Test Bank Family Practice Guidelines 5th Edition Cash Glass Mullen

Test Bank Family Practice Guidelines 5th Edition Cash Glass MullenTable of Contents Chapter 1. Health Maintenance Guidelines ................................ ................. 1 Chapter 2. Public Health Guidelines ................................ ..................... 24 Chapter 3. Pain Management Guidelines ................................ ................. 46 Chapter 4. Dermatology Guidelines ................................ ..................... 54 Chapter 7: Nasal Guidelines ................................ ............................ 60 Chapter 8: Throat and Mouth Guidelines ................................ ................. 64 Chapter 9: Respiratory Guidelines ................................ ....................... 75 Chapter 10. Cardiovascular Guidelines ................................ .................. 92 Chapter 11: Gastrointestinal Guidelines ................................ ................. 111 Chapter 12: Genitourinary Guidelines ................................ ................... 129 Chapter 13. Obstetrics Guidelines................................ ...................... 148 Chapter 14: Gynecologic Guidelines ................................ .................... 163 Chapter 15: Sexually Transmitted Infections Guidelines ................................ ... 187 Chapter 16: Infectious Disease Guidelines ................................ ............... 204 Chapter 17. Systemic Disorders Guidelines ................................ .............. 223 Chapter 18. Musculoskeletal Guidelines ................................ ................. 256 Chapter 19. Neurologic Guidelines ................................ ..................... 275 Chapter 20. Endocrine Guidelines ................................ ..................... 290 Chapter 21. Rheumatological Guidelines ................................ ................ 297 Chapter 22: Psychiatric Guidelines ................................ ..................... 309 Chapter 23. Assessment Guide for Sport Participation ................................ .... 335 Chapter 1. Health Maintenance Guidelines 1 | P a g eMultiple Choice Identify the choice that best completes the statement or answers the question. 1. The nurse is preparing to teach a patient of the Asian culture to perform postoperative dressing changes at home after discharge. Which statement made by the nurse indicates cultural competence? a. Tell me how you feel about your surgery. b. Asian people are smart, so this should be easy for you to understand. c. American surgeons are highly qualified; Im sure you will heal quickly. d. Will you tell me about any traditional healing practices that you would like to use? 2. An unconscious victim of a house fire is brought to the emergency department by the paramedics. Tied to the right wrist is an emblem that appears be a religious talisman. Which action should the nurse take? a. Tape it in place. b. Do nothing with it. c. Remove it and lock it up for safekeeping. d. Place it in a clothing bag with the rest of the patients belongings. 3. A 43-year-old patient of Arab descent is admitted to the hospital. To comply with the state laws of the organization, the nurse offers the patient a Papanicolaou smear, which she refuses. Which action should the nurse take first? a. Notify the physician. b. Report the refusal to the supervisor. c. Explain the rationale for and benefits of the test. d. Tell her it is state law and that she does not have a choice. 4. A patient who is a Jehovahs Witness has severe gastrointestinal bleeding and a dangerously low hemoglobin level. The patient is fully alert and competent and refuses to accept the blood transfusion ordered by the physician. Which action by the nurse is most appropriate? a. Obtain a court order to give the blood. b. Administer the blood while the patient is sleeping. c. Have the patients spouse sign the consent to have the blood administered. d. Ensure the patient understands possible consequences and then respect the patients wishes. 5. A patient of Mexican descent sees a curandero for asthma; the curandero has prescribed a special tea to be taken four times a day to open the airways. How should the nurse respond to this situation? a. Encourage the patient to continue drinking the tea. b. Encourage the patient to drink only one cup of the tea each day. 2 | P a g ec. Ask the patient to bring in the tea package and have the pharmacist check the ingredients. d. Advise the patient to stop drinking the tea because of potential interactions with other medications. 6. The nurse is caring for a young adult male patient who refuses personal care from a female nursing assistant. Which approach by the nurse is best? a. Encourage the patients family to talk with him about his care. b. Have a registered nurse (RN) help with his personal care. c. Assign a male assistant to help with his personal care if one is available. d. Explain to him that males and females take care of both genders in this hospital. 7. The nurse is providing medication instructions to a 45-year-old patient who does not maintain eye contact. What should this patients behavior indicate to the nurse? a. The patient is not interested. b. The nurse threatens the patients ego. c. The nurse is in a hierarchical position. d. The patient does not intend to follow the instructions. 8. The nurse is caring for a patient of Spanish descent who is experiencing pain, but does not speak English. An interpreter is located to help with the assessment. What should the nurse do to facilitate communication with this patient? a. Use hand signals to determine the cause of the pain. b. Ensure the interpreter is not left alone with the patient. c. Maintain eye contact with the patient and the interpreter. d. Use only physical examination data; do not rely on verbal communication. 9. A new mother of Guatemalan descent brings her 10-day-old infant to a clinic for a well- baby checkup. To promote healing, she has a coin taped to the infants umbilicus. What should the nurse do about this situation? a. Teach the mother how to clean the coin daily and reapply it. b. Explain to the mother that the coin is not necessary for healing. c. Tell the mother to remove the coin, because it could cause an infection. d. Teach the mother how to apply a dry sterile dressing in place of the coin. 10. An older patient who follows the Muslim religion is approaching death. The family says the patients bed should be turned toward the opposite wall, so it can face Mecca to ensure an easier passage into the next life. The wall they want the bed to face has wall suction and oxygen, which the patient is using. Which action by the nurse is appropriate? a. Get permission from the physician to move the bed. b. Rearrange the furniture to accommodate the request. 3 | P a g ec. Tell them you will move the bed when the patient is closer to death. d. Tell them it is impossible because of the short tubing on the oxygen and suction. 11. A patient of northern European descent recovering from surgery denies postoperative pain; however, vital signs indicate an elevated pulse and blood pressure. The patient refuses to move in bed. Which nursing action would best ensure comfort and timely discharge? a. Give the pain medicine as prescribed. b. Ask the physician to prescribe the analgesics around the clock. c. Explain that the pain medicine will help prevent complications. d. Respect the patients denial of pain, and do not encourage the pain medicine. 