Test Bank Family Practice Guidelines 5th Edition Cash Glass Mullen
Table of Contents Chapter 1. Health Maintenance Guidelines
... [Show More] ................................ ................. 1 Chapter 2. Public Health Guidelines ................................ ..................... 24 Chapter 3. Pain Management Guidelines ................................ ................. 46 Chapter 4. Dermatology Guidelines ................................ ..................... 54 Chapter 7: Nasal Guidelines ................................ ............................ 60 Chapter 8: Throat and Mouth Guidelines ................................ ................. 64 Chapter 9: Respiratory Guidelines ................................ ....................... 75 Chapter 10. Cardiovascular Guidelines ................................ .................. 92 Chapter 11: Gastrointestinal Guidelines ................................ ................. 111 Chapter 12: Genitourinary Guidelines ................................ ................... 129 Chapter 13. Obstetrics Guidelines................................ ...................... 148 Chapter 14: Gynecologic Guidelines ................................ .................... 163 Chapter 15: Sexually Transmitted Infections Guidelines ................................ ... 187 Chapter 16: Infectious Disease Guidelines ................................ ............... 204 Chapter 17. Systemic Disorders Guidelines ................................ .............. 223 Chapter 18. Musculoskeletal Guidelines ................................ ................. 256 Chapter 19. Neurologic Guidelines ................................ ..................... 275 Chapter 20. Endocrine Guidelines ................................ ..................... 290 Chapter 21. Rheumatological Guidelines ................................ ................ 297 Chapter 22: Psychiatric Guidelines ................................ ..................... 309 Chapter 23. Assessment Guide for Sport Participation ................................ .... 335
Chapter 1. Health Maintenance Guidelines 1 | P a g eMultiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is preparing to teach a patient of the Asian culture to perform postoperative
dressing changes at home after discharge. Which statement made by the nurse indicates cultural
competence?
a. Tell me how you feel about your surgery.
b. Asian people are smart, so this should be easy for you to understand.
c. American surgeons are highly qualified; Im sure you will heal quickly.
d. Will you tell me about any traditional healing practices that you would like to use?
2. An unconscious victim of a house fire is brought to the emergency department by the
paramedics. Tied to the right wrist is an emblem that appears be a religious talisman. Which
action should the nurse take?
a. Tape it in place.
b. Do nothing with it.
c. Remove it and lock it up for safekeeping.
d. Place it in a clothing bag with the rest of the patients belongings.
3. A 43-year-old patient of Arab descent is admitted to the hospital. To comply with the
state laws of the organization, the nurse offers the patient a Papanicolaou smear, which she
refuses. Which action should the nurse take first?
a. Notify the physician.
b. Report the refusal to the supervisor.
c. Explain the rationale for and benefits of the test.
d. Tell her it is state law and that she does not have a choice.
4. A patient who is a Jehovahs Witness has severe gastrointestinal bleeding and a
dangerously low hemoglobin level. The patient is fully alert and competent and refuses to accept
the blood transfusion ordered by the physician. Which action by the nurse is most appropriate?
a. Obtain a court order to give the blood.
b. Administer the blood while the patient is sleeping.
c. Have the patients spouse sign the consent to have the blood administered.
d. Ensure the patient understands possible consequences and then respect the patients wishes.
5. A patient of Mexican descent sees a curandero for asthma; the curandero has prescribed
a special tea to be taken four times a day to open the airways. How should the nurse respond to
this situation?
a. Encourage the patient to continue drinking the tea.
b. Encourage the patient to drink only one cup of the tea each day.
2 | P a g ec. Ask the patient to bring in the tea package and have the pharmacist check the ingredients.
d. Advise the patient to stop drinking the tea because of potential interactions with
other medications.
6. The nurse is caring for a young adult male patient who refuses personal care from a
female nursing assistant. Which approach by the nurse is best?
a. Encourage the patients family to talk with him about his care.
b. Have a registered nurse (RN) help with his personal care.
c. Assign a male assistant to help with his personal care if one is available.
d. Explain to him that males and females take care of both genders in this hospital.
7. The nurse is providing medication instructions to a 45-year-old patient who does not
maintain eye contact. What should this patients behavior indicate to the nurse?
a. The patient is not interested.
b. The nurse threatens the patients ego.
c. The nurse is in a hierarchical position.
d. The patient does not intend to follow the instructions.
