TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity
12. The nurse plans health care for a community with a large number of recent immigrants
from Vietnam.Which intervention is the most important for the nurse to implement?
a. Hepatitis testing
b. Tuberculosis screening
c. Contraceptive teaching
d. Colonoscopy
informationANS: B
Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much higher
in immigrants from Vietnam than in the general U.S. population. Teaching about contraceptive
use, colonoscopy, and testing for hepatitis may also be appropriate for some patients but is not
generally indicated for all members of thiscommunity.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
13. When doing an admission assessment for a patient, the nurse notices that the patient
pauses beforeanswering questions about the health history. Which action by the nurse is
most appropriate?
a. Interview a family member instead.
b. Wait for the patient to answer the questions.
c. Remind the patient that you have other patients who need care.
d. Give the patient an assessment form listing the questions and a pen.
ANS: B
Patients from some cultures take time to consider a question carefully before answering. The
nurse will show respect for the patient and help develop a trusting relationship by allowing the
patient time to give a thoughtful answer. Asking the patient why the answers are taking so much
time, stopping the assessment, and handing thepatient a form indicate that the nurse does not
have time for the patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
14. Which strategy should be a priority when the nurse is planning care for a diabetic
patient who isuninsured?
, a. Obtain less expensive medications.
b. Follow evidence-based practice guidelines.
c. Assist with dietary changes as the first action.
d. Teach about the impact of exercise on diabetes.
ANS: B
The use of standardized evidence-based guidelines will reduce the incidence of health care
disparities amongvarious socioeconomic groups. The other strategies may also be appropriate,
but the priority concern should bethat the patient receives care that meets the accepted
standard.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process:
PlanningMSC: NCLEX: Health Promotion and Maintenance
15. A Hispanic patient complains of abdominal cramping caused by empacho. Which action should the
nurse take first?
a. Ask the patient what treatments are likely to help.
b. Massage the patients abdomen until the pain is gone.
c. Administer prescribed medications to decrease the cramping.
d. Offer to contact a curandero(a) to make a visit to the patient.
ANS: A
Further assessment of the patients cultural beliefs is appropriate before implementing any
interventions for aculture-bound syndrome such as empacho. Although medication, a visit by a
curandero(a), or massage may behelpful, more information about the patients beliefs is needed to
determine which intervention(s) will be most helpful.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process:
AssessmentMSC: NCLEX: Psychosocial Integrity
16. The nurse performs a cultural assessment with a patient from a different culture. Which
action by the nurseshould be taken first?
,a. Request an interpreter before interviewing the patient.
b. Wait until a family member is available to help with the assessment.
c. Ask the patient about any affiliation with a particular cultural group.
d. Tell the patient what the nurse already knows about the patients culture.
ANS: C
An early step in performing a cultural assessment is to determine whether the patient feels an
affiliation with any cultural group. The other actions may be appropriate if the patient does
identify with a particular culture.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process:
AssessmentMSC: NCLEX: Psychosocial Integrity
17. The nurse working in a clinic in a primarily African American community notes a higher
incidence of uncontrolled hypertension in the patients. To correct this health disparity, which
action should the nurse takefirst?
a. Initiate a regular home-visit program by nurses working at the clinic.
b. Schedule teaching sessions about low-salt diets at community events.
c. Assess the perceptions of community members about the care at the clinic.
d. Obtain low-cost antihypertensive drugs using funding from government grants.
ANS: C
Before other actions are taken, additional assessment data are needed to determine the reason for
the disparity.The other actions also may be appropriate, but additional assessment is needed
before the next action is selected.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process:
AssessmentMSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is performing an admission assessment for a non-English speaking patient who is
from China.Which actions could the nurse take to enhance communication (select all that apply)?
a. Use an electronic translation application.
, b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Ask the patients teenage daughter to interpret.
e. Use exaggerated gestures to convey information.
ANS: A, B, C
Electronic translation applications, telephone-based interpreters, and agency interpreters are
all appropriate touse to communicate with nonEnglish-speaking patients. When no interpreter
is available, family members maybe considered, but some information that will be needed in an
admission assessment may be misunderstood or not shared if a child is used as the interpreter.