12. A nurse who emigrated from China begins working on a medical unit. The preceptor explains the unit routines, including the medication administration system. When the preceptor asks if the nurse understands, the answer is always: Yes, I understand. What should the preceptor do to measure the nurses comprehension? a. Give the nurse a medication quiz. b. Have the nurse repeat the instructions. c. Have the nurse demonstrate the procedures. d. Ask the nurse which information is hard to understand. 13. A 52-year-old from Haiti is hospitalized with heart failure and wants to have a voodoo practitioner visit to say prayers. How should the nurse respond to this request? a. Report the request to the physician immediately. b. Tell the patient that this is not permitted during hospitalization. c. Tell the patient it is okay for the voodoo practitioner to say prayers. d. Have the patient meet with the voodoo practitioner in the hospital lobby. 14. The nurse is caring for a patient from a non-English speaking culture. While providing care, the nurse shows an appreciation for and attention to arts, music, crafts, clothing, and foods belonging to the patients culture. What did the nurse demonstrate while caring for this patient? a. Cultural beliefs b. Cultural awareness c. Cultural sensitivity d. Cultural competence 15. A female Caucasian nurse, overhead discussing a patient from another culture, asks why the patient wants to see a practitioner from his own culture, since everyone sees physicians when they are ill. What characteristic is the nurse exhibiting? a. Stereotyping 4 | P a g eb. Ethnocentrism c. Cultural sensitivity d. Cultural generalization 16. During an assessment, the nurse determines that a patient from a non-English speaking culture practices activities that are past-oriented. What behavior did the nurse assess in this patient? a. Investing time and money b. Enjoying each day as it comes c. Worshipping ancestors and maintaining traditions d. Learning from the past to avoid making the same mistakes in the future 17. The nurse notes that a patient of Arab descent is not eating anything on the meal trays. What should the nurse do about this situation? a. Wait for the patient to ask for specific foods. b. Ask if the patient has special food preferences. c. Consult with a physician of Arab descent on staff. d. Contact the dietitian to find out what patients of Arab descent patients like to eat. 18. The mother of a 6-year-old Vietnamese child admitted with pneumonia is rubbing a coin on the childs back. The coin leaves red marks. What should the nurse do about this observation? a. Report the possibility of child abuse. b. Do not allow the mother to be alone with her child. c. Explain to the mother that she cannot do this in the hospital. d. Add a statement to the care plan that the family practices coining. 19. The family of an older Arab-American patient does not want the patient to be informed of a diagnosis of cancer. What should the nurse do? a. Call a religious counselor. b. Respect the familys wishes. c. Insist that the family tell the patient about the diagnosis. d. Tell the patient anyway, because patients have a right to know. 20. A patient with diabetes mellitus who comes to the clinic for a routine examination agrees to have a diagnostic test, but is concerned that her transportation will not wait for the test to be performed. What should the nurse do? a. Contact the department to have the test done now. b. Ask the patient to schedule an appointment for the test. c. Refer the patient to the community health nurse practitioner. 5 | P a g ed. Schedule the test for the next time the patient comes to the clinic. 21. The nurse is assessing a patient who believes in a balance of yin and yang in the body, has a brother with stomach cancer, and frequently uses acupuncture for headache treatment. The nurse should validate that the patient is a member of which cultural group? a. Hispanic/Latino b. Asian American c. African American d. American Indian/Native Alaskan 22. An older patient is observed wearing a copper bracelet to relieve the pain of arthritis. What type of practice should the nurse realize this patient is demonstrating? a. Allopathy b. Acupressure c. Reflexology d. Folk medicine 23. The nurse is preparing discharge teaching for an older patient who immigrated to the United States a few years ago. What should the nurse remember when preparing these instructions? a. The patient most likely has limited financial resources. b. The patient will prefer to follow cultural medical practices. c. The patient will most likely live with other family members. d. The patient will attend all follow-up appointments as needed. 24. During a home visit to a family of a non-English speaking culture, the nurse observes the male parent becoming upset when the youngest child refuses to speak the native language in the home. What should the nurse realize is occurring within the family at this time? a. Ethnocentrism b. Cultural shock c. Cultural conflict d. Cultural assimilation 25. An older male patient is admitted to the hospital for treatment of a chronic disease. The spouse is at the bedside for most hours of the day, and the patients children come to visit every day after work to discuss activities and ask for advice. What should the nurse realize about the social organization of this family? a. The male patient is the head of the household. b. The spouse does not trust health care providers. c. The children want to learn everything before the patient dies. 6 | P a g ed. The children are concerned that the patient is not receiving adequate care. Multiple Response Identify one or more choices that best complete the statement or answer the question. 26. The nurse is planning care for a patient from a non-English speaking culture. Which cultural factors should the nurse be aware of in order to provide culturally competent care to this patient? (Select all that apply.) a. The patients nutritional habits b. The patients communication style c. The patients sense of personal space d. Complementary therapies the patient is using e. The prescribed medications the patient is taking 27. A female nurse is providing smoking cessation counseling and education during a community health fair. The nurse should avoid physical closeness, shaking hands, or touching during instruction with which of the following? (Select all that apply.) a. A 35-year-old man of Asian descent b. A 45-year-old woman of Arab descent c. A 28-year-old man of Hispanic descent d. A 52-year-old woman of African American descent e. A 41-year-old woman of American Indian descent 28. The nurse is providing care in a clinic with a culturally diverse patient population. Which actions should the nurse take to ensure care is culturally appropriate? (Select all that apply.) a. Awareness of cultural bias b. Desire to be culturally competent c. Educational training related to world politics d. Awareness of personal communication patterns e. Number of face-to-face encounters with people from various cultural backgrounds 29. The staff development instructor is planning a seminar on improving cultural sensitivity when providing patient care. What should the instructor include in this seminar? (Select all that apply.) a. Information about different cultural groups b. Recognition that patient are unique and not defined by their culture c. Ways to enhance cultural assimilation in the health care environment d. The importance of nurses knowing information about their own cultural group e. Strategies to incorporate patients cultural values and practices into