,
,Chapter 1. Health Maintenance Guidelines Mul tip
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le Choice
n%
Identify the choice that best completes the statement or answers the question.
n% n% n% n% n% n% n% n% n% n% n%
n % 1. The nurse is preparing to teach a patient of the Asian culture to perform postoperativ
n % n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
e d ressing changes at home after discharge. Which statement made by the nurse indicates cultu
n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
ral co mpetence?
n% n%
a. Tell me how you feel about your surgery.
n% n% n% n% n% n% n%
b. Asian people are smart, so this should be easy for you to understand.
n% n% n% n% n% n% zp n% n% n% n% n%
c. American surgeons are highly qualified; Im sure you will heal quickly.
zp n% n% n% n% n% n% n% n% n%
d. Will you tell me about any traditional healing practices that you would like to use?
n% n% n% n% n% n% n% n% n% n% n% n% n% n%
n % 2. An unconscious victim of a house fire is brought to the emergency department by t
n % n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
he paramedics. Tied to the right wrist is an emblem that appears be a religious talisman.
n% n% zp n% n% n% n% n% n% n% n% n% n% n% n% n%
Which action should the nurse take?
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a. Tape it in place. n% n% zp
b. Do nothing with it. n% n% n%
c. Remove it and lock it up for safekeeping. n% zp n% n% n% n% n%
d. Place it in a clothing bag with the rest of the patients belongings.
n% n% n% n% n% zp n% n% n% n% n% n%
n % n3. A 43-year-
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old patient of Arab descent is admitted to the hospital. To comply with the state laws of the
zp n% n% n% zp n% n% zp n% n% n% n% n% n% n% n% n% n%
or ganization, the nurse offers the patient a Papanicolaou smear, which she refuses. Which
n% n% n% n% n% n% n% n% n% n% n% n% n% n%
actio n should the nurse take first?
n% n% n% n% n% n%
a. Notify the physician. n% n%
b. Report the refusal to the supervisor. n% n% n% n% n%
c. Explain the rationale for and benefits of the test.
n% n% n% n% n% n% n% n%
d. Tell her it is state law and that she does not have a choice.
n% n% n% n% n% n% n% n% n% n% n% n% zp
4. A patient who is a Jehovahs Witness has severe gastrointestinal bleeding and a danger
n% n% n% n% n% n% n% n% n% n% n% n% n% n%
ou sly low hemoglobin level. The patient is fully alert and competent and refuses to accept the
n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
blood transfusion ordered by the physician. Which action by the nurse is most appropriate?
n% n% n% n% n% n% n% n% n% n% n% n% n%
a. Obtain a court order to give the blood. n% n% n% n% n% n% n%
b. Administer the blood while the patient is sleeping. n% n% n% n% n% n% n%
c. Have the patients spouse sign the consent to have the blood administered.
n% n% n% n% n% n% n% n% n% n% n%
, d. Ensure the patient understands possible consequences and then respect the patients wishes.
n% n% n% n% n% n% n% n% n% n% n%
5. A patient of Mexican descent sees a curandero for asthma; the curandero has prescrib
n% n% n% n% zp n% n% n% n% n% n% n% n% n%
ed a special tea to be taken four times a day to open the airways. How should the nurse respo
n% n% n% n% n% n% zp n% n% n% n% n% n% n% n% n% n% n% n%
nd to t his situation?
n% n% n% n%
a. Encourage the patient to continue drinking the tea. n% n% n% n% n% n% n%
b. Encourage the patient to drink only one cup of the tea each day. n% n% n% n% n% n% n% n% n% n% n% n%
c. Ask the patient to bring in the tea package and have the pharmacist check the ingredients.
n% n% n% n% n% n% n% zp n% n% n% n% n% zp n%
d. Advise the patient to stop drinking the tea because of potential interactions with othe
n% n% n% n% n% n% n% n% n% n% n% n% n%
r medications.
n%
6. The nurse is caring for a young adult male patient who refuses personal care from a
n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
f emale nursing assistant. Which approach by the nurse is best?
n% n% n% n% n% n% n% n% n% n%
a. Encourage the patients family to talk with him about his care. n% n% n% n% n% n% n% n% n% n%
b. Have a registered nurse (RN) help with his personal care.