8. The nurse is caring for a patient of Spanish descent who is experiencing pain, but does
not speak English. An interpreter is located to help with the assessment. What should the nurse
do to facilitate communication with this patient?
a. Use hand signals to determine the cause of the pain.
b. Ensure the interpreter is not left alone with the patient.
c. Maintain eye contact with the patient and the interpreter.
d. Use only physical examination data; do not rely on verbal communication.
9. A new mother of Guatemalan descent brings her 10-day-old infant to a clinic for a well-
baby checkup. To promote healing, she has a coin taped to the infants umbilicus. What should
the nurse do about this situation?
a. Teach the mother how to clean the coin daily and reapply it.
b. Explain to the mother that the coin is not necessary for healing.
c. Tell the mother to remove the coin, because it could cause an infection.
d. Teach the mother how to apply a dry sterile dressing in place of the coin.
10. An older patient who follows the Muslim religion is approaching death. The family
says the patients bed should be turned toward the opposite wall, so it can face Mecca to ensure
an easier passage into the next life. The wall they want the bed to face has wall suction and
oxygen, which the patient is using. Which action by the nurse is appropriate?
a. Get permission from the physician to move the bed.
b. Rearrange the furniture to accommodate the request.
3 | P a g ec. Tell them you will move the bed when the patient is closer to death.
d. Tell them it is impossible because of the short tubing on the oxygen and suction.
11. A patient of northern European descent recovering from surgery denies
postoperative pain; however, vital signs indicate an elevated pulse and blood pressure. The
patient refuses to move in bed. Which nursing action would best ensure comfort and timely
discharge?
a. Give the pain medicine as prescribed.
b. Ask the physician to prescribe the analgesics around the clock.
c. Explain that the pain medicine will help prevent complications.
d. Respect the patients denial of pain, and do not encourage the pain medicine.
12. A nurse who emigrated from China begins working on a medical unit. The preceptor
explains the unit routines, including the medication administration system. When the preceptor
asks if the nurse understands, the answer is always: Yes, I understand. What should the preceptor
do to measure the nurses comprehension?
a. Give the nurse a medication quiz.
b. Have the nurse repeat the instructions.
c. Have the nurse demonstrate the procedures.
d. Ask the nurse which information is hard to understand.
13. A 52-year-old from Haiti is hospitalized with heart failure and wants to have a voodoo
practitioner visit to say prayers. How should the nurse respond to this request?
a. Report the request to the physician immediately.
b. Tell the patient that this is not permitted during hospitalization.
c. Tell the patient it is okay for the voodoo practitioner to say prayers.
d. Have the patient meet with the voodoo practitioner in the hospital lobby.
14. The nurse is caring for a patient from a non-English speaking culture. While providing
care, the nurse shows an appreciation for and attention to arts, music, crafts, clothing, and foods
belonging to the patients culture. What did the nurse demonstrate while caring for this patient?
a. Cultural beliefs
b. Cultural awareness
c. Cultural sensitivity
d. Cultural competence
15. A female Caucasian nurse, overhead discussing a patient from another culture, asks
why the patient wants to see a practitioner from his own culture, since everyone sees
physicians when they are ill. What characteristic is the nurse exhibiting?
a. Stereotyping
4 | P a g eb. Ethnocentrism
c. Cultural sensitivity
d. Cultural generalization
16. During an assessment, the nurse determines that a patient from a non-English speaking
culture practices activities that are past-oriented. What behavior did the nurse assess in this
patient?
a. Investing time and money
b. Enjoying each day as it comes
c. Worshipping ancestors and maintaining traditions
d. Learning from the past to avoid making the same mistakes in the future
17. The nurse notes that a patient of Arab descent is not eating anything on the meal
trays. What should the nurse do about this situation?
a. Wait for the patient to ask for specific foods.
b. Ask if the patient has special food preferences.
c. Consult with a physician of Arab descent on staff.
d. Contact the dietitian to find out what patients of Arab descent patients like to eat.
18. The mother of a 6-year-old Vietnamese child admitted with pneumonia is rubbing a
coin on the childs back. The coin leaves red marks. What should the nurse do about this
observation?
a. Report the possibility of child abuse.
b. Do not allow the mother to be alone with her child.
c. Explain to the mother that she cannot do this in the hospital.
d. Add a statement to the care plan that the family practices coining.
19. The family of an older Arab-American patient does not want the patient to be informed
of a diagnosis of cancer. What should the nurse do?
a. Call a religious counselor.
b. Respect the familys wishes.
c. Insist that the family tell the patient about the diagnosis.
d. Tell the patient anyway, because patients have a right to know.