the plan of care 7 | P a g e30. The nurse is visiting the home of a patient who recently immigrated to the United States from Buenos Aires. Which observations in the patients home should the nurse question to determine the patients health beliefs? (Select all that apply.) a. Black bracelet woven with a cross being worn on the patients left wrist b. A lit candle burning near a picture of a saint on a side table in the living room c. Cup of hot black liquid that the patient is sipping from periodically during the visit d. A copy of a magazine printed in Spanish sitting on the coffee table in the living room e. A pillow placed between the patient and the nurse after the nurse sits down on the couch Chapter 4. Cultural Influences on Nursing Care Answer Section MULTIPLE CHOICE 1. ANS: D D. Cultural sensitivity is using language and statements that do not offend another persons cultural beliefs. Cultural competence includes the skills and knowledge required to provide effective nursing care. The use of traditional healers and healing therapies is common for Asian individuals, and assessing the patients desire to use such healers or therapies shows the nurse is culturally sensitive and competent to provide care. B. This statement represents a stereotypean opinion or belief about a group of people which is ascribed to an individual. C. This statement exemplifies ethnocentrism or the tendency for people to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways. A. This is an assessment designed to elicit the patients emotional reaction to the surgery. This may be an important part of adult learning, but it is not the best option to represent cultural competence. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 2. ANS: A A. Often folk practices are not harmful and can be added to the patients plan of care. Tape the emblem in place to keep it from getting lost or damaged. C. D. Removing it could be very distressing to the patient. B. The item could get lost if nothing is done with it. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 3. ANS: C 8 | P a g eC. A Pap smear can provide important health information. The patient may refuse it, because she does not understand what it is. A. B. Teaching is a nursing action and does not need to be approved by a physician or supervisor. D. The state law simply says the patient must be offered the test, not that she must accept it. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application 4. ANS: D D. Patients beliefs should be respected, even when their decisions go against medical advice. The patient needs to understand the consequences of his decision. A. B. C. Administering the blood without the patients knowledge or consent is unethical. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 5. ANS: C C. Often, folk practices are not harmful and may even be helpful; they may be incorporated into the patients plan of care. Checking with the pharmacist ensures that the tea is safe and will not interact with other essential medications. A. B. D. As long as it is safe, there is no reason to have the patient stop or limit tea intake. PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Analysis 6. ANS: C C. It is important to respect differences in gender relationships when providing care. Some people may be especially modest because of their religion, seeking out same-gender nurses and physicians for intimate care. Respect these patients modesty by providing privacy and assigning a same-gender care provider when possible. A. B. D. Having a registered nurse (unless male) provide care and talking to his family do not solve the problem or respect the patients preferences. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 7. ANS: C C. Use and degree of eye contact is culturally influenced. Many cultures view health care workers 9 | P a g eas having higher status, making it rude to maintain eye contact. A. B. D. The nurse should not make assumptions about the patients level of interest, intent to follow instructions, or ego. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 8. ANS: C C. The use of eye contact can help the nurse interpret the information that is being exchanged between the interpreter and patient. A. B. D. There is no reason to avoid leaving the interpreter with the patient, to rely on hand signals, or to avoid verbal communication when an interpreter is available. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 9. ANS: A A. Often, folk practices are not harmful and can be added to the patients plan of care. In the case of the coin, it should be cleaned daily to keep the area clean and free of infection. B. C. D. There is no reason to tell the mother to remove it or to apply a sterile dressing in place of the coin. PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application 10. ANS: B B. Often, folk practices are not harmful and can be added to the patients plan of care. There is no reason not to move the patients bed. A. There is no reason to involve the physician. C. There is no way to know the exact time the patient will die, so waiting to move the bed is not appropriate. D. Oxygen and suction tubing can have extensions added. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 11. ANS: C C. Explaining that pain control can help prevent complications allows the patient to make an informed decision. A. B. The patients wishes must be respected, so giving the medication without the patients consent is not appropriate. D. Respecting the patients denial of pain and not encouraging the pain medication may not necessarily support the patients comfort and allow for appropriate healing of the incision. PTS: 1 DIF: Difficult 10 | P a g eKEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis 12. ANS: C C. The best measure of learning is observing the nurse demonstrate the procedures. A. B. D. Having the nurse talk about the instructions or fill out a quiz may be helpful, but the only way to know for sure if the teaching has been effective is to observe the behavior. PTS: 1 DIF: Moderate KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application 13. ANS: C C. Often, folk practices are not harmful and can be added to the patients plan of care. A. There is no reason to involve the physician in non-harmful folk practices. B. A patient should only be told that something is not permitted if it is prohibited by policy. D. Allowing the practice to occur in the lobby may be unsafe for the patient and confusing to other patients and visitors. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 14. ANS: B B. Cultural awareness focuses on history and ancestry and emphasizes an appreciation for and attention to arts, music, crafts, celebrations, foods, and traditional clothing. A. Beliefs are assertions that are based on assumptions. C. Cultural sensitivity is using politically correct language and not making statements that may offend another persons cultural beliefs. D. Cultural competence includes the skills and knowledge required to provide effective nursing care. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 15. ANS: B B. Ethnocentrism is the tendency for human beings to think that their ways of thinking, acting, and believing are the only right ways. A. A stereotype is an opinion or belief about a group of people, which is ascribed to an individual from that group. C. Cultural sensitivity is using politically correct language and not making statements that may offend another persons cultural beliefs. D. A generalization, or assumption, may be true for the group, but it does not necessarily fit an individual. