Download Religion, Spirituality, and Culture in Nursing: Final Exam Practice and more Exams Nursing in PDF only on Docsity!
NURS 1023C Final Exam Practice Test
- The nursing student learns which facts about religion and spirituality? (Select all that apply.) a. Spirituality focuses on the meaning of life to people. b. Religion and spirituality are mutually exclusive. c. Religion implies an organized way of worship. d. Religion provides the structure by which to understand spirituality. e. Spirituality is an individual practice that does not include others. Spirituality focuses on the meanings of life, death, and existence. Religion is an organized and structured method of practicing or expressing one’s spirituality, so they are interconnected and not mutually exclusive. Religion provides the structure for expressing spirituality. Spirituality can be expressed through relationships with others 2.A patient, who is a Muslim is in the hospital. The patient has high caloric requirements but is refusing to eat during Ramadan. What action by the nurse is best? a. Insert a feeding tube and provide enteral feedings. b. Ask the provider about Total Peripheral Nutrition. c. Call the patient's religious leader for advice. d. Tell the patient he has to eat to get better. With permission, the nurse should consult with the patient's religious leader on this situation. There may be exceptions to the rule to fast during Ramadan for medical conditions. The other options ignore the patient's religious preferences, and both the tube feeding and parenteral nutrition have potential serious side effects. 3.A patient in the hospital is an adherent Muslim. Which of the five pillars of Islam can the nurse assist the patient in meeting? a. Praying five times a day b. Having privacy c. Personal cleanliness d. Giving alms e. Maintaining modesty
The five pillars of Islam are: believe in one God, pray five times a day facing
Mecca, giving alms to the less fortunate, fasting during Ramadan, and making
a pilgrimage to Mecca. The nurse is best able to help the patient maintain the
practice of praying five times a day while hospitalized.
- When teaching an Asian patient with newly diagnosed diabetes, the nurse notes the patient nodding yes to everything that is being said. With a better understanding of cultural interdependence in self-concept, a nurse should immediately a. write everything down for the patient to refer to later. b. prompt further to elicit additional questions or concerns. c. call the recognized elder for this patient. d. call the oldest male relative for help with decision making. When a nurse provides nutritional education to a patient who is from a culture that values greater power distance, it might appear that the patient is willing to accept all that the nurse suggests, when further prompting would elicit additional questions or concerns. The patient from a collectivist culture will usually consult family members for a best course of action. It is not
acceptable for nurses to take it upon themselves to call the recognized elder or oldest male relative for help with decision making. While writing everything down may be OK for some cultures, with Asian patients it may be best to prompt further to elicit additional questions or concerns
- To enhance cultural awareness, nursing students need to make an in-depth self- examination of which attributes? a. Motivation and commitment to caring b. Social, cultural, and biophysical factors c. Engagement in cross-cultural interactions d. Background, recognizing personal biases and prejudices Cultural awareness is an in-depth self-examination of one's own background, including recognizing one's biases and prejudices and assumptions about other people. 6.A nurse develops a nursing diagnosis for a patient. Which factor can cause a culturally insensitive diagnosis? a. Cultural bias b. Medical history c. Generalization d. Cultural care repatterning The nurse's cultural biases can affect the accuracy of the nursing diagnosis, leading to a culturally insensitive diagnosis. This is because the nurse may not be able to understand the reasoning behind the patient's behavior. The patient's medical history will help in formulating an accurate nursing diagnosis, as it helps understand the patient's current condition. Generalizing will not adversely affect the nursing diagnosis; it helps anticipate and understand patient behaviors. Cultural care repatterning respects the patient's cultural values while helping the patient adopt new and different health care patterns for a healthier life.