Gestures are appropriate to use, but exaggeration of the gestures is not needed.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
12. The nurse plans health care for a community with a large number of recent immigrants
from Vietnam.Which intervention is the most important for the nurse to implement?
a. Hepatitis testing
b. Tuberculosis screening
c. Contraceptive teaching
d. Colonoscopy
informationANS: B
Tuberculosis (TB) is endemic in many parts of Asia, and the incidence of TB is much higher
in immigrants from Vietnam than in the general U.S. population. Teaching about contraceptive
use, colonoscopy, and testing for hepatitis may also be appropriate for some patients but is not
generally indicated for all members of thiscommunity.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
13. When doing an admission assessment for a patient, the nurse notices that the patient
pauses beforeanswering questions about the health history. Which action by the nurse is
most appropriate?
a. Interview a family member instead.
b. Wait for the patient to answer the questions.
c. Remind the patient that you have other patients who need care.
d. Give the patient an assessment form listing the questions and a pen.
ANS: B
Patients from some cultures take time to consider a question carefully before answering. The
nurse will show respect for the patient and help develop a trusting relationship by allowing the
patient time to give a thoughtful answer. Asking the patient why the answers are taking so much
time, stopping the assessment, and handing thepatient a form indicate that the nurse does not
have time for the patient.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
14. Which strategy should be a priority when the nurse is planning care for a diabetic
patient who isuninsured?
, a. Obtain less expensive medications.
b. Follow evidence-based practice guidelines.
c. Assist with dietary changes as the first action.
d. Teach about the impact of exercise on diabetes.
ANS: B
The use of standardized evidence-based guidelines will reduce the incidence of health care
disparities amongvarious socioeconomic groups. The other strategies may also be appropriate,
but the priority concern should bethat the patient receives care that meets the accepted
standard.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process:
PlanningMSC: NCLEX: Health Promotion and Maintenance
15. A Hispanic patient complains of abdominal cramping caused by empacho. Which action should the
nurse take first?
a. Ask the patient what treatments are likely to help.
b. Massage the patients abdomen until the pain is gone.
c. Administer prescribed medications to decrease the cramping.
d. Offer to contact a curandero(a) to make a visit to the patient.
ANS: A
Further assessment of the patients cultural beliefs is appropriate before implementing any
interventions for aculture-bound syndrome such as empacho. Although medication, a visit by a
curandero(a), or massage may behelpful, more information about the patients beliefs is needed to
determine which intervention(s) will be most helpful.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process:
AssessmentMSC: NCLEX: Psychosocial Integrity
16. The nurse performs a cultural assessment with a patient from a different culture. Which
action by the nurseshould be taken first?
,a. Request an interpreter before interviewing the patient.
b. Wait until a family member is available to help with the assessment.
c. Ask the patient about any affiliation with a particular cultural group.
d. Tell the patient what the nurse already knows about the patients culture.
ANS: C
An early step in performing a cultural assessment is to determine whether the patient feels an
affiliation with any cultural group. The other actions may be appropriate if the patient does
identify with a particular culture.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process:
AssessmentMSC: NCLEX: Psychosocial Integrity
17. The nurse working in a clinic in a primarily African American community notes a higher
incidence of uncontrolled hypertension in the patients. To correct this health disparity, which
action should the nurse takefirst?
a. Initiate a regular home-visit program by nurses working at the clinic.
b. Schedule teaching sessions about low-salt diets at community events.
c. Assess the perceptions of community members about the care at the clinic.
d. Obtain low-cost antihypertensive drugs using funding from government grants.
ANS: C
Before other actions are taken, additional assessment data are needed to determine the reason for
the disparity.The other actions also may be appropriate, but additional assessment is needed
before the next action is selected.
DIF: Cognitive Level: Apply (application)
OBJ: Special Questions: Prioritization TOP: Nursing Process:
AssessmentMSC: NCLEX: Health Promotion and Maintenance
MULTIPLE RESPONSE
1. The nurse is performing an admission assessment for a non-English speaking patient who is
from China.Which actions could the nurse take to enhance communication (select all that apply)?
a. Use an electronic translation application.
, b. Use a telephone-based medical interpreter.
c. Wait until an agency interpreter is available.
d. Ask the patients teenage daughter to interpret.
e. Use exaggerated gestures to convey information.
ANS: A, B, C
Electronic translation applications, telephone-based interpreters, and agency interpreters are
all appropriate touse to communicate with nonEnglish-speaking patients. When no interpreter
is available, family members maybe considered, but some information that will be needed in an
admission assessment may be misunderstood or not shared if a child is used as the interpreter.
Gestures are appropriate to use, but exaggeration of the gestures is not needed.
DIF: Cognitive Level: Apply (application)
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity
