Question 1

The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube? A)Flush and aspirate the tube with warm water B)Instill a digestive enzyme solution into the tube C)Instill cola or cranberry juice into the tube D)Use a small-barrel syringe to flush the tube

Accepted Answer

Enteral feeding tubes are more likely to become obstructed if the tube is not flushed frequently enough, medications are not adequately crushed or diluted before administration, a thick feeding formula is used, or a small-bore feeding tube is required. Interventions to unclog a feeding tube are more successful if they are initiated immediately. The nurse should first attempt to dislodge the clogged contents by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube (Option A). (Option B) If a feeding tube cannot be unclogged with warm water, the nurse may then attempt to use a digestive enzyme solution. These commercial declogging kits contain prefilled syringes of enzymatic solution that must be added to the tube and dwell in it for a period of time (usually 30 minutes to 1 hour) before flushing and aspiration are attempted. (Option C) Instilling a carbonated beverage (eg, dark cola) or cranberry juice into a clogged feeding tube is not appropriate. The acidity of either liquid can worsen an obstruction, and the dark color may mask gastrointestinal bleeding. (Option D) Flushing a feeding tube with a small-barrel syringe can create too much pressure and rupture the tube. Educational objective: When a feeding tube becomes clogged, the nurse should first attempt to unclog the tube by using a large-barrel syringe to flush and aspirate warm water in a back-and-forth motion through the tube. A digestive enzyme solution may help if warm water flushing is not effective.

Question 2

The nurse is preparing to irrigate the ears of a 67-year-old client with impacted cerumen. Place the following steps for ear irrigation in the correct order. All options must be used. A)Assess the client for fever, ear infection, or tympanic membrane injury B)Gently irrigate the ear canal with a slow, steady flow of solution C)Place a towel and an emesis basin under the ear D)Place the client in a sitting position with the head tilted toward the affected ear E)Straighten the ear canal by pulling the pinna up and back

Accepted Answer

11ecbb05_cb24_57fb_b433_03d60cbaa657_MD0009_00 Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure: Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies (Option A). Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies (Option A). Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). Place the client in a side-lying or sitting position with the head tilted toward the affected ear (Option D). Place a towel and an emesis basin under the ear (Option C). Place the client in a side-lying or sitting position with the head tilted toward the affected ear (Option D). Place a towel and an emesis basin under the ear (Option C). Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ?3 years (Option E). Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ?3 years (Option E). Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal (Option B). Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness. Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal (Option B). Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled. Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching. Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching. Educational objective: To perform ear irrigation, assess for contraindications (fever, ear infection, tympanic membrane injury); tilt the affected ear down; straighten the ear canal; and use a solution at body temperature to irrigate gently, aiming toward the top of the ear canal until it is clear.

Question 3

The nurse is providing postmortem care for a client who has died after a long hospitalization. The client had a do-not-resuscitate prescription in place at the time of death. Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home? Select all that apply. A)Allow family member to assist with care B)Call the medical examiner for an autopsy C)Gently close the client's eyes D)Place a pad under the perineum E)Remove the client's dentures

Accepted Answer

11ecbb05_cb26_a1ec_b433_ffcaa4db1d23_MD0009_00 Postmortem care is conducted with respect and dignity. The nurse should provide opportunities for family participation and accommodate religious and cultural rituals when possible (Option A). To perform postmortem care: Maintain standard or isolation precautions in place at the time of death. Gently close the client's eyes (Option C). Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending. Straighten and wash the body and change the linens. Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased. Leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor mortis sets in (Option E). A towel folded under the chin may be needed to keep the jaw closed. Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters (Option D). Place a pillow under the head to prevent blood from pooling and discoloring the face. Remove equipment and soiled linens from the room. Give client's belongings to a family member or send with the body. (Option B) This client's death was expected. It is not necessary to contact the medical examiner for autopsy. Educational objective: Postmortem care involves preparing the body for presentation to the family and includes hygiene (removing soiled linens and dressings, cleaning the body and room) and positioning (head on pillow, pad under perineum, mouth and eyes closed).