- The nurse is caring for a patient from a culture that is unfamiliar. The patient nodded her head "yes" when asked if she will take her prescriptions as ordered, but the nurse discovers the patient does not take the medication but uses herbs for treatment. What action by the nurse is best? a. Warn the patient of the consequences on noncompliance. b. Tell the patient how the medication will help the condition. c. Ask the patient why herbal preparations are preferred. d. Ask the patient to explain the meaning of the herbal products. Ethnocentrism is the belief that one's cultural beliefs are superior to others. In order to avoid practicing in an ethnocentric manner, the nurse needs to understand the meaning of the herbal preparation to the patient. Warning the patient of bad outcomes will not achieve the desired results if the herbs are culturally important and meaningful to her. Patient education is always important but is not the best answer because it does not allow the nurse to learn from the patient. Asking "why" questions is a communication barrier likely to put the patient on the defensive. 8.A nurse is caring for a refugee patient who wants the community shaman to perform a healing ritual at the bedside. What action by the nurse is best? a. Work with the patient to allow the shaman to perform the ritual. b. Investigate whether the ritual will harm the patient.
b. Standing at the end of the bed with arms crossed c. Facial grimacing at the sight of the wound d. Gentle touching of the patient's shoulder Therapeutic touch, such as holding the patient's hand or touching the patient's shoulder, can provide comfort and may alleviate pain. This is especially true when a patient is undergoing a painful or stressful procedure. Making inappropriate facial expressions may be offensive and hurtful to patients or their family members. The nurse must control his or her facial expressions to avoid communicating disdain or judgmental attitudes in challenging patient care situations. Maintaining a neutral facial expression establishes an environment of caring and openness in which the patient and family members can feel safe to share their innermost concerns. The use of gestures may be challenging to nurses practicing in a multicultural environment. Although they may enhance verbal communication, gestures may be viewed as inappropriate by patients of various cultures. Standing with crossed arms may be indicating a lack of openness or acceptance. 12.The student nurse learns that which item is the most important symbolic aspect of culture? a. Flags b. Language c. Art d. Music 13.If the patient needs prayer time or a spiritual leader – the nurse’s job is to make that happen A patient who claims to be very involved in church is near death. What action by the nurse is best? a. Get permission to contact the religious leader. b. Allow the family to stay at the patient’s bedside. c. Call the hospital chaplain to come to the bedside. d. Ask if the patient and family want to pray. Organized religions use rituals to mark important life events such as birth, marriage, and death. This patient would most likely want end-of-life rituals as practiced in his/her church. The nurse's best action is to contact the religious leader (with permission) of that church or institution. Allowing the family to remain at the bedside is important but not the best option to care for the patient's spirituality needs. The hospital chaplain is a valuable resource, but the patient's own religious leader would be better. Praying with the family is always acceptable, but it is best to let the family take the lead in prayer. 14.Which statement made by an elderly patient whose spouse died a week ago indicates spiritual distress? a. "All my prayers and good deeds were in vain." b. "I will have to move to an assisted-living facility." c. "Can you arrange a meeting with the chaplain?" d. "I wish we could have spent more time together." The patient is going through a phase of disturbed faith and lacks confidence in his or her prayers and good deeds. This indicates that the patient is experiencing spiritual distress. When the patient is thinking about moving to an assisted-living facility, the patient is trying to find practical solutions to meet health care needs. If the patient seeks a meeting with the chaplain, the patient is trying to reconcile with self and overcome grief. The patient expresses sadness, not spiritual distress, at being unable to spend more time with the spouse.