n% n% n% n% n% n% n% n% n%
c. Assign a male assistant to help with his personal care if one is available.
n% n% n% n% n% n% n% n% n% n% n% n% n%
d. Explain to him that males and females take care of both genders in this hospital.
n% n% zp n% n% n% n% n% n% n% n% n% n% n%
7. The nurse is providing medication instructions to a 45-year-
n% n% n% n% n% n% n% n% n%
old patient who does not maintain eye contact. What should this patients behavior indicate to
zp n% n% n% n% n% n% n% n% n% n% n% n% n% n%
the nurse? n%
a. The patient is not interested.
n% n% n% n%
b. The nurse threatens the patients ego.
n% n% n% n% n%
c. The nurse is in a hierarchical position.
n% n% n% n% n% n%
d. The patient does not intend to follow the instructions.
n% zp n% n% n% n% n% n%
n % 8. The nurse is caring for a patient of Spanish descent who is experiencing pain, b
n % n % n % n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
ut doe s not speak English. An interpreter is located to help with the assessment. What shoul
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d the nurs e do to facilitate communication with this patient?
n% n% n% n% n% n% n% n% n% n%
a. Use hand signals to determine the cause of the pain.
n% n% n% n% n% n% n% n% n%
b. Ensure the interpreter is not left alone with the patient.
n% n% n% n% n% n% n% n% n%
c. Maintain eye contact with the patient and the interpreter.
n% n% n% n% n% n% n% n%
d. Use only physical examination data; do not rely on verbal communication.
n% n% n% n% n% n% n% n% n% n%
9. A new mother of Guatemalan descent brings her 10-day-
n% n% n% n% n% n% n% n% n%
old infant to a clinic for a well-
n% n% n% zp n% n% n%
baby checkup. To promote healing, she has a coin taped to the infants umbilicus. What shou
n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
ld t he nurse do about this situation?
n% n% n% n% n% n% n%
a. Teach the mother how to clean the coin daily and reapply it.
n% n% n% n% n% n% n% n% n% n% n%
,Chapter 1. Health Maintenance Guidelines Mul tip
n% n% zp n% n% n%
le Choice
n%
Identify the choice that best completes the statement or answers the question.
n% n% n% n% n% n% n% n% n% n% n%
n % 1. The nurse is preparing to teach a patient of the Asian culture to perform postoperativ
n % n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
e d ressing changes at home after discharge. Which statement made by the nurse indicates cultu
n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
ral co mpetence?
n% n%
a. Tell me how you feel about your surgery.
n% n% n% n% n% n% n%
b. Asian people are smart, so this should be easy for you to understand.
n% n% n% n% n% n% zp n% n% n% n% n%
c. American surgeons are highly qualified; Im sure you will heal quickly.
zp n% n% n% n% n% n% n% n% n%
d. Will you tell me about any traditional healing practices that you would like to use?
n% n% n% n% n% n% n% n% n% n% n% n% n% n%
n % 2. An unconscious victim of a house fire is brought to the emergency department by t
n % n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
he paramedics. Tied to the right wrist is an emblem that appears be a religious talisman.
n% n% zp n% n% n% n% n% n% n% n% n% n% n% n% n%
Which action should the nurse take?
n% n% n% n% n%
a. Tape it in place. n% n% zp
b. Do nothing with it. n% n% n%
c. Remove it and lock it up for safekeeping. n% zp n% n% n% n% n%
d. Place it in a clothing bag with the rest of the patients belongings.
n% n% n% n% n% zp n% n% n% n% n% n%
n % n3. A 43-year-
% n % n % n% n%
old patient of Arab descent is admitted to the hospital. To comply with the state laws of the
zp n% n% n% zp n% n% zp n% n% n% n% n% n% n% n% n% n%
or ganization, the nurse offers the patient a Papanicolaou smear, which she refuses. Which
n% n% n% n% n% n% n% n% n% n% n% n% n% n%
actio n should the nurse take first?
n% n% n% n% n% n%
a. Notify the physician. n% n%
b. Report the refusal to the supervisor. n% n% n% n% n%
c. Explain the rationale for and benefits of the test.
n% n% n% n% n% n% n% n%
d. Tell her it is state law and that she does not have a choice.