Question 4

The educator on a rehabilitation unit is teaching a graduate nurse (GN) about caring for clients who have had a stroke. Which of the following statements by the GN indicate correct understanding of the teaching? Select all that apply. A)"Approach clients with visual impairment from the affected side when entering the room." B)"Instruct clients with unilateral weakness to dress by donning clothes on the affected side first." C)"Provide written instructions for activities of daily living to clients with receptive aphasia." D)"Teach clients with left-sided neglect to turn their heads to scan the environment." E)"Teach families of clients with right-sided stroke to expect impulsive behaviors."

Accepted Answer

Clients with unilateral weakness from stroke may have limited mobility and control on the affected side. Clients being taught to dress independently should first clothe the affected side, which decreases the need for movement of impaired extremities and allows unrestricted use of unaffected limbs for assistance (Option B). Unilateral neglect is an alteration in sensory perception that causes clients to ignore input from the affected side, leading to performing actions only on one side (eg, eating food on only the right side of the plate). Teaching clients to turn the head to fully scan the environment reduces the tendency to neglect one side (Option D). Clients with right-sided cerebrovascular accidents tend to be impulsive and unaware of deficits. Teaching the client's family to expect disinhibition and emotional outbursts helps family members cope with the behavioral changes and reduces frustration during interactions (Option E). (Option A) The nurse should approach clients with unilateral blindness from the unaffected side to avoid startling the client. (Option C) Receptive aphasia (ie, Wernicke aphasia) is impairment of verbal and written language comprehension. Visual aids and hand gestures may be more effective means of communication. Educational objective: Neurological impairments from a stroke may include unilateral weakness and neglect, impulsiveness, and aphasia. The nurse should teach the client methods to improve visual perception (eg, turning head to affected side, scanning the environment) and overcome unilateral weakness (eg, dressing affected side first).

Question 5

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? A)Arrange for the client's service dog to come to the health care facility as soon as possible B)Describe the environment in detail so the client can ambulate safely with a cane C)Instruct the unlicensed assistive personnel to walk beside the client and lead by the hand D)Walk slightly ahead of the client with the client's hand resting on the nurse's elbow

Accepted Answer

11ecbb05_cb29_d63e_b433_618f2bf04359_MD0009_00 On the first postoperative day, the nurse assists the client with ambulation to evaluate alertness, pain level, signs of orthostatic hypotension, problems with gait or mobility, and ability to ambulate safely. The nurse also considers pre-existing limitations to ambulation such as the use of assistive aids (eg, sighted guides, canes, guide dogs). Clients who used any ambulatory assistive aids before surgery require postoperative evaluation prior to ambulatory independence. When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client. (Option A) The service dog may be brought to the hospital to assist in ambulation once the nurse has determined the client can ambulate safely. (Option B) After evaluation by the nurse, the client may be allowed to use a cane to ambulate around the nursing unit. (Option C) Instructing the unlicensed assistive personnel to ambulate the client is an inappropriate assignment for a client who is 1 day postoperative and legally blind. Nursing assessment is required to determine if the client is able to ambulate safely. Educational objective: When ambulating a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead with the client holding the nurse's elbow.

Question 6

The nurse is teaching a client of American Indian heritage how to self-administer insulin. As the nurse describes the necessary steps in the injection process, the client continuously avoids eye contact and occasionally turns away from the nurse. Which action is most appropriate for the nurse to take in this situation? A)Continue teaching the client and verify understanding by return demonstration B)Discuss how important it is for the client to pay attention during the teaching C)Maintain eye contact during the teaching by following the client's movements D)Provide written instructions and a private place for the client to learn independently

