct answer- A nurse is assessing a client with a cast to the extremity. Which assessment finding is the priority? a. Warmth b. Numbness c. Skin desquamation d. Generalized discomfort b Correct answer- Which color of cerebrospinal fluid (CSF) may indicate subarachnoid hemorrhage in the client? a. Hazy b. Yellow c. Brown d. Colorless c Correct answer- A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments? a. Level of consciousness and pupil size b. Characteristics of pain and blood pressure c. Quality of respirations and presence of pulses d. Observation of abdominal contusions and other wounds b Correct answer- Which color tag will be given by the triage nurse to a client assigned to class IV, during a mass casualty situation? a. Red b. Black c. Green d. Yellow a Correct answer- A client who sustained a burn injury involving 36% of the body surface area is receiving hydrotherapy. Which is the best nursing intervention when providing wound care? a. Use a consistent approach to care and encourage participation. b. Prepare equipment while doing the procedure and explain the treatment to the client. c. Rinse the burn area with 105° F (40.6° C) water to prevent loss of body temperature. d. Arrange for a change of staff every 4 to 5 days and have the client select the time for the procedure to be done. b Correct answer- Which clinical manifestation can a client experience during a fat embolism syndrome (FES)? a. Nausea b. Dyspnea c. Orthopnea d. Paresthesia b Correct answer- A client was admitted with full-thickness burns 2 weeks ago. Since admission, the client has lost an average of 1 lb (0.5 kg) of weight each day. Which action will the nurse most likely take based upon the adjusted dietary plan? a. Provide low-sodium milk. b. Provide high-protein drinks. c. Provide foods that are low in potassium. d. Provide 10% more calories in the form of fats. d Correct answer- A burn victim has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms. The nurse calculates the percentage of total body surface area (TBSA). Which percentage will the nurse report? a. 20 b. 25 c. 30 d. 36 d Correct answer- A nurse places a client with severe burns on a circulating air bed. Which goal is the nurse trying to achieve? a. Increasing mobility b. Preventing contractures c. Limiting orthostatic hypotension d. Preventing pressure on peripheral blood vessels a Correct answer- Which noninvasive assessment and management skills certification would the nurse be required to use for airway maintenance and cardiopulmonary resuscitation (CPR)? a. Basic Life Support (BLS) b. Certified Emergency Nurse (CEN) c. Advanced Cardiac Life Support (ACLS) d. Pediatric Advanced Life Support (PALS) b Correct answer- The nurse is caring for different clients in a mass casualty event. Which client is assigned the lowest priority for care? a. Client with red tag b. Client with black tag c. Client with green tag d. Client with yellow tag b Correct answer- On the morning of surgery a client is admitted for resection of an abdominal aortic aneurysm. While awaiting surgery, the client suddenly develops symptoms of shock. Which nursing action is priority? a. Prepare for blood transfusions. b. Notify the surgeon immediately. c. Make the client nothing by mouth (NPO). d. Administer the prescribed preoperative sedative. a Correct answer- A nurse understands that value clarification is a technique useful in therapeutic communication because initially it helps clients do what? a. Become aware of their personal values b. Gain information related to their needs c. Make correct decisions related to their health d. Alter their value systems to make them more socially acceptable b Correct answer- An Asian client arrives at the mental health clinic with symptoms of anxiety and panic. While speaking with the client, the nurse notes that the client makes very little eye contact. What does this assessment data suggest? a. Shyness b. Cultural variation c. Symptom of depression d. Shame regarding treatment d Correct answer- Before effectively responding to a sexually abused victim on the phone, it is essential that the nurse in the rape crisis center do what? a. Get the client's full name and address. b. Call for assistance from the psychiatrist. c. Know some myths and facts about sexual assault. d. Be aware of any personal bias about sexual assault. c Correct answer- Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? a. Irish Americans b. African Americans c. Chinese Americans d. Egyptian Americans a Correct answer- The preschool-age client is learning sociocultural mores. What should this imply to the nurse regarding this client? a. The child is developing a conscience. b. The child is learning about gender roles. c. The child is developing a sense of security. d. The child is learning about the political process. c Correct answer- A client who has a hemoglobin of 6 gm/dL (60 mmol/L) is refusing blood because of religious reasons. What is the most appropriate action by the nurse? a. Call the chaplain to convince the client to receive the blood transfusion. b. Discuss the case with coworkers. c. Notify the primary healthcare provider of the client's refusal of blood products. d. Explain to the client that they will die without the blood transfusion. b Correct answer- Obesity in children is an ever-worsening problem. What concept should a nurse consider when caring for school-aged children who are obese? a. Enjoyment of specific foods is inherited. b. There are familial influences on childhood eating habits. c. Childhood obesity is usually not a predictor of adult obesity. d. Children with obese parents are destined to become obese themselves. d Correct answer- After determining that the nurses on the psychiatric unit are uncomfortable caring for clients who