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Ban
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Chapter 1. Health Maintenance Guidelines
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Mu ltiple Choice
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Identify the choice that best completes the statement or answers the question.
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1. A patient who is a Jehovahs Witness has severe gastrointestinal bleeding and a
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ss danger ously low hemoglobin level. The patient is fully alert and competent and refuses to
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ss accept the blood transfusion ordered by the physician. Which action by the nurse is most
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ss appropriate? a. Obtain a court order to give the blood. ss ss ss ss ss ss ss ss ss
b. Administer the blood while the patient is sleeping. ss ss ss ss ss ss ss
c. Have the patients spouse sign the consent to have the blood administered.
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d. Ensure the patient understands possible consequences and then respect the patients wishes.
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s s s s 2. A patient of Mexican descent sees a curandero for asthma; the curandero
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has prescribed a special tea to be taken four times a day to open the airways. How
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should the nurse respond to this situation?
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a. Encourage the patient to continue drinking the tea. ss ss ss ss ss ss ss
b. Encourage the patient to drink only one cup of the tea each day.
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c. Ask the patient to bring in the tea package and have the pharmacist check the ingredients.
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d. Advise the patient to stop drinking the tea because of potential interactions with
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ot her medications.
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3. The nurse is caring for a young adult male patient who refuses personal care
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ss fro mma female nursing assistant. Which approach by the nurse is best?
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a. Encourage the patients family to talk with him about his care.
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b. Have a registered nurse (RN) help with his personal care.
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c. Assign a male assistant to help with his personal care if one is available.
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d. Explain to him that males and females take care of both genders in this hospital.
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4. The nurse is providing medication instructions to a 45-year-
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old patient who does not maintain eye contact. What should this patients behavior
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ss indicat e to the nurse? a. The patient is not interested.
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b. The nurse threatens the patients ego.
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c. The nurse is in a hierarchical position.
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d. The patient does not intend to follow the instructions.
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5. The nurse is caring for a patient of Spanish descent who is experiencing pain,
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but do es not speak English. An interpreter is located to help with the assessment.
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What should the nurse do to facilitate communication with this patient?
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a. Use hand signals to determine the cause of the pain.
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b. Ensure the interpreter is not left alone with the patient.
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c. Maintain eye contact with the patient and the interpreter.
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d. Use only physical examination data; do not rely on verbal communication.
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6. A new mother of Guatemalan descent brings her 10-day-
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old infant to a clinic for a wellbaby checkup. To promote healing, she has a coin
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taped t o the infants umbilicus. What should the nurse do about this situation?
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a. Teach the mother how to clean the coin daily and reapply it.
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b. Explain to the mother that the coin is not necessary for healing.
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c. Tell the mother to remove the coin, because it could cause an infection.
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d. Teach the mother how to apply a dry sterile dressing in place of the coin.
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7. An older patient who follows the Muslim religion is approaching death. The family
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says the patients bed should be turned toward the opposite wall, so it can face Mecca
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to en sure an easier passage into the next life. The wall they want the bed to
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ss face has wall suctio n and oxygen, which the patient is using. Which action by the
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nurse is appropriate? a. Get permission frommthe physician to move the bed.
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b. Rearrange the furniture to accommodate the request. ss ss ss ss ss ss
c. Tell them you will move the bed when the patient is closer to death.
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d. Tell them it is impossible because of the short tubing on the oxygen and suction.
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s s s s s s 8. A patient of northern European descent recovering from surgery denies
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postoperativ e pain; however, vital signs indicate an elevated pulse and blood pressure.
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The patient refus es to move in bed. Which nursing action would best ensure comfort
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ss and timely discharge?
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a. Give the pain medicine as prescribed.
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b. Ask the physician to prescribe the analgesics around the clock.
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c. Explain that the pain medicine will help prevent complications.
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d. Respect the patients denial of pain, and do not encourage the pain medicine.
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9. The nurse is preparing to teach a patient of the Asian culture to perform postoperative
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dre ssing changes at home after discharge. Which statement made by the nurse indicates
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cultural
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Material
competence?
a. Tell me how you feel about your surgery.
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b. Asian people are smart, so this should be easy for you to understand.
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c. American surgeons are highly qualified; Im sure you will heal quickly.
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d. Will you tell me about any traditional healing practices that you would like to use?
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10. An unconscious victimmof a house fire is brought to the emergency department by
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the paramedics. Tied to the right wrist is an emblem that appears be a religious
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talisman. W hich action should the nurse take? a. Tape it in place.
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b. Do nothing with it. ss ss ss
c. Remove it and lock it up for safekeeping. ss ss ss ss ss ss ss
d. Place it in a clothing bag with the rest of the patients belongings.
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11. A 43-year- ss ss
old patient of Arab descent is admitted to the hospital. To comply with the state
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laws of the organization, the nurse offers the patient a Papanicolaou smear, which she
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refuses. Which action should the nurse take first? a. Notify the physician.
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b. Report the refusal to the supervisor. ss ss ss ss ss
c. Explain the rationale for and benefits of the test.
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B Tell her it is state law and that she does not have a choice
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12. A nurse who emigrated from China begins working on a medical unit. The preceptor
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expla ins the unit routines, including the medication administration system. When the
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preceptor asks if the nurse understands, the answer is always: Yes, I understand. What
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ss should s s the preceptor do to measure the nurses comprehension? a. Give the nurse a
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medication quiz.
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b. Have the nurse repeat the instructions.
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c. Have the nurse demonstrate the procedures.
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d. Ask the nurse which information is hard to understand.
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s s s s s s s s 13. A 52-year- ss ss
old from Haiti is hospitalized with heart failure and wants to have a voodoo practitioner
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visit to say prayers. How should the nurse respond to this request? a. Report the request to
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the p hysician immediately.
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b. Tell the patient that this is not permitted during hospitalization.
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c. Tell the patient it is okay for the voodoo practitioner to say prayers.
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d. Have the patient meet with the voodoo practitioner in the hospital lobby.
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14. The nurse is caring for a patient from a non-
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English speaking culture. While providing care, the nurse shows an appreciation for and
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atten tion to arts, music, crafts, clothing, and foods
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