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 11 | P a g e16. ANS: C C. Past-oriented individuals maintain traditions that were meaningful in the past, and they may worship ancestors. A. Future-oriented people may invest time and money in the future. B. Present-oriented people accept the day as it comes, with little regard for the past. D. Some cultures combine all three. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 17. ANS: B B. Cultural assessment must provide the basis for nursing care. This should include a review of food preferences. A, C, and D are insensitive actions and risk stereotyping and providing inappropriate care to the patient. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Application 18. ANS: D D. Individuals from Asian cultures may practice coining. This is an example of a cultural practice that is harmless and may be included in the patients care. A, B, and C are culturally insensitive responses. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 19. ANS: B B. Initially, the familys wishes should be respected. This may be important in their culture. An ethics committee may be contacted for further input if the situation warrants it. A, C, and D are culturally insensitive responses. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 20. ANS: A A. Because it may be difficult for the patient to obtain transportation, the test should be performed now. B, C, and D risk further delay of the test. PTS: 1 DIF: Moderate KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: 12 | P a g eApplication 21. ANS: B B. Asian-Americans hold these beliefs. A. C. D. Individuals from the other cultural groups do not believe in yin and yang and do not practice acupuncture. African Americans may have an increased risk for stomach cancer, but they do not believe in yin and yang or acupuncture. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 22. ANS: D C. Examples of folk medicines include covering a boil with axle grease, wearing copper bracelets for arthritic pain, and drinking herbal teas. A. Allopathy is another name for traditional Western medicine. B. C. Acupressure and reflexology are complementary therapies. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 23. ANS: A A. Compared with white or European American older adults, ethnic minorities are more likely to live in poverty. The nurse needs to take the patients finances into consideration when preparing discharge instructions. B. The nurse needs to assess the patients preference for using cultural or Western medicine practices. C. There is no information to support that the patient lives with other family members. D. The patient may have difficulty accessing health care, so it is incorrect to assume that the patient will attend all follow-up appointments. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 24. ANS: D D. Cultural assimilation occurs when a new member takes on the dominant cultures values, beliefs, and practices, sometimes at the cost of losing some of his or her cultural heritage. This process is often viewed as negative as evidenced by the male parent becoming upset with the youngest child refusing to speak the native language in the home. A. Ethnocentrism is the tendency for humans to think that their ways of thinking, acting, and believing are the only right, proper, and natural ways. B. Cultural shock is when values, beliefs, and practices sanctioned by the new culture are very different from the ones of the native culture. There is no evidence that cultural shock is occurring within the family. C. Cultural conflict is when one culture conflicts with another. There is no evidence that cultural conflict is occurring within the family. 13 | P a g ePTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 25. ANS: A A. Family organization includes the perceived head of the household, gender roles, and roles of the elderly and extended family members. Because the spouse stays at the bedside and the children visit every day to discuss events and ask advice, this household is most likely patriarchal. B. There is no evidence to suggest that the spouse does not trust health care providers. C. Although the patient has a chronic disease, there is no evidence to suggest that death is imminent. D. There is no evidence to support that the children are concerned that the patient is not receiving adequate care. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis MULTIPLE RESPONSE 26. ANS: A, B, C, D A, B, C, and D describe characteristics of cultural diversity of which the nurse should be aware. E. Prescribed medications are related to physiological needs, not cultural needs. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis 27. ANS: A, E A. E. For American Indians/Native Alaskans, touch is not acceptable from strangers. Asians and Pacific Islanders avoid physical closeness and touching. B. Touch between persons of the same gender is acceptable, and personal space is very close for Arab Americans. C. Hispanics/Latinos/Spanish individuals value touching and closeness. D. African Americans have close personal space and touch frequently, although less with strangers. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 28. ANS: A, B, D, E A. B. D. E. Cultural competence requires self-awareness and a desire to provide culturally competent care. The number of encounters and experience with various groups can be helpful as is knowledge of your own communication patterns. C. Educational training on world politics is not required to provide culturally competent care. 14 | P a g ePTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 29. ANS: A, B, D, E A. B. D. E. The staff development instructor can help nurses improve cultural sensitivity by using the acronym BALI or 1) be aware of your personal cultural heritage; 2) appreciate that each patient is unique, influenced but not defined by his or her culture; 3) learn about the patients cultural groups; and 4) incorporate the patients cultural values, beliefs, and practices into their plan of care. C. Cultural assimilation is a personal endeavor, one in which the nurse may have little influence. PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 30. ANS: A, B, C A. B. C. To determine health beliefs the nurse should ask about the practice of special rituals or prayers to maintain health, the wearing of bracelets to ward off illnesses and the drinking of herbs or special teas when ill. D. A copy of a magazine printed in Spanish would help indicate the patients communication style. E. The use of a pillow between the nurse and patient could be identifying a boundary for personal space. 31. Pertussis vaccination should begin at which age? a. Birth b. 2 months c. 6 months d. 12 months ANS: B The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The first dose is usually given at the 2-month well-child visit. Infants are highly susceptible to pertussis, which can be a life-threatening illness in this age group. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 32. A mother tells the nurse that she does not want her infant immunized because of 15 | P a g ethe discomfort associated with injections. What should the nurse explain? a. This cannot be prevented. b. Infants do not feel pain as adults do. c. This is not a good reason for refusing immunizations. d. A topical anesthetic can be applied before injections are given. ANS: D To minimize the discomfort associated with intramuscular injections, a topical anesthetic agent can be used on the injection site. These include EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays. Pain associated with many procedures can be prevented or minimized by using the principles of atraumatic care. Infants have neural pathways that will indicate pain. Numerous research studies have indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process. TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 33. A 4-month-old infant comes to the clinic for a well-infant checkup. Immunizations she should receive are DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated poliovirus vaccine). She is recovering from a cold but is otherwise healthy and afebrile. Her older sister has cancer and is receiving chemotherapy. Nursing considerations should include which? a. DTaP and IPV can be safely given. b. DTaP and IPV are contraindicated because she has a cold. c. IPV is contraindicated because her sister is immunocompromised. d. DTaP and IPV are contraindicated because her sister is immunocompromised. ANS: A These immunizations can be given safely. Serious illness is a contraindication. A mild illness with or without fever is not a contraindication. These are not live vaccines, so they do not pose a risk to her sister. 16 | P a g eTOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 34. Which serious reaction should the nurse be alert for when administering vaccines? a. Fever b. Skin irritation c. Allergic reaction d. Pain at injection site ANS: C Each vaccine administration carries the risk of an allergic reaction. The nurse must be prepared to intervene if the child demonstrates signs of a severe reaction. Mild febrile reactions do occur after administration. The nurse includes management of fever in the parent teaching. Local skin irritation may occur at the injection site after administration. Parents are informed that this is expected. The injection can be painful. The nurse can minimize the discomfort with topical analgesics and nonpharmacologic measures. MSC: Client Needs: Physiological Integrity 35. Which muscle is contraindicated for the administration of immunizations in infants and young children? a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Anterolateral thigh ANS: B The dorsogluteal site is avoided in children because of the location of nerves and veins. The deltoid is recommended for 12 months and older. The ventrogluteal and anterolateral thigh sites can safely be used for the administration of vaccines to infants. TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 17 | P a g e36. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid? a. Cyst b. Papule c. Pustule d. Vesicle ANS: D A vesicle is elevated, circumscribed, superficial, smaller than 1 cm in diameter, and filled with serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid or semisolid material. A papule is elevated; palpable; firm; circumscribed; smaller than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and similar to a vesicle but filled with purulent fluid. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 37. Which vitamin supplementation has been found to reduce both morbidity and mortality in measles? a. A b. B1 c. C d. Zinc ANS: A Evidence suggests that vitamin A supplementation reduces both morbidity and mortality in measles. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 38. What does impetigo ordinarily results in? a. No scarring b. Pigmented spots c. Atrophic white scars 18 | P a g ed. Slightly depressed scars ANS: A Impetigo tends to heal without scarring unless a secondary infection occurs. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 39. What often causes cellulitis? a. Herpes zoster b. Candida albicans c. Human papillomavirus d. Streptococci or staphylococci ANS: D Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C. albicans is associated with candidiasis, or thrush. Human papillomavirus is associated with various types of human warts. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 40. Lymphangitis (streaking) is frequently seen in what? a. Cellulitis b. Folliculitis c. Impetigo contagiosa d. Staphylococcal scalded skin ANS: A Lymphangitis is frequently seen in cellulitis. If it is present, hospitalization is usually required for parenteral antibiotics. Lymphangitis is not associated with folliculitis, impetigo, or staphylococcal scalded skin. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 19 | P a g e41. What is most important in the management of cellulitis? a. Burow solution compresses b. Oral or parenteral antibiotics c. Topical application of an antibiotic d. Incision and drainage of severe lesions ANS: B Oral or parenteral antibiotics are indicated depending on the extent of the cellulitis. Warm water compresses may be indicated for limited cellulitis. The antibiotic needs to be administered systemically. Incision and drainage of severe lesions presents a risk of spreading infection or making the lesion worse. TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 42. What causes warts? a. A b. A fungus c. A parasite d. Bacteria virus ANS: A Human warts are caused by the human papillomavirus. Infection with fungus, parasites, or bacteria does not result in warts. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 43. What is the primary treatment for warts? a. Vaccination b. Local destruction c. Corticosteroids d. Specific antibiotic therapy ANS: B Local destructive therapy is individualized according to location, type, and number; surgical 20 | P a g eremoval, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapies are used. Vaccination is prophylaxis for warts, not a treatment. Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 44. Herpes zoster is caused by the varicella virus and has an affinity for which? a. Sympathetic nerve fibers b. Parasympathetic nerve fibers c. Lateral and dorsal columns of the spinal cord d. Posterior root ganglia and posterior horn of the spinal cord ANS: D The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the spinal cord, and the skin. The zoster virus does not involve the nerve fibers listed. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 45. Treatment for herpes simplex virus (type 1 or 2) includes which? a. Corticosteroids b. Oral griseofulvin c. Oral antiviral agent d. Topical or systemic antibiotic ANS: C Oral antiviral agents are effective for viral infections such as herpes simplex. Corticosteroids, antibiotics, and griseofulvin (an antifungal agent) are not effective for viral infections. TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity 46. What should the nurse explain about ringworm? a. It is not contagious. b. It is a sign of uncleanliness. c. It is expected to resolve spontaneously. d. It is spread by both direct and indirect contact. 21 | P a g eANS: D Ringworm is spread by both direct and indirect contact. Infected children should wear protective caps at night to avoid transfer of ringworm to bedding. Ringworm is infectious. Because ringworm is easily transmitted, it is not a sign of uncleanliness. It can be transmitted by seats with head rests, gym mats, and animal-to-human transmission. The drug griseofulvin is indicated for a prolonged course, possibly several months. TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 47. When giving instructions to a parent whose child has scabies, what should the nurse include? a. Treat all family members if symptoms develop. b. Be prepared for symptoms to last 2 to 3 weeks. c. Carefully treat only areas where there is a rash. d. Notify practitioner so an antibiotic can be prescribed. ANS: B The mite responsible for the scabies will most likely be killed with the administration of medications. It will take 2 to 3 weeks for the stratum corneum to heal. That is when the symptoms will abate. Initiation of therapy does not wait for clinical symptom development. All individuals in close contact with the affected child need to be treated. Permethrin, a scabicide, is the preferred treatment and is applied to all skin surfaces. TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Integrity 48. Which is usually the only symptom of pediculosis capitis (head lice)? a. Itching b. Vesicles c. Scalp rash d. Localized inflammatory response 22 | P a g eANS: A Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is made by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and localized inflammatory response are not symptoms of head lice. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 49. The school reviewed the pediculosis capitis (head lice) policy and removed the no nit requirement. The nurse explains that now, when a child is found to have nits, the parents must do which before the child can return to school? a. No treatment is necessary with the policy change. b. Shampoo and then trim the childs hair to prevent reinfestation. c. The child can remain in school with treatment done at home. d. Treat the child with a shampoo to treat lice and comb with a fine-tooth comb every day until nits are eliminated. ANS: C Many children have missed significant amounts of school time with no nit policies. The child should be appropriately treated with a pediculicide and a fine-tooth comb. The environment needs to be treated to prevent reinfestation. The treatment with the pediculicide will kill the lice and leave nit casings. Cutting the childs hair is not recommended; lice infest short hair as well as long. With a no nit policy, treating the child with a shampoo to treat lice and combing the hair with a fine-tooth comb every day until nits are eliminated is the correct treatment. The policy change recognizes that most nits do not become lice. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 50. The nurse should know what about Lyme disease? a. Very difficult to prevent b. Easily treated with oral antibiotics in stages 1, 2, and 3 c. Caused by a spirochete that enters the skin through a tick bite d. Common in geographic areas where the soil contains the mycotic spores that cause the disease ANS: C 23 | P a g eLyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeve shirts and long pants tucked into socks should be the attire. Early treatment of erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is caused by a spirochete, not mycotic spores. TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 51. The nurse is teaching a nursing student about standard precautions. Which statement made by the student indicates a need for further teaching? a. I will use precautions when I give an infant oral care. b. I will use precautions when I change an infants diaper. c. I will use precautions when I come in contact with blood and body fluids. d. I will use precautions when administering oral medications to a school-age child. ANS: D Standard precautions involve the use of barrier protection (personal protective equipment [PPE]), such as gloves, goggles, a gown, or a mask, to prevent contamination from (1) blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood; (3) nonintact skin; and (4) mucous membranes. Precautions should be taken when giving oral care, when changing diapers, and when coming in contact with blood and body fluids. Further teaching is needed if the student indicates the need to use precautions when administering an oral medication to a school-age child. Chapter 2. Public Health Guidelines MULTIPLE CHOICE 1. Children are taught the values of their culture through observation and feedback relative to their own behavior. In teaching a class on cultural competence, the nurse should be aware that which factor may be culturally determined? a. Ethnicity b. Racial variation c. Status d. Geographic boundaries 24 | P a g eANS: C Status is culturally determined and varies according to each culture. Some cultures ascribe higher status to age or socioeconomic position. Social roles also are influenced by the culture. Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and linguistic heritage. It is one component of culture. Race and culture are two distinct attributes. Whereas racial grouping describes transmissible traits, culture is determined by the pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. Cultural development may be limited by geographic boundaries, but the boundaries are not culturally determined. TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity 2. The nurse is aware that if patients different cultures are implied to be inferior, the emotional attitude the nurse is displaying is what? a. Acculturation b. Ethnocentrism c. Cultural shock d. Cultural sensitivity ANS: B Ethnocentrism is the belief that ones way of living and behaving is the best way. This includes the emotional attitude that the values, beliefs, and perceptions of ones ethnic group are superior to those of others. Acculturation is the gradual changes that are produced in a culture by the influence of another culture that cause one or both cultures to become more similar. The minority culture is forced to learn the majority culture to survive. Cultural shock is the helpless feeling and state of disorientation felt by an outsider attempting to adapt to a different culture group. Cultural sensitivity, a component of culturally competent care, is an awareness of cultural similarities and differences. MSC: Client Needs: Psychosocial Integrity 3. Which term best describes the sharing of common characteristics that differentiates one group from other groups in a society? 25 | P a g ea. Race b. Culture c. Ethnicity d. Superiority ANS: C Ethnicity is a classification aimed at grouping individuals who consider themselves, or are considered by others, to share common characteristics that differentiate them from the other collectivities in a society, and from which they develop their distinctive cultural behavior. Race is a term that groups together people by their outward physical appearance. Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people. A culture is composed of individuals who share a set of values, beliefs, and practices that serve as a frame of reference for individual perception and judgments. Superiority is the state or quality of being superior; it does not apply to ethnicity. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 4. After the family, which has the greatest influence on providing continuity between generations? a. Race b. School c. Social class d. Government ANS: B Schools convey a tremendous amount of culture from the older members to the younger members of society. They prepare children to carry out the traditional social roles that will be expected of them as adults. Race is defined as a division of humankind possessing traits that are transmissible by descent and are sufficient to characterize race as a distinct human type; although race may have an influence on childrearing practices, its role is not as significant as that of schools. Social class refers to the familys economic and educational levels. The social class of a family may change between generations. The government establishes parameters for children, including amount of schooling, but this is usually at a local level. The school culture has the most significant influence on continuity besides family. 