15.Which observations by the nurse indicate positive outcomes in a patient with a nursing diagnosis of spiritual distress? Select all that apply. a. The patient expresses increased hope of becoming healthy. b. The patient’s relationship with his partner is satisfactory. c. The patient is compliant with his medication regimen. d. The patient is not talking to his family and friends. e. The patient remains at home and watches TV all day. When evaluating for goal-directed outcomes, the nurse should check for an increase in hope; purpose of life; increased connectedness with self, others, and God or another supreme being; and an increase in overall health. Goals set during the planning phase should be the benchmark for assessing the extent of positive outcomes of care. Patients who are hopeful for good health and who have an increased level of connectedness to their partners exhibit positive outcomes. The patient with positive outcomes tends to become compliant with the prescribed medication regimen. Patients who avoid family and friends and remain confined to home and a single activity exhibit further need for spiritual intervention. 16.Which signs or behaviors of spiritual distress would the nurse identify in the patient with breast cancer? Select all that apply. a. The patient is angry and expresses a lack of faith in God. b. The patient is disturbed and expresses an inability to pray. c. The patient does not wish to speak to friends and family. d. The patient desires to meet with a spiritual adviser. e. The patient seeks reconciliation with family members. Patients often experience spiritual distress when confronted with life-threatening diagnoses. A patient with spiritual distress may be angry and express a lack of faith in a higher authority or God. The patient may be disturbed and express an inability to pray or communicate with God. The patient may be depressed and may not want to talk to his or her friends and family. A patient who has accepted the diagnosis may also desire to meet a spiritual advisor. A patient who seeks reconciliation with family members has likely accepted the situation. 17.The spouse of a patient who is terminally ill is in spiritual distress. Which other situations would adversely affect the spirituality of an individual? Select all that apply. a. Diagnosis of diabetes b. Major motor vehicle accident c. Successful surgery d. Birth of twins e. Near-death experience Spirituality is significantly influenced by chronic illness, acute illness, and near-death experiences. Diagnosis of diabetes, a chronic illness, creates stress and anxiety in a person, because that person will have to modify his or her lifestyle and diet. A person who experiences a major motor vehicle accident may be in distress and confused, possibly leading to spiritual distress. A patient who had a near-death experience feels that no one will believe his or her experiences. A successful surgery and birth of twins likely would elevate the spirituality of an individual. 18.The nurse is assessing an Asian patient with arthritis. The patient asks the nurse about the benefits of alternative therapies for arthritis. Which response made by the nurse would demonstrate ethnocentrism? a. Some alternative therapies might prove useful for your condition.
d. Pleasant but quiet.
There are many cues to alert the nurse that a patient might have unmet
spiritual needs, including facing a terminal illness. The nurse should conduct
spiritual assessments on all patients, but this one is the priority.
22.A patient has the Nursing diagnosis Spiritual Distress. What assessment by the patient best indicates that an important goal has been met? a. Observed praying quietly. b. Indecisive about treatment. c. Asks nurse if God exists. d. Executes living will.
Patients may have spiritual distress when facing situations that threaten their
meaning and purpose in life, such as in the face of a terminal diagnosis.
Patients often express anger, frustration, neediness, or crying. The patient
who has worked through this situation and is able to pray has best shown goal
attainment. Indecision and questioning do not indicate the resolution of this
diagnosis. Executing a living will may be an indication of pragmatism.