are from different cultures than their own, the nurse manager establishes a unit goal that by the next annual review the unit will have achieved what? a. Increased cultural sensitivity b. Decreased cultural imposition c. Decreased cultural dissonance d. Increased cultural competence a Correct answer- A client who only speaks Spanish is being cared for at a hospital in which nursing personnel only speak English. What communication technique would be appropriate for the nurse to use when discussing healthcare decisions with the client? a. Contact an interpreter provided by the hospital. b. Contact the client's family member to translate for the client. c. Communicate with the client using Spanish phrases the nurse learned in a college course. d. Communicate with the client with the use of a hospital-approved Spanish dictionary. b Correct answer- During a routine checkup a patient reports concerns over weight gain despite trying juice cleanses and other trend diets. The nurse records the patient's weight and BMI at a healthy range, but the patient states, "I wish I were as thin as my co-workers." The patient is at risk for what culturally-bound condition? a. Neurasthenia b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios a Correct answer- The nurse is caring for an Asian client who had a laparoscopic cholecystectomy six hours ago. When asked whether there is pain, the client smiles and says, "No." What should the nurse do? a. Monitor for nonverbal cues of pain b. Check the pressure dressing for bleeding c. Assist the client to ambulate around his room d. Irrigate the client's nasogastric tube with sterile water a Correct answer- A 5-year-old child who is newly arrived from Latin America attends a nursery school where everyone speaks English. The child's mother tells the nurse that her child is no longer outgoing and has become very passive in the classroom. What is the probable reason for the child's behavior? a. Culture shock b. Social immaturity c. Experience of discrimination d. Lack of interest in school activities d Correct answer- A nurse manager works on a unit where the nursing staff members are uncomfortable taking care of clients from cultures that are different from their own. How should the nurse manager address this situation? a. Assign articles about various cultures so that they can become more knowledgeable. b. Relocate the nurses to units where they will not have to care for clients from a variety of cultures. c. Rotate the nurses' assignments so they have an equal opportunity to care for clients from other cultures. d. Plan a workshop that offers opportunities to learn about the cultures they might encounter while at work. a Correct answer- A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage? a. Coin in the umbilicus b. Tight diaper over the umbilicus c. Binder that encircles the umbilicus d. Adhesive tape across the umbilicus c Correct answer- What should a nurse consider about the past experiences of clients who have immigrated to this country? a. It affects all of their inherited traits. b. There will be little impact on their lives today. c. It is important that their values be assessed first. d. How they will interact is permanently established. a Correct answer- Which behavior is seen in children at the undifferentiated stage of spiritual development, as propounded by Fowler? a. Children have no concept of right or wrong to guide their behaviors. b. Children imitate the religious behaviors without comprehending any meaning. c. Children reason and question some of the established parental religious standards. d. Children have a reverence for religious matters and are able to articulate their faith. c Correct answer- A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? a. "Hospital policies should put a stop to this." b. "Everyone should conform to the prevailing culture." c. "Nontraditional approaches to health care can be beneficial." d. "You are right because they may have a negative impact on people's health." a Correct answer- A resident in a nursing home recently immigrated to the United States (Canada) from Italy. How does the nurse plan to provide emotional support? a. By offering choices consistent with the client's heritage b. By assisting the client in adjusting to American culture c. By ensuring that the client understands American beliefs d. By correcting the client's misconceptions about appropriate health practices b Correct answer- A multigravida of Asian descent weighs 104 lb (47.2 kg), having gained 14 pounds (6.4 kg) during the pregnancy. On her second postpartum day, the client's temperature is 99.2° F (37.3° C). She has had poor dietary intake since admission. What should the nurse do? a. Ask the nursing supervisor to discuss this with the healthcare provider. b. Encourage the family to bring in special foods preferred in their culture. c. Order a high-protein milkshake as a between-meal snack to stimulate her appetite. d. Explain to the family that the dietitian plans nutritious meals that the client should eat. d Correct answer- Which internal variable influences health beliefs and practices? a. Family practices b. Cultural background c. Socioeconomic factors d. Intellectual background c Correct answer- A new mother said to the nurse, "I would like to care for my baby independently rather than depending on the baby's grandparents." What does the nurse infer from this information? a. The patient is of Asian culture. b. The patient is of African culture. c. The patient is of North American culture. d. The patient is of Latin American culture. c Correct answer- As the nurse is discussing psychiatric care with an older adult client, the client says, "When I was growing up I was taught to accept my lot in life and not complain. I'm proud of