26 | P a g eTOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 5. The nurse is planning care for a patient with a different ethnic background. Which should be an appropriate goal? a. Adapt, as necessary, ethnic practices to health needs. b. Attempt, in a nonjudgmental way, to change ethnic beliefs. c. Encourage continuation of ethnic practices in the hospital setting. d. Strive to keep ethnic background from influencing health needs. ANS: A Whenever possible, nurses should facilitate the integration of ethnic practices into health care provision. The ethnic background is part of the individual; it should be difficult to eliminate the influence of ethnic background. The ethnic practices need to be evaluated within the context of the health care setting to determine whether they are conflicting. MSC: Client Needs: Psychosocial Integrity 6. The nurse discovers welts on the back of a Vietnamese child during a home health visit. The childs mother says she has rubbed the edge of a coin on her childs oiled skin. The nurse should recognize this as what? a. Child abuse b. Cultural practice to rid the body of disease c. Cultural practice to treat enuresis or temper tantrums d. Child discipline measure common in the Vietnamese culture ANS: B This is descriptive of coining. The welts are created by repeatedly rubbing a coin on the childs oiled skin. The mother is attempting to rid the childs body of disease. Coining is a cultural healing practice. Coining is not specific for enuresis or temper tantrums. This is not child abuse or discipline. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 7. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this? 27 | P a g ea. The parent is trying to feed the child only what the child likes most. b. Hispanics believe the evil eye enters when a person gets cold. c. The parent is trying to restore normal balance through appropriate hot remedies. d. Hispanics believe an innate energy called chi is strengthened by eating soup. ANS: C In several cultures, including Filipino, Chinese, Arabic, and Hispanic, hot and cold describe certain properties completely unrelated to temperature. Respiratory conditions such as pneumonia are cold conditions and are treated with hot foods. The child may like broth but is unlikely to always prefer it to Jell-O, Popsicles, and juice. The evil eye applies to a state of imbalance of health, not curative actions. Chinese individuals, not Hispanic individuals, believe in chi as an innate energy. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 8. How is family systems theory best described? a. The family is viewed as the sum of individual members. b. A change in one family member cannot create a change in other members. c. Individual family members are readily identified as the source of a problem. d. When the family system is disrupted, change can occur at any point in the system. ANS: D Family systems theory describes an interactional model. Any change in one member will create change in others. Although the family is the sum of the individual members, family systems theory focuses on the number of dyad interactions that can occur. The interactions, not the individual members, are considered to be the problem. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 9. Which family theory is described as a series of tasks for the family throughout its life span? a. Exchange theory b. Developmental theory c. Structural-functional theory d. Symbolic interactional theory 28 | P a g eANS: B In developmental systems theory, the family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. Exchange theory assumes that humans, families, and groups seek rewarding statuses so that rewards are maximized while costs are minimized. Structural-functional theory states that the family performs at least one societal function while also meeting family needs. Symbolic interactional theory describes the family as a unit of interacting persons with each occupying a position within the family. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 10. Which family theory explains how families react to stressful events and suggests factors that promote adaptation to these events? a. Interactional theory b. Family stress theory c. Eriksons psychosocial theory d. Developmental systems theory ANS: B Family stress theory explains the reaction of families to stressful events. In addition, the theory helps suggest factors that promote adaptation to the stress. Stressors, both positive and negative, are cumulative and affect the family. Adaptation requires a change in family structure or interaction. Interactional theory is not a family theory. Interactions are the basis of general systems theory. Eriksons theory applies to individual growth and development, not families. Developmental systems theory is an outgrowth of Duvalls theory. The family is described as a small group, a semiclosed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others. 11. Historically, what was the justification for the victimization of women? a. Women were regarded as possessions. b. Women were the weaker sex. c. Control of women was necessary to protect them. d. Women were created subordinate to men. ANS: A 29 | P a g eMisogyny, patriarchy, devaluation of women, power imbalance, a view of women as property, gender-role stereotyping, and acceptance of aggressive male behaviors as appropriate contributed and continue to contribute to the subordinate status of women in many of the worlds societies. Viewing women as the weaker sex is a cultural and modern stereotype that contributes to the victimization of women. Control of women to protect them is another cultural and modern stereotype that contributes to the victimization of women. Yet another cultural stereotype that contributes to the victimization of women is the idea that women were created as subordinate to men. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 12. What is the primary theme of the feminist perspective regarding violence against women? a. Role of testosterone as the underlying cause of mens violent behavior b. Basic human instinctual drive toward aggression c. Male dominance and coercive control over women d. Cultural norm of violence in Western society ANS: C The contemporary social view of violence is derived from the feminist theory. With the primary theme of male dominance and coercive control, this view enhances an understanding of all forms of violence against women, including wife battering, stranger and acquaintance rape, incest, and sexual harassment in the workplace. The role of testosterone as an underlying cause of mens violent behavior, the basic human instinctual drive toward aggression, and the cultural norm of violence in Western society are not associated with the feminist perspective regarding violence against women. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 13. Which trait is least likely to be displayed by a woman experiencing intimate partner violence (IPV)? a. Socially isolated b. Assertive personality c. Struggling with depression d. Dependent partner in a relationship ANS: B 30 | P a g eEvery segment of society is represented among women who are suffering abuse. However, traits of assertiveness, independence, and willingness to take a stand have been documented as more characteristic of women who are in nonviolent relationships. Women who are financially more dependent have fewer resources and support systems, exhibit symptoms of depression, and are more often seen as victims. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 14. A woman who is 6 months pregnant has sought medical attention, saying she fell down the stairs. What scenario would cause an emergency department nurse to suspect that the woman has been a victim of IPV? a. The woman and her partner are having an argument that is loud and hostile. b. The woman has injuries on various parts of her body that are in different stages of healing. c. Examination reveals a fractured arm and fresh bruises. d. She avoids making eye contact and is hesitant to answer questions. ANS: B The client may have multiple injuries in various stages of healing that indicates a pattern of violence. An argument is not always an indication of battering. A fractured arm and fresh bruises could be caused by the reported fall and do not necessarily indicate IPV. It may be normal for the woman to be reticent and have a dull affect. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 15. Which statement is most accurate regarding the reporting of IPV in the United States? a. Asian women report more IPV than do other minority groups. b. Caucasian women report less IPV than do non-Caucasians. c. Native-American women report IPV at a rate similar to other groups. d. African-American women are less likely to report IPV than Caucasian women. ANS: B Caucasian women report less IPV than other ethnic groups. Asian women report significantly less IPV than do other racial groups. Native-American and Alaska Native women report significantly more IPV than do women of any other racial background. African-American 31 | P a g ewomen tend to report violence at a slightly higher rate than Caucasian women. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 16. Intervention for the sexual abuse survivor is often not attempted by maternity and womens health nurses because of the concern about increasing the distress of the woman and the lack of expertise in counseling. What initial intervention is appropriate and most important in facilitating the womans care? a. Initiating a referral to an expert counselor b. Setting limits on what the client discloses c. Listening and encouraging therapeutic communication skills d. Acknowledging the nurses discomfort to the client as an expression of empathy ANS: C The survivor needs support on many different levels, and a womens health nurse may be the first person to whom she relates her story. Therapeutic communication skills and listening are initial interventions. Referring this client to a counselor is an appropriate measure but not the most important initial intervention. A client should be allowed to disclose any information she feels the need to discuss. A nurse should provide a safe environment in which she can do so. Either verbal or nonverbal shock and horror reactions from the nurse are particularly devastating. Professional demeanor and professional empathy are essential. TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 17. A young woman arrives at the emergency department and states that she thinks she has been raped. She is sobbing and expresses disbelief that this could happen because the perpetrator was a very close friend. Which statement is most appropriate at this time? a. Rape is not limited to strangers and frequently occurs by someone who is known to the victim. b. I would be very upset if my best friend did that to me; that is very unusual. c. You must feel very betrayed. In what way do you think you might have led him on? d. This does not sound like rape. Didnt you just change your mind about having sex after the fact? ANS: A Acquaintance rape involves individuals who know one another. Sexual assault occurs when the trust of a relationship is violated. Victims may be less prone to recognize what is happening to 32 | P a g ethem because the dynamics are different from those of stranger rape. It is not at all unusual for the victim to know and trust the perpetrator. Stating that the woman might have led the man to attack her indicates that the sexual assault was somehow the victims fault. This type of mentality is not constructive. Nurses must first reflect on their own feelings and learn to be unbiased when dealing with victims. A statement of this type can be very psychologically damaging to the victim. Nurses must display compassion by first believing what the victim states. The nurse is not responsible for deciphering the facts involving the victims claim. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 18. Nurses are often the first health care professional with whom a woman comes into contact after being sexually assaulted. Which statement best describes the initial care of a rape victim? a. All legal evidence is preserved during the physical examination. b. The victim appreciates the legal information; however, decides not to pursue legal proceedings. c. The victim states that she is going to advocate against sexual violence. d. The victim leaves the health care facility without feeling re-victimized. ANS: D Nurses can assist clients through an examination that is as nontraumatic as possible with kindness, skill, and empathy. The initial care of the victim affects her recovery and decision to receive follow-up care. Preservation of all legal evidence is very important; however, this may not be the best measure in terms of evaluating the care of a rape victim. Offering legal information is not the best measure of evaluating the care that this victim received. The victim may well decide not to pursue legal proceedings. Advocating against sexual violence may be extremely therapeutic for the client after her initial recovery but not a measure of evaluating her care. MSC: Client Needs: Psychosocial Integrity 19. When the nurse is alone with a battered client, the client seems extremely anxious and says, It was all my fault. The house was so messy when he got home, and I know he hates that. What is the most suitable response by the nurse? a. No one deserves to be hurt. Its not your fault. How can I help you? b. What else do you do that makes him angry enough to hurt you? c. He will never find out what we talk about. Dont worry. Were here to help you. 33 | P a g ed. You have to remember that he is frustrated and angry so he takes it out on you. ANS: A The nurse should stress that the client is not at fault. Asking what the client did to make her husband angry is placing the blame on the woman and would be an inappropriate statement. The nurse should not provide false reassurance. To assist the woman, the nurse should be honest. Often the batterer will find out about the conversation. TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 20. Nurses who provide care to victims of IPV should be keenly aware of what? a. Relationship violence usually consists of a single episode that the couple can put behind them. b. Violence often declines or ends with pregnancy. c. Financial coercion is considered part of IPV. d. Battered women are generally poorly educated and come from a deprived social background. ANS: C Economic coercion may accompany physical assault and psychologic attacks. IPV almost always follows an escalating pattern. It rarely ends with a single episode of violence. IPV often begins with and escalates during pregnancy. It may include both psychologic attacks and economic coercion. Race, religion, social background, age, and education level are not significant factors in differentiating women at risk. TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity 21. In 1979, Lenore Walker pioneered the cause of women as victims of violence when she published her book The