n% n% n% n% n% n% n% n% n% n% n% n% zp
4. A patient who is a Jehovahs Witness has severe gastrointestinal bleeding and a danger
n% n% n% n% n% n% n% n% n% n% n% n% n% n%
ou sly low hemoglobin level. The patient is fully alert and competent and refuses to accept the
n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
blood transfusion ordered by the physician. Which action by the nurse is most appropriate?
n% n% n% n% n% n% n% n% n% n% n% n% n%
a. Obtain a court order to give the blood. n% n% n% n% n% n% n%
b. Administer the blood while the patient is sleeping. n% n% n% n% n% n% n%
c. Have the patients spouse sign the consent to have the blood administered.
n% n% n% n% n% n% n% n% n% n% n%
, d. Ensure the patient understands possible consequences and then respect the patients wishes.
n% n% n% n% n% n% n% n% n% n% n%
5. A patient of Mexican descent sees a curandero for asthma; the curandero has prescrib
n% n% n% n% zp n% n% n% n% n% n% n% n% n%
ed a special tea to be taken four times a day to open the airways. How should the nurse respo
n% n% n% n% n% n% zp n% n% n% n% n% n% n% n% n% n% n% n%
nd to t his situation?
n% n% n% n%
a. Encourage the patient to continue drinking the tea. n% n% n% n% n% n% n%
b. Encourage the patient to drink only one cup of the tea each day. n% n% n% n% n% n% n% n% n% n% n% n%
c. Ask the patient to bring in the tea package and have the pharmacist check the ingredients.
n% n% n% n% n% n% n% zp n% n% n% n% n% zp n%
d. Advise the patient to stop drinking the tea because of potential interactions with othe
n% n% n% n% n% n% n% n% n% n% n% n% n%
r medications.
n%
6. The nurse is caring for a young adult male patient who refuses personal care from a
n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
f emale nursing assistant. Which approach by the nurse is best?
n% n% n% n% n% n% n% n% n% n%
a. Encourage the patients family to talk with him about his care. n% n% n% n% n% n% n% n% n% n%
b. Have a registered nurse (RN) help with his personal care.
n% n% n% n% n% n% n% n% n%
c. Assign a male assistant to help with his personal care if one is available.
n% n% n% n% n% n% n% n% n% n% n% n% n%
d. Explain to him that males and females take care of both genders in this hospital.
n% n% zp n% n% n% n% n% n% n% n% n% n% n%
7. The nurse is providing medication instructions to a 45-year-
n% n% n% n% n% n% n% n% n%
old patient who does not maintain eye contact. What should this patients behavior indicate to
zp n% n% n% n% n% n% n% n% n% n% n% n% n% n%
the nurse? n%
a. The patient is not interested.
n% n% n% n%
b. The nurse threatens the patients ego.
n% n% n% n% n%
c. The nurse is in a hierarchical position.
n% n% n% n% n% n%
d. The patient does not intend to follow the instructions.
n% zp n% n% n% n% n% n%
n % 8. The nurse is caring for a patient of Spanish descent who is experiencing pain, b
n % n % n % n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
ut doe s not speak English. An interpreter is located to help with the assessment. What shoul
n% n % n% n% n% n% n% n% n% zp n% n% n% n% n% n%
d the nurs e do to facilitate communication with this patient?
n% n% n% n% n% n% n% n% n% n%
a. Use hand signals to determine the cause of the pain.
n% n% n% n% n% n% n% n% n%
b. Ensure the interpreter is not left alone with the patient.
n% n% n% n% n% n% n% n% n%
c. Maintain eye contact with the patient and the interpreter.
n% n% n% n% n% n% n% n%
d. Use only physical examination data; do not rely on verbal communication.
n% n% n% n% n% n% n% n% n% n%
9. A new mother of Guatemalan descent brings her 10-day-
n% n% n% n% n% n% n% n% n%
old infant to a clinic for a well-
n% n% n% zp n% n% n%
baby checkup. To promote healing, she has a coin taped to the infants umbilicus. What shou
n% n% n% n% n% n% n% n% n% n% n% n% n% n% n% n%
ld t he nurse do about this situation?
n% n% n% n% n% n% n%
a. Teach the mother how to clean the coin daily and reapply it.
n% n% n% n% n% n% n% n% n% n% n%