- The nurse concerned about a patient’s spiritual needs can best address this by which action? a. Leaving a note on the chart for other professionals b. Calling the chaplain to come see the patient c. Collaborating during interdisciplinary rounds d. Informing the provider of the patient’s needs Spiritual care must be multidisciplinary in order to be most effective. The nurse best addresses patients' spiritual needs by discussing them during interdisciplinary rounds. 24.Which are true statements about the definition of spirituality in nursing? (Select all that apply.) a. Patient’s quality of life, health, and sense of wholeness are affected by spirituality. b. An exact definition was developed and adopted in the late 1980s. c. Encompasses principle, an experience, attitudes, and belief regarding God d. Head knowledge affects spirituality more than heart knowledge. e. Mind, body, spirit, love, and caring are interconnected. The concept of spirituality is an elusive concept to define. Authors who write about spirituality in nursing advocate the position that a patient’s quality of life, health, and sense of wholeness are affected by spirituality, yet still the profession of nursing struggles to define it. Why? There are a number of explanations for this. One explanation is that spirituality represents “heart” not “head” knowledge and “heart” knowledge is difficult to encapsulate into words. A second explanation is that spirituality is unique to each person so a precise definition is somewhat elusive. The definitions of spirituality encompass the following: a principle, an experience, attitudes and belief regarding God, a sense of God, the inner person. Most descriptions of spirituality include not only transcendence but also the connection of mind, body, and spirit, plus love, caring, and compassion and a relationship with the Divine. 25.When does the nurse assess patients’ spirituality? (Select all that apply.) a. Upon admission b. New diagnosis c. Life-changing diagnosis d. When the chaplain makes rounds
c. 1 mL syringe with 27 gauge, 5/8 inch needle d. 3 mL syringe with 18 gauge, 1 inch needle 30.The majority of the body's water is contained in which of the following fluid compartments? a. interstitial b. intracellular c. extracellular d. Intravascular The intracellular fluid (ICF) compartment holds 40% of the body's water, making it the largest of the three compartments. 31.For a patient with a nursing dx of fluid volume excess, the nurse is alert to which one of the following signs and symptoms? a. Dry mucous membranes b. Weak, thready pulse c. Hypertension d. Flushed skin 32.For the patient with a vitamin D deficiency and inadequate calcium intake, the nurse observes for: a. Anxiety b. Diaphoresis c. Chvostek sign d. Nausea and vomiting 33.Which of the following are symptoms of hypovolemia? a. oliguria b. weight gain c. decreased pulse and increased BP d. distended jugular veins 34.Which tertiary prevention measure should be included in the health promotion plan of care for a patient newly diagnosed with diabetes? a. Avoiding carcinogens b. Foot screening techniques c. Glaucoma screening d. Seat belt use Foot screening is considered a tertiary prevention measure, one that minimizes the problems with foot ulcers, an effect of diabetic disease and disability. Avoiding carcinogens is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity. Glaucoma screening is considered secondary screening—measures designed to identify individuals in an early state of a disease process so that prompt treatment can be started. Seat belt use is considered primary prevention—those strategies aimed at optimizing health and disease prevention in general and not linked to a single disease entity.
35.A 40-year-old patient presents to her provider for a yearly physical. The provider notes a family history of breast cancer in the patient’s mother. The provider schedules the patient for a mammogram. The nurse recognizes this as what level of prevention? a. Tertiary b. Primary c. Secondary d. Holistic Secondary prevention is undertaken in cases of latent (hidden) disease. Although the patient may be asymptomatic, the disease process can be detected by medical tests. Nurses may use screening tests to assess for latent disease in vulnerable populations. Examples of screening tests used as secondary prevention strategies include the purified protein derivative (PPD) skin test for tuberculosis, fecal occult blood test for colorectal cancer, and mammograms for breast cancer. 36.When teaching a patient with a family history of hypertension about health promotion, the nurse describes blood pressure screening as which type of prevention? a. Illness b. Primary c. Secondary d. Tertiary Blood pressure screening is considered secondary prevention. It is a measure diesinged to identify individuals in an early state of a disease process to that promote 37.The nurse knows that use of seatbelts and airbags in automobiles is an example of which term? a. Secondary prevention b. Tertiary prevention c. Holistic care d. Primary prevention Primary prevention is instituted before disease becomes established by removing the causes or increasing resistance. Examples include the use of seatbelts and airbags in automobiles, helmet use when riding bicycles or motorcycles, and the occupational use of mechanical devices when lifting heavy objects. 38.At the well-child clinic, how does the nurse correctly teach a mother about health promotion activities and describe immunizations? a. Unique for children b. Primary prevention c. Secondary prevention d. Tertiary prevention Immunizations are considered primary preventing measures. 39.A patient has the Nursing diagnosis Spiritual Distress. What assessment by the patient best indicates that an important goal has been met? a. Observed praying quietly.