the fact that despite my issues I can still function independently. I don't want to be just put away." The nurse understands that the factors that influence the client's mental health are examples of what? a. Setting of care b. Anxiety disorder c. Attitudes and beliefs d. Cultural and ethnic disparities d Correct answer- The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? a. Dietary practices b. Concept of space c. Immigration status d. Role within the family c Correct answer- How can the lines of communication be improved in a healthcare organization during the process of delegation? a. By considering all aspects of client care b. By selecting experienced nursing assistants as delegatees c. By appreciating and valuing each other's cultural perspectives d. By selecting a delegatee having similar strengths as that of the delegator b Correct answer- During a survey, the community nurse meets a client who has not visited a gynecologist after the birth of her second child. The client says that her mother or sister never had annual gynecologic examinations. Which factor is influencing the client's health practice? a. Spiritual belief b. Family practices c. Emotional factors d. Cultural background d Correct answer- The nurse is caring for an African American client with renal failure. The client states that the illness is a punishment for sins. Which cultural health belief does the client communicate? a. Yin/Yang balance b. Biomedical belief c. Determinism belief d. Magicoreligious belief a Correct answer- A pregnant immigrant notices cultural differences in the way that pregnant women are cared for where she now lives. Which component of cultural competence is being demonstrated when the nurse motivates the immigrant to accept these differences? a. Cultural desire b. Cultural awareness c. Cultural knowledge d. Cultural encounters a Correct answer- A nurse notices that a client is in spiritual distress. Which nursing action establishes the nurse as a caregiver? a. The nurse provides therapeutic treatment to the client. b. The nurse teaches the client about signs of spiritual distress. c. The nurse communicates the wishes of the client to family members. d. The nurse collaborates with the agency chaplain to pursue the best treatment plan. a,b,c Correct answer- Which nursing interventions are examples of the nurse as a caregiver? (Select all that apply) a. Encouraging the client to exercise daily b. Setting goals for the client to reduce weight c. Arranging for the client to meet a spiritual advisor d. Evaluating the client's understanding of prescribed diet e. Demonstrating the procedure to self-administer insulin injection b Correct answer- An African-American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African-American people?" What is the nurse's best response? a. "The prevalence of hypertension is about equal for women of all races." b. "The higher-risk population is composed of African-American men and women." c. "The highest-risk population consists of older Caucasian-American men and women." d. "The prevalence of hypertension is greater for African-American men than for African-American women." c Correct answer- A nurse understands that when a client is a member of a different ethnic community it is important to do what? a. Ensure that the nurse's biases are understood by the family. b. Make plans to counteract the client's misconceptions about therapies. c. Offer a therapeutic regimen compatible with the lifestyle of the family. d. Recognize that the client's responses will be similar to other clients' responses. d Correct answer- Which carative factor is involved in creating a healing environment at all levels, physical and non-physical, according to Watson's Transpersonal Caring? a. Promoting transpersonal teaching-learning b. Promoting and expressing positive and negative feelings c. Developing a helping, trusting, human caring relationship d. Providing for a supportive, protective, and/or spiritual environment d Correct answer- The nurse leader states, "The people in rural America dress and act differently from those in urban centers." What concept describes this statement? a. Acculturation b. Ethnocentrism c. Cultural imposition d. Cultural marginality c Correct answer- A daughter of a Chinese-speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? a. Prejudice b. Stereotyping c. Assimilation d. Ethnocentrism d Correct answer- The nurse is assessing a Latino-Caribbean patient who was brought to the hospital by family members. The family reports the patient started crying, shouting, trembling, had uncontrolled jerking of the extremities, and then fell into a trance-like state. What condition does the nurse suspect? a. Bulimia nervosa b. Anorexia nervosa c. Shenjing shuairuo d. Ataque de nervios a Correct answer- A foreign language-speaking client needs to undergo chemotherapy; a signed consent form is required. What should the nurse do to explain the terms of the consent to the client? a. Seek the help of an official interpreter. b. Seek the help of the primary healthcare provider to assist the client. c. Seek help from the client's family friend who speaks the client's language. d. Seek help from the client's caregiver who speaks the same language as the client. c Correct answer- A hospice nurse is caring for a dying client and the client's family members during the developing awareness stage of grief. What is the most important thing about the family that the nurse should assess before providing care? a. Cohesiveness b. Educational level c. Cultural background d. Socioeconomic status c Correct answer- A nurse is caring for an adult client who immigrated to this country 5 years ago. What does the nurse know about the past experiences of clients who have immigrated to this