Accepted Answer

Communication with individuals of various cultures may be difficult for the nurse at times due to cultural language differences (ie, verbal and nonverbal communication styles including the use of silence). The mainstream American and European cultures value direct eye contact, believing that it is a sign of attention and trustworthiness. People of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away, not allowing the nurse to maintain eye contact. If the client avoids eye contact during a teaching episode, the most appropriate action is to continue with the instruction and verify understanding by return demonstration. (Option B) Lecturing the client about the importance of listening to the instructions for insulin self-injection would most likely be interpreted as degrading and disrespectful. (Option C) In the American Indian culture, it is disrespectful to maintain eye contact during a conversation. (Option D) A client learning the process of self-administration of insulin requires guidance and evaluation from the registered nurse before, during, and after the teaching session. The client should not be sent to a quiet place to learn the procedure independently. Educational objective: Individuals of American Indian and Asian cultures view direct eye contact as rude and disrespectful and will likely move the eyes away during conversations in an attempt to prevent it. The nurse demonstrates culturally competent care by respecting and accepting this cultural communication pattern.

Question 7

The home health nurse is following up with the parent of a Native American infant recently diagnosed with lactose intolerance. In accordance with principles of culturally competent care, what is the most important question for the nurse to ask the parent? A)Do your other children have this condition? B)How long did your infant have diarrhea? C)How often are you feeding the infant? D)What do you think caused your infant's illness?

Accepted Answer

All clients have cultural influences that can affect their beliefs and concerns about causes of medical conditions and expectations for treatment. The nurse should have clients express what caused their medical illnesses or problems to gain knowledge of their beliefs and understandings about the conditions; this is fundamental to developing a culturally sensitive and appropriate teaching and care plan. Culturally competent care requires the nurse to recognize that the client's interpretation of an illness is more significant than the nurse's knowledge of the illness. Clients' beliefs about health and disease may be complex and tightly rooted in centuries-old traditions. Some clients welcome scientific explanations about their conditions, whereas others ignore a nurse's teaching that does not align with their personal perspectives. The nurse must never assume that a client knows (or does not know) about a subject; accurate assessment about knowledge and beliefs is necessary. (Option A) The nurse may ask about other family members; however, this does not address cultural beliefs and concerns. (Option B) Knowing the duration of diarrhea will help determine the infant's nutritional status and fluid balance but does not address cultural beliefs and concerns. (Option C) Although it is important to determine that nutritional intake is adequate for normal growth and development, this does not address cultural beliefs and concerns. Educational objective: When providing culturally competent care, it is most important for the nurse to assess the client's beliefs regarding the cause of current illnesses. This will facilitate development of a culturally sensitive and appropriate teaching and care plan.

Question 8

A Muslim woman is admitted to the inpatient trauma unit after falling and sustaining a head injury. In providing culturally competent care for this client, which consideration is most important? A)Allowing the client's husband to be with her during clinical examinations B)Assigning the client to a private room C)Ensuring that female health care workers are available to provide care to the client D)Obtaining the services of a local Muslim imam

Accepted Answer

For the observant Muslim client, maintaining modesty is an important moral value. Covering up the body is essential when a Muslim woman is in the presence of a man who is not related to her, even if the man is a health care provider. Special provision should be made for female health care workers to provide care and examine Muslim women. If a female health care provider is not available, a female nurse or clinical staff person should be present. In addition, privacy screens should be used and room doors should be kept closed consistently. (Option A) A husband will often request to be with his wife during an examination; efforts should be made to fulfill this request, but it is not the priority consideration. (Option B) A private room may not be necessary. This client should be assigned to a room with another Muslim woman or a woman with similar practices regarding modesty. Otherwise, male visitors to the client's roommate could be problematic and cause distress. (Option D) Consulting with a local Muslim imam or hospital chaplaincy staff may enhance culturally congruent care; however, this is not the most pressing consideration. Educational objective: In the care of female Muslim clients, modesty is highly valued and most body parts are covered. Female health care workers should be available to provide care and conduct examinations. If a male health care provider must be involved in care, female clinical staff should also be present whenever possible.