The nurse should watch the patient self-administer an injection to make sure that the patient is doing it correctly. This will give the nurse an opportunity to point out and correct any mistakes and offer the patient reassurance about the technique. 44.The nurse makes a medication error. Which action will the nurse take first? a. Prepare an incident report. b. Explain to the patient that a medication error has occurred. c. Assess the patient for any adverse reactions. d. Document the medication given, the response, and corrective actions taken. The nurse should watch the patient self-administer an injection to make sure that the patient is doing it correctly. This will give the nurse an opportunity to point out and correct any mistakes and offer the patient reassurance about the technique. 45.The nurse is reviewing the patient’s laboratory results. Which result must be communicated to the physician immediately? a. Serum chloride level 85 mEq/L b. Serum sodium level 134 mEq/L c. Serum potassium level 6.8 mEq/L d. Serum magnesium level 2.3 mEq/L Normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 6. mEq/L is very high and puts the patient at risk for cardiac arrhythmias. The potassium level should be reported to the physician immediately. 46.The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient’s body to correct the pH? a. The patient’s respirations are very deep and rapid. b. The patient’s urine is dark and concentrated. c. The patient’s skin is pale, cool, and diaphoretic. d. The patient is sleepy and difficult to arouse. The patient with diabetic ketoacidosis is in a state of metabolic acidosis. The body will attempt to compensate for the acidosis by blowing off extra amounts of carbon dioxide through deep, rapid respirations. Since carbon dioxide is converted to carbonic acid, removal of carbon dioxide will help shift the body's pH to a less acidotic state. 47.The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur due to this therapy? a. Hypocalcemia b. Hypernatremia c. Hypokalemia d. Hyperphosphatemia Furosemide (Lasix) is a loop diuretic that causes loss of potassium through the urine. Patients taking Lasix are at risk for hypokalemia, so the nurse should check the patient's electrolyte values closely, particularly the serum potassium level. 48.The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to
walk to the bathroom and fainted right after getting out of bed. The nurse knows which condition to be the most likely cause of the patient’s collapse? a. Orthostatic hypotension b. Circulatory overload c. Hemolytic reaction d. Catheter embolism The patient with dehydration is at risk for orthostatic hypotension, or falling of the blood pressure when the patient rises to a standing position. When the blood pressure falls sufficiently, fainting may occur. The patient should be assisted to rise slowly from a supine to a sitting position first before slowly getting to his feet. 49.The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform? a. Perform regular neurologic checks and institute seizure precautions. b. Encourage the patient to eat foods that are high in sodium. c. Administer hypotonic IV solutions as ordered by the physician. d. Assess for signs and symptoms of digoxin (Lanoxin) toxicity. A serum sodium level of 124 mEq/L is dangerously low and may cause neurologic problems including seizures, confusion, and weakness. Regular neurologic checks should be performed and the patient should be placed on seizure precautions until the sodium level is corrected. Encouraging the patient to eat high-sodium foods is fine, but it is not as important as the patient's safety. A hypotonic saline solution will further lower the patient's sodium level. Lanoxin toxicity is seen with hypokalemia rather than hyponatremia. 50.The nurse is caring for a patient who has a serum magnesium level of 0.8 mEqL. Which is the highest priority goal to include in the patient’s plan of care? a. The patient will maintain urine output of at least 30 mL/hr. b. The patient will verbalize the importance of sufficient dietary intake of magnesium. c. The patient’s oral mucous membranes will remain free of ulceration and pain. d. The patient will remain alert and oriented ×3 with no confusion or seizure activity.
A patient with low serum magnesium is at risk for neurologic symptoms
including confusion, disorientation, and seizures. The highest priority goal for
this patient is to avoid neurologic problems that could lead to injury. The other
goals are applicable to the patient with low magnesium but are less important.