20. A patient with diabetes mellitus who comes to the clinic for a routine examination
agrees to have a diagnostic test, but is concerned that her transportation will not wait for the
test to be performed. What should the nurse do?
a. Contact the department to have the test done now.
b. Ask the patient to schedule an appointment for the test.
c. Refer the patient to the community health nurse practitioner.
5 | P a g ed. Schedule the test for the next time the patient comes to the clinic.
21. The nurse is assessing a patient who believes in a balance of yin and yang in the body,
has a brother with stomach cancer, and frequently uses acupuncture for headache treatment.
The nurse should validate that the patient is a member of which cultural group?
a. Hispanic/Latino
b. Asian American
c. African American
d. American Indian/Native Alaskan
22. An older patient is observed wearing a copper bracelet to relieve the pain of arthritis.
What type of practice should the nurse realize this patient is demonstrating?
a. Allopathy
b. Acupressure
c. Reflexology
d. Folk medicine
23. The nurse is preparing discharge teaching for an older patient who immigrated to
the United States a few years ago. What should the nurse remember when preparing these
instructions?
a. The patient most likely has limited financial resources.
b. The patient will prefer to follow cultural medical practices.
c. The patient will most likely live with other family members.
d. The patient will attend all follow-up appointments as needed.
24. During a home visit to a family of a non-English speaking culture, the nurse observes
the male parent becoming upset when the youngest child refuses to speak the native language in
the home. What should the nurse realize is occurring within the family at this time?
a. Ethnocentrism
b. Cultural shock
c. Cultural conflict
d. Cultural assimilation
25. An older male patient is admitted to the hospital for treatment of a chronic disease. The
spouse is at the bedside for most hours of the day, and the patients children come to visit every
day after work to discuss activities and ask for advice. What should the nurse realize about the
social organization of this family?
a. The male patient is the head of the household.
b. The spouse does not trust health care providers.
c. The children want to learn everything before the patient dies.
6 | P a g ed. The children are concerned that the patient is not receiving adequate
care. Multiple Response
Identify one or more choices that best complete the statement or answer the question.
26. The nurse is planning care for a patient from a non-English speaking culture. Which
cultural factors should the nurse be aware of in order to provide culturally competent care to
this patient? (Select all that apply.)
a. The patients nutritional habits
b. The patients communication style
c. The patients sense of personal space
d. Complementary therapies the patient is using
e. The prescribed medications the patient is taking
27. A female nurse is providing smoking cessation counseling and education during a
community health fair. The nurse should avoid physical closeness, shaking hands, or touching
during instruction with which of the following? (Select all that apply.)
a. A 35-year-old man of Asian descent
b. A 45-year-old woman of Arab descent
c. A 28-year-old man of Hispanic descent
d. A 52-year-old woman of African American descent
e. A 41-year-old woman of American Indian descent
28. The nurse is providing care in a clinic with a culturally diverse patient population.
Which actions should the nurse take to ensure care is culturally appropriate? (Select all that
apply.)
a. Awareness of cultural bias
b. Desire to be culturally competent
c. Educational training related to world politics
d. Awareness of personal communication patterns
e. Number of face-to-face encounters with people from various cultural backgrounds
29. The staff development instructor is planning a seminar on improving cultural sensitivity
when providing patient care. What should the instructor include in this seminar? (Select all that
apply.)
a. Information about different cultural groups
b. Recognition that patient are unique and not defined by their culture
c. Ways to enhance cultural assimilation in the health care environment
d. The importance of nurses knowing information about their own cultural group
e. Strategies to incorporate patients cultural values and practices into the plan of care
7 | P a g e30. The nurse is visiting the home of a patient who recently immigrated to the United States
from Buenos Aires. Which observations in the patients home should the nurse question to
determine the patients health beliefs? (Select all that apply.)