Question 9

The nurse is caring for a client newly prescribed crutches. Which finding indicates the need for further teaching? A)The axillary pads are torn and show signs of wear B)The client has a 30-degree bend at the elbow when walking C)The crutches and injured foot are moved simultaneously in a 3-point gait D)There is a 3 finger-width space noted between the axilla and axillary pad

Accepted Answer

11ecbb05_cb27_653d_b433_15c1b2b8c867_MD0009_00 The proper fit and use of crutches are important in preventing injury. They include: Proper measurement and fit - There should be a 3-4 finger-width space (1-2 in [2.5-5 cm]) between the axilla and axillary pad (Option D). Clients are taught to support body weight on the hands and arms, not the axillae. Handgrip location should allow 20-30 degrees of flexion at the elbow (Option B). Proper gait - The 3-point gait is used for restrictions of partial or no weight-bearing on the affected extremity. The injured extremity and crutches are moved simultaneously (Option C). The client who is rehabilitating from an injury of the lower extremity usually progresses from non-weight-bearing status (3-point gait) to partial weight-bearing status (2-point gait) to full weight-bearing status (4-point gait). (Option A) Wear and tear of the axillary pads raises concern for the incorrect use or fit of crutches. Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axillae. This leads to a reversible condition known as crutch paralysis, or palsy, and is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Educational objective: Proper crutch fit includes a 3-4 finger-width space between the axillary pad and axilla and a handgrip location that allows 20-30 degrees of elbow flexion. Clients should support their body weight on the hands and arms, not the axillae. Wear and tear on the crutch pads may indicate improper use or fit. Clients progress from 3-point gait (no to partial weight-bearing) to 2-point gait and then 4-point gait as rehabilitation continues.

Question 10

A client is brought to the emergency department with multiple trauma injuries. The nurse sees the client's Jehovah's Witness identification card. As part of providing culturally competent care, the nurse would anticipate the client accepting which of the following? Select all that apply. A)Epoetin alfa B)Fresh frozen plasma C)Homologous packed red blood cells D)Normal saline E)Platelet transfusion

Accepted Answer

Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major components (ie, red cells, white cells, platelets, and plasma) (Options B, C, and E). Shock prevention is a major concern in the setting of blood loss and can be accomplished with the use of non-blood volume expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered safely to clients who refuse blood products (Option D). Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's Witnesses. These medications stimulate the bone marrow to produce more red blood cells, resulting in increased hematocrit and hemoglobin levels (Option A). Educational objective: Jehovah's Witnesses believe that transfusion of blood and blood products is not acceptable. Acceptable blood product alternatives include non-blood volume expanders (eg, saline, lactated Ringer's, dextran, hetastarch) and albumin-free erythropoietin. Unacceptable treatments are transfusions of whole blood, red cells, white cells, platelets, and plasma.

Question 11

The charge nurse is instructing a new graduate nurse on performing postmortem care. Which client situations might cause the nurse to delay or not perform postmortem care? Select all that apply. A)Client died following a prolonged illness B)Client's family was not present when death occurred C)Client's religious background requires special ceremonial treatment of the body D)Death occurred in the emergency department following a suicide attempt E)Family requests a priest to perform last rites

Accepted Answer

Postmortem care typically is performed immediately following the pronouncement of death to allow visitation of the deceased by the family. There are several circumstances in which postmortem care may be delayed or not performed. Certain cultural or religious beliefs require that care be performed by the family or clergy (Option C). The family also may want religious ceremonies performed or last rites given before the body is cleaned or disturbed in any way (Option E). Postmortem care can also be delayed, altered, or not performed in accordance with state law and agency policies. These situations include deaths that are considered non-natural, traumatic, or associated with criminal activity (Option D). (Option A) Death following a prolonged illness may be expected and would not cause a delay in postmortem care unless the family requests it. (Option B) Unless family members notify the agency of any religious or cultural needs related to the deceased, they do not have to be present for postmortem care to take place. Educational objective: Postmortem care may be delayed or not performed if the family has certain cultural or religious beliefs or if the death is considered to be non-natural, traumatic, or associated with criminal activity.

Question 12

The nurse is interviewing a non-English-speaking client. Which best practices will the nurse use when working with a professional medical interpreter for clients of limited English proficiency? Select all that apply. A)Address the interpreter directly B)Ask the client's adult child to translate C)Hold a pre-conference with the interpreter D)Identify any gender or age preferences E)Speak in short sentences

Accepted Answer

Title IV of the Civil Rights Act of 1964 initiated national standards for appropriate care of culturally diverse clients. Clients with limited English proficiency have the right to receive medical interpreter services free of charge. When working with an interpreter, the nurse should apply the following best practices to maximize communication and understanding with the client: Address the client directly in the first person Speak in short sentences, pausing to allow the interpreter to speak (Option E) Ask only one question at a time Avoid complex issues, idioms, jokes, and medical jargon Hold a pre-conference with the medical interpreter to review the goals of the interview (Option C) Use a qualified professional interpreter whenever possible The nurse should avoid using interpreters from conflicting cultures (eg, Palestinian, Jewish) and be mindful of any cultural, gender, or age preferences (Option D). (Option A) The nurse should speak directly to the client, not the interpreter. (Option B) A family member or friend may not have the vocabulary, knowledge, or skills to provide the best communication for the client. Untrained interpreters may omit or simplify critical pieces of information if they do not understand the terminology. Educational objective: When working with a medical interpreter, the nurse should apply best practices to maximize communication and understanding with the client. Key practices include speaking to the client directly; using short, simple sentences; avoiding the use of family members as interpreters; and being mindful of cultural, gender, or age preferences.

Question 13

A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker "force feed" the client. What is the priority nursing action? A)Explain to the family that this is a normal physiological response to dying B)Explore the family's thoughts and concerns about the client's refusal of food C)Recommend a feeding tube D)Tell the family that "force feeding" the client could cause the client to choke on the food

Accepted Answer

When a terminally ill person refuses food, family members often become upset and frustrated in their roles of nurturers and caregivers; they may feel personally rejected. Refusal of food is associated with "giving up" and is a reminder that their loved one is dying. It is not uncommon for family members to believe that a client would get stronger by eating instead of refusing food. The registered nurse needs to explore family members' concerns and fears and listen as they express their feelings. The nurse can help them identify other ways to express how they care. The nurse should also provide education about the effects of food and water during all stages of the illness. (Option A) Families and caregivers need to understand the effects of food and water in all stages of a terminal illness; however, it is more important to first explore the family's feelings and concerns. (Option C) Although it is not unusual for a client to be admitted to hospice with a feeding tube already in place, tubes are generally not placed after a client begins receiving hospice services. (Option D) This is a true statement, but it is not the priority nursing action. Educational objective: It is very common for family members to become distressed when a terminally ill loved one refuses food. The nurse needs to explore their fears and concerns and help them identify other ways to express how they care.

Question 14

A client calls the nurse to report exacerbation of chronic lower back pain after working in the yard all weekend.  Knowing that this worsened back pain is probably due to acute inflammation, the nurse recommends which nonpharmacologic intervention?
A)Heating pad
B)Positioning for comfort
C)Rest from pain-aggravating activities
D)Stretching exercises

Accepted Answer

Acute exacerbation of chronic back pain is usually associated with inflammation triggered by (strenuous and/or repetitive) activities that stress the previously injured area. Interventions should be directed toward reducing inflammation. Nonpharmacologic intervention to treat the inflammation includes rest from pain-aggravating activities which may continue to promote inflammation and delay healing. (Option A) Applying heat to the injured area can promote the inflammatory process (via vasodilation); therefore, this is not the best intervention at this time. However, after the acute inflammation has resolved (usually within a few days) heat application would be appropriate to reduce pain and muscle spasms. (Option B) Although the nurse should teach the client to ensure positioning for comfort to reduce pain, this is less likely to impact the inflammatory processes causing the pain. (Option D) Stretching exercises can also be helpful for back pain but should begin after the acute pain and inflammation have subsided. Educational objective: Rest from activities that aggravate pain and inflammation is a nonpharmacologic comfort intervention to decrease the inflammation due to acute pain.