51.The nurse is assessing a patient's spirituality and observes the patient meditating before any treatments. What is the nurse’s best action? a. Document that the patient is not religious. b. Offer the patient a copy of the Bible to read. c. Arrange for quiet time for the patient as needed. d. Limit the time patient can meditate before procedures. The nurse can best promote the patient’s spirituality practices by arranging for the patient to be left alone when possible to meditate. Meditation is an exemplar of spirituality, not necessarily of the Christian faith. The Bible is most often read by believers in the Christian faith. Meditation does not imply that the patient is not religious. Time for meditation should not be limited, whenever possible
c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill The process of cultural competence consists of four interrelated constructs: cultural desire, self- awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members. 56.The client states, "this is home now. I am part of this culture." This demonstrates: a. socialization. b. acculturation. c. ethnocentrism. d. Assimilation. 57.QSEN cultural competency focuses on the following areas for the nurse to overcome. (Select all that apply) a. prejudice b. personal attitudes c. lifelong learning d. feeling of superiority 58.Traditional Western medicine, in contrast to alternative therapy, uses which of the following? a. prescribed medications b. prayer c. herbs d. Acupuncture 59.Unlike ethnicity, culture incorporates the following elements: a. learned, symbolic, shared, and integrated. b. nationality, shared, learned, and symbolic. c. race, nationality, shared, and integrated. d. symbolic, learned, race, and nationality. 60.The nurse is noting an order for a medication to be given TID. Which times will the nurse plan to administer the medication to the patient? a. 9 a.m., 1 p.m., 5 p.m., and 10 p.m. b. 9 a.m. and 9 p.m. c. 9 a.m., 1 p.m., and 5 p.m. d. Nightly before the patient goes to sleep 61.A charge nurse works on an inpatient unit in a diverse city. To provide culturally congruent care to the patient, which action by the nurse would be most appropriate?
a. Using puns and sarcasm to help draw the patient into sharing information b. Working to understand the socioeconomic status of the patient so teaching is culturally sensitive and appropriate c. Assuming a patient from a minority population does not have the economic means to pay for home care follow-up d. Admonishing a Hispanic patient for showing up for a preoperative teaching class 15 minutes late 62.A nurse has been told he has many obvious stereotypes about a specific cultural group. What action by the nurse is best? a. Ask to not care for members of this cultural group. b. Ask to take care of as many members of this group as possible. c. Begin to educate himself on aspects of this cultural group. d. Vow to not allow his stereotypes to show when providing care. 63.A nurse is caring for a homeless patient and tells the manager, “I will make sure he doesn’t steal food from our nourishment center.” What action by the manager is best? a. Tell the nurse she is right to monitor the patient’s activity. b. Inform the nurse that not all homeless people will steal. c. Educate the nurse that hunger might make the patient steal. d. Remind the nurse to initiate a social work consultation. This nurse is guilty of being prejudiced against the patient, who is a member of the homeless culture. Although hunger might drive a homeless person to steal, prejudice leads the nurse to believe that all homeless people steal. The manager informs the nurse of this information, gently pointing out the nurse's bias. A social work consultation may be a good idea for the patient but does not address the prejudiced nurse. 64.A new graduate nurse tells the manager that she does not believe she needs more in- service training on culturally congruent care because she already recognizes that there are significant differences among cultures to consider when providing care. What response by the manager is best? a. “You have done a great job becoming culturally competent.” b. “Providing culturally congruent care takes ongoing work and effort.” c. “That is a great start but be sure to sign up for the in-service.” d. “Cultural sensitivity and cultural competence are not the same.” Cultural sensitivity is the recognition that there are profound differences among cultures that can affect health care. But in order to provide culturally congruent care, the nurse must do more than just recognize these differences. This is an on- going process. Option B is the only one that provides useful information to the nurse as to why she must continue to work on this aspect of her profession. 65.A nurse is working with a patient who has limited English proficiency. What action by the nurse is best? a. Use a qualified interpreter. b. Ask family members to translate. c. Use drawings and pictures.