a. Black bracelet woven with a cross being worn on the patients left wrist
b. A lit candle burning near a picture of a saint on a side table in the living room
c. Cup of hot black liquid that the patient is sipping from periodically during the visit
d. A copy of a magazine printed in Spanish sitting on the coffee table in the living room
e. A pillow placed between the patient and the nurse after the nurse sits down on the couch
Chapter 4. Cultural Influences on Nursing Care
Answer Section
MULTIPLE CHOICE
1. ANS: D
D. Cultural sensitivity is using language and statements that do not offend another persons
cultural beliefs. Cultural competence includes the skills and knowledge required to provide
effective nursing care. The use of traditional healers and healing therapies is common for Asian
individuals, and assessing the patients desire to use such healers or therapies shows the nurse
is
culturally sensitive and competent to provide care. B. This statement represents a stereotypean
opinion or belief about a group of people which is ascribed to an individual. C. This statement
exemplifies ethnocentrism or the tendency for people to think that their ways of thinking, acting,
and believing are the only right, proper, and natural ways. A. This is an assessment designed to
elicit the patients emotional reaction to the surgery. This may be an important part of adult
learning, but it is not the best option to represent cultural competence.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
2. ANS: A
A. Often folk practices are not harmful and can be added to the patients plan of care. Tape the
emblem in place to keep it from getting lost or damaged. C. D. Removing it could be very
distressing to the patient. B. The item could get lost if nothing is done with it.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
3. ANS: C
8 | P a g eC. A Pap smear can provide important health information. The patient may refuse it, because she
does not understand what it is. A. B. Teaching is a nursing action and does not need to be
approved by a physician or supervisor. D. The state law simply says the patient must be offered
the test, not that she must accept it.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
4. ANS: D
D. Patients beliefs should be respected, even when their decisions go against medical advice. The
patient needs to understand the consequences of his decision. A. B. C. Administering the blood
without the patients knowledge or consent is unethical.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
5. ANS: C
C. Often, folk practices are not harmful and may even be helpful; they may be incorporated into
the patients plan of care. Checking with the pharmacist ensures that the tea is safe and will not
interact with other essential medications. A. B. D. As long as it is safe, there is no reason to have
the patient stop or limit tea intake.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Analysis
6. ANS: C
C. It is important to respect differences in gender relationships when providing care. Some
people may be especially modest because of their religion, seeking out same-gender nurses and
physicians for intimate care. Respect these patients modesty by providing privacy and assigning
a same-gender care provider when possible. A. B. D. Having a registered nurse (unless male)
provide care and talking to his family do not solve the problem or respect the patients
preferences.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
7. ANS: C
C. Use and degree of eye contact is culturally influenced. Many cultures view health care workers
9 | P a g eas having higher status, making it rude to maintain eye contact. A. B. D. The nurse should not
make assumptions about the patients level of interest, intent to follow instructions, or ego.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
8. ANS: C
C. The use of eye contact can help the nurse interpret the information that is being exchanged
between the interpreter and patient. A. B. D. There is no reason to avoid leaving the interpreter
with the patient, to rely on hand signals, or to avoid verbal communication when an interpreter
is available.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
9. ANS: A
A. Often, folk practices are not harmful and can be added to the patients plan of care. In the case
of the coin, it should be cleaned daily to keep the area clean and free of infection. B. C. D. There is
no reason to tell the mother to remove it or to apply a sterile dressing in place of the coin.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
10. ANS: B
B. Often, folk practices are not harmful and can be added to the patients plan of care. There is no
reason not to move the patients bed. A. There is no reason to involve the physician. C. There is no
way to know the exact time the patient will die, so waiting to move the bed is not appropriate.
D. Oxygen and suction tubing can have extensions added.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
11. ANS: C
C. Explaining that pain control can help prevent complications allows the patient to make an
informed decision. A. B. The patients wishes must be respected, so giving the medication
without the patients consent is not appropriate. D. Respecting the patients denial of pain and not
encouraging the pain medication may not necessarily support the patients comfort and allow for
appropriate healing of the incision.
PTS: 1 DIF: Difficult
10 | P a g eKEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis
12. ANS: C
C. The best measure of learning is observing the nurse demonstrate the procedures. A. B. D. Having
the nurse talk about the instructions or fill out a quiz may be helpful, but the only way to know for
sure if the teaching has been effective is to observe the behavior.
PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive
Level: Application
13. ANS: C
C. Often, folk practices are not harmful and can be added to the patients plan of care. A. There is
no reason to involve the physician in non-harmful folk practices. B. A patient should only be told
that something is not permitted if it is prohibited by policy. D. Allowing the practice to occur in
the lobby may be unsafe for the patient and confusing to other patients and visitors.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
14. ANS: B
B. Cultural awareness focuses on history and ancestry and emphasizes an appreciation for and
attention to arts, music, crafts, celebrations, foods, and traditional clothing. A. Beliefs are
assertions that are based on assumptions. C. Cultural sensitivity is using politically correct
language and not making statements that may offend another persons cultural beliefs. D. Cultural
competence includes the skills and knowledge required to provide effective nursing care.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
15. ANS: B
B