Question 15

The family of a terminally ill, dying client verbalizes concern that the client is becoming dehydrated due to poor fluid intake.  When the family asks the nurse about administering IV fluids, the nurse's response is based on an understanding of which statement?
A)Providing artificial hydration at the end of life will make the client feel more comfortable
B)The decision whether to provide artificial hydration should consider client preferences and goals
C)The health care provider will prescribe artificial hydration when the client can no longer swallow
D)Withholding artificial hydration at the end of life speeds up the dying process

Accepted Answer

The decision about providing artificial nutrition to a dying client is complex. Although certain situations involving terminal illness, such as a terminally ill client who wants to attend an important family function, can justify the decision to provide IV fluids, providing artificial hydration in other situations may not be justified and may even be harmful. Ethical principles dictate that client preferences should be respected and that clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life. (Option A) Artificial hydration does not seem to help dying clients feel more comfortable, and IV fluids could cause distressful symptoms such as respiratory distress, vomiting and diarrhea, and the need for urinary catheterization. (Option C) The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration. (Option D) There is no evidence that withholding artificial hydration at the end of life speeds up the dying process. Research indicates that dying clients who do not receive artificial hydration live just as long as those who do receive IV fluids. Educational objective: The majority of hospice and palliative health care providers do not recommend routine administration of artificial hydration; however, client preferences should be respected - clients/family members have the right to make decisions about artificial nutrition and hydration at the end of life.

Question 16

Before examining the infant of a Mexican American mother, the nurse compliments the child's outfit. The mother becomes visibly distressed. What is the best next action for the nurse to take? A)Ask the mother's permission to touch the child's hand B)Interview the mother about the reason for bringing the child to the clinic C)Reassure the mother that there is no reason for distress D)Suggest postponing the examination until the mother calms down

Accepted Answer

In Latin American culture, an illness called "mal de ojo" ("evil eye") is believed to be caused when a stranger or someone perceived as powerful admires or compliments a child. The "illness," or "curse," is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child or immediately afterward (Option A). Mexican American mothers may worry when strangers compliment their babies without touching them. To protect against mal de ojo, the child may wear charms or beaded bracelets. If a child is believed to be afflicted with mal de ojo, the parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse. (Option B) Asking the mother about the reason for bringing the child to the clinic will not relieve the mother's distress. (Option C) This response is nontherapeutic and dismissive, and indicates the nurse's lack of cultural awareness. (Option D) Postponing the examination does not address the cause of the mother's distress. Educational objective: Many Latin Americans believe in "mal de ojo," or "evil eye," a cultural belief in an illness thought to be manifested in children by vomiting, fever, and crying. It is believed to be caused when a stranger admires a child without touching the child at the same time or immediately afterward.

Question 17

The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply. A)Cervical cancer B)Hypertension C)Ischemic stroke D)Osteoporosis E)Skin melanoma

Accepted Answer

The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women (Option A). African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women (Option B). African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia (Option C). (Option D) White and Asian women have a higher incidence of osteoporosis than African Americans, but the disease affects all ethnic groups. (Option E) Melanoma of the skin is more common in people who are of white ancestry, light-skinned, and over age 60 with frequent sun exposure. The incidence of melanoma is 10 times higher in white Americans than African Americans. Educational objective: African Americans have the highest incidence of hypertension in the world as well as increased incidence of stroke and cervical cancer. Whites have a high incidence of osteoporosis and skin cancer (melanoma).

Question 18

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action? A)Ask the health care provider to prescribe a different calcium channel blocker B)Consult with the pharmacist to see if an alternate form of the drug is available C)Open the capsule and sprinkle the medication in a cup of applesauce D)Warn the client about the dangers of uncontrolled hypertension

