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