country? a. They affect their inherited traits. b. They have little effect on their lives today. c. They are important in assessment of their values. d. They establish personal interactions throughout life. a Correct answer- When caring for a client who adheres to a kosher diet, which important thing should the nurse make sure to exclude from the client's meals? a. Pork and shellfish b. Blood-containing food c. All meat, fish, and poultry d. Animal and dairy products during Lent d Correct answer- A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? a. "Do you like living in this country?" b. "When did you come to this country?" c. "Is there a family member who can translate for you?" d. "Which family member do you prefer to receive information?" a Correct answer- A client says "Do not cut the thread on my wrist before sending me for surgery because the thread is a blessing from God." Which internal variable influences the client's health belief in this scenario? a. Spiritual factors b. Emotional factors c. Developmental stage factors d. Intellectual background factor b Correct answer- A pregnant client states, "Abortion is banned in our community because it interferes with God's creative work." According to the nurse, which variable influences the client's health belief? a. Emotional factors b. Cultural background c. Socioeconomic factors d. Perception of functioning d Correct answer- A school nurse works with adolescents who recently immigrated to the U.S. and are adjusting to life in the public schools. What characteristics help the nurse differentiate students who are assimilating from students who are acculturating? a. Students who acculturate shun all aspects of their new culture. b. Students who assimilate are generally unhappy in their new culture. c. Students who acculturate tend to be more social in their new culture. d. Students who assimilate abandon all aspects of their original culture. c Correct answer- A nurse is helping a client who observes the traditional Jewish dietary laws to prepare a dietary menu. What considerations should the nurse make? a. Eating beef and veal is prohibited. b. Consumption of fish with scales is forbidden. c. Meat and milk at the same meal are forbidden. d. Consuming alcohol, coffee, and tea are prohibited. c Correct answer- The nurse starts a new job and recognizes that the patient population is very diverse. What action will help the nurse to provide culturally competent care? a. Read about all of the cultural groups in the local population. b. Treat all of the patients the same, regardless of their cultural background. c. Increase self-awareness of cultural identity, cultural knowledge, and potential biases. d. Attempt to remain culturally neutral while treating patients of a different culture. c Correct answer- Among which group of women are breast cancer death rates the lowest? a. Hawaiian b. Puerto Rican c. Asian American d. African American a,b,c,d Correct answer- When compared with their non-Hispanic white counterparts, which factors contribute to the health disparities Hispanic older adults face? (Select all that apply). a. Value differences b. Language barrier c. Lack of health care facility d. Inadequate health insurance e. Poor diet and nutrition a,b,e Correct answer- What statements about culturally congruent care by the student nurse are correct? (Select all that apply). a. "It is the main goal of transcultural nursing." b. "It is provided through cultural competence." c. "It is provided in accordance with set criteria." d. "It is bound to the professional health care system." e. "It depends on the patterns and needs of an individual." b Correct answer- A patient with a terminal illness is grateful for the care received in the hospital and has slowly started to come to terms with imminent death. The nurse recognizes that the patient's behavior and attitude is most consistent with which cultural group? a. German culture b. Somalian culture c. Ukrainian culture d. More secular culture d Correct answer- A patient who does not understand English requires an interpreter. Which nursing student action may exacerbate health disparities? a. The student expects the interpreter to act as the patient's advocate. b. The student expects the interpreter to have a health care background. c. The student maintains steady eye contact with the patient. d. The student talks only to the interpreter about the patient. b Correct answer- While talking with a 60-year-old patient, the nurse learns that the patient emigrated 15 years ago from China and likes to live independently away from the patient's grown children. The patient eats only Chinese foods at home. What should the nurse infer from these findings? a. The patient has undergone assimilation. b. The patient has undergone biculturalism. c. The patient has undergone acculturation. d. The patient has undergone enculturation. b Correct answer- Which instruction would be most beneficial for an aging African-American client with hypertension? a. "Check the pulse daily." b. "Have an annual urinalysis." c. "Record blood pressure weekly." d. "Visit an ophthalmologist monthly." c Correct answer- An elderly adult suffered an injury after falling down in the washroom. The primary healthcare provider performed a surgical procedure on the client and orders a blood transfusion. A family member of the client mentions that blood transfusions are not permitted in their community. What should the nurse do in order to handle the situation? a. The nurse should wait for the court's order to give blood to the client. b. The nurse should proceed with the transfusion in order to save the client's life. c. The nurse should inform the primary healthcare provider and not give blood to the client. Download to view full Test bank..