a. Perform nursing care with a high degree of professionalism. b. Watch family interaction patterns closely and try to copy them. c. Tell the family you need to learn about their culture. d. Apologize after performing tasks that make the patient uncomfortable. Nurses should observe family dynamics carefully, including communication, and try to copy them as much as possible. For instance, if the family does not make eye contact with the nurse, he/she should avoid trying to make direct eye contact with the family. The other options are reasonable, although telling the family you need to learn about their culture may place the burden of educating the nurse on them. 70.A patient has hypertension and is on a very-low-sodium diet. However, the patient is going to celebrate an important religious holiday soon that includes many food items high in sodium. What action by the nurse is best? a. Tell the patient you are so sorry she can’t have any of these foods. b. Consult with the prescriber about increasing the blood pressure medications. c. Collaborate with the patient and dietitian to include some of these foods. d. Tell the patient eating these foods once won’t hurt her condition.
Food has important meaning to many people, especially when they are part
of celebrations, religious, or cultural activities. The nurse should collaborate
with the patient and dietitian and try to find ways to incorporate some of
these items. The nurse should not just tell the patient she can't have them.
Increasing the medications or encouraging the patient to be non-adherent
could lead to adverse outcomes.
71.The nurse understands that which are important in the process of developing a cultural identity? (Select all that apply.) a. School b. Church/religious institution c. Family d. History e. Community Many institutions and groups, both formal and informal, assist an individual in developing a cultural identity, including school, religious institutions, family, and community. 72.The nursing student learns that which are correct regarding acculturation and assimilation? (Select all that apply.) a. Assimilation is forced entry into a different culture. b. Acculturation depends on first-hand contact between groups. c. Acculturation results in changes to the minority culture only. d. Assimilation can occur at the group or individual level. e. Assimilation causes a minority group member to blend into the majority group Acculturation occurs from first-hand contact between a minority group and the majority cultural group and can result in changes to one or both cultures. Assimilation occurs when members of a minority group blend into the majority group and can occur at the group or individual level. Assimilation is not a forced change. 73.The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the
patient to improve oxygenation? a. Insert an oral airway. b. Lower the head of the bed. c. Turn the patient’s head to the side. d. Monitor the patient’s pulse oximetry. An oral airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to the side will not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation or clear the airway. 74.The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse? a. Administer the ordered intravenous diuretic. b. Prepare for insertion of a chest tube. c. Suction secretions from the patient’s respiratory tract. d. Have the patient use the ordered incentive spirometer.
The patient's respiratory distress is due to pulmonary edema and fluid
overload from left-sided congestive heart failure. A diuretic will pull the
excess fluid out of the body through the urine and relieve the patient's
distress. A chest tube is not needed as the fluid is within the alveoli rather
than between the lung and chest wall. Suctioning and use of an incentive
spirometer will not address fluid overload or improve the patient's
symptoms.
75.The nurse is caring for a hospitalized patient with hyperparathyroid disease and a serum calcium level of 14.2 mg/dL. What is the priority intervention of the nurse? a. Instruct the patient to always call for assistance before getting out of bed. b. Assist the patient to change into dry clothing after episodes of diaphoresis. c. Teach stress-relieving techniques, including progressive muscle relaxation. d. Notify the provider if urine output is less than 30 mL/hr. The patient with hypercalcemia should always call for assistance before getting out of bed because of the risk of falling as a result of muscle weakness, soft bones, and lethargy. Diaphoresis and decreased urine output are not common symptoms of hypercalcemia. Teaching stress-relieving techniques is not a priority, especially since lethargy and stupor are symptoms of hypercalcemia. 76.The nurse is providing care for a patient of the Jehovah’s Witness faith. Based on the nurse’s knowledge of the patient’s religious beliefs, the nurse would question which order? a. Obtain vital signs every shift. b. Regular diet as tolerated. c. Activity as tolerated. d. Infuse 1 unit packed red blood cells. 77.After completing a patient’s initial assessment and developing a plan of care, what action by the nurse is most appropriate?