Accepted Answer

Members of the Orthodox Jewish faith observe strict dietary laws that dictate whether certain foods and medications are considered kosher (fit to be consumed). Most capsules are coated in gelatin, a substance made from the collagen of animals, which is generally considered nonkosher. The nurse should first ask the pharmacist if an equivalent, gelatin-free form of the medication (eg, tablets) is available. If no alternate form is available, the client may want to consult with a rabbi as laws may be relaxed for those who are ill. (Option A) It is not necessary to ask the health care provider to prescribe a different medication unless the religious dietary laws cannot be relaxed or the client desires a kosher alternate form of diltiazem (Cardizem) that is unavailable. (Option C) Extended-release capsules should be swallowed whole. Crushing or breaking the capsule may cause uncontrolled delivery of the medication and increase the risk of overdose or other serious adverse effects. (Option D) Although it is important to perform client teaching, the nurse should first assess the reason for this client's nonadherence to the prescribed regimen. Additionally, the nurse should avoid using scare tactics in client teaching. Educational objective: Due to Orthodox Jewish dietary laws, it is not acceptable for clients who follow a kosher diet to consume capsules made from gelatin. The nurse should ask the pharmacist if an alternate form of the medication is available. If not, the client may want to consult a rabbi as laws may be relaxed for those who are ill.

Question 19

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. A)Ask a family member about the client's preferences for room arrangement B)Offer the client an elbow to hold, and walk a half-step ahead for guidance C)Say "goodbye" when leaving the room to help orient the client D)Speak slowly and slightly louder so the client can understand E)Use a clock-face pattern to explain food arrangement on the client's meal tray

Accepted Answer

The nurse should create a therapeutic and safe environment for the client who is blind while fostering as much independence as possible. Nursing interventions include the following: Offer the client an elbow for guidance while walking slightly ahead and describing the environment (Option B). Announce room entry and exit to orient and avoid startling the client (Option C). Describe the location of items (eg, food, hygiene supplies) using a clock-face orientation so the client can find them easily (Option E). Instruct the client to use a cane with the dominant hand and to sweep areas in front from side to side for orientation. Orient the client to the room and maintain this orientation for safety. (Option A) Asking the caregiver or family member about the client's personal preferences does not promote independence or self-advocacy. The nurse should ask the client directly about the desired room arrangement. (Option D) The nurse should speak to the client in a normal tone of voice to facilitate communication. Speaking slowly and slightly louder would be useful for a client with a hearing deficit. Educational objective: When caring for a client who is blind, the nurse should create a safe therapeutic environment and foster client independence by orienting the client to the surroundings, announcing room entry and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face description to orient the client to the location of objects, and asking the client directly about preferences.

Question 20

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse? A)Administer an analgesic B)Assess the child's level of pain using a numeric rating scale C)Come back later in the day D)Tell the child, "Get up and walk if you want to go home soon."

Accepted Answer

11ecbb05_cb21_e6fa_b433_95b99ae5baf8_MD0009_00 Postoperative pain control is a priority intervention for a child of any age. However, the nurse needs to first perform an assessment of the child's pain to determine the appropriate pharmacological or non-pharmacological measure to implement. This assessment will also provide a baseline against which the effectiveness of the chosen pain relief method can be evaluated. A numeric pain scale can be used with most children who can count and understand the concept of numbers, generally at around age 5. The scale uses a straight line with divisions marked in units from 0-10; 0 is identified as no pain, 5 as moderate pain, and 10 as worst pain. (Option A) Analgesics (opiates and nonsteroidal antiinflammatory drugs), along with adjuvant analgesics, are appropriate pain control measures in children. However, pain should be assessed before medications are administered. (Option C) Returning later in the day allows the child to rest but does nothing to relieve current pain. (Option D) This non-therapeutic response ignores the child's expressed pain and poses a threat that could be upsetting to the child. Educational objective: When a client is in pain, assessment is the first necessary nursing action. The pain assessment helps to determine the appropriate relief measure and serves as a baseline for evaluating the effectiveness of the chosen pharmacological or non-pharmacological measure.

Exam 4: Fundamentals

The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?

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The community health nurse is preparing to teach a group of African American women about prevention of diseases common to their ethnic group. Based on the incidence of disease within this group, which disorders should the nurse plan to discuss? Select all that apply.

The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states "I cannot take the medication in this form." What is the nurse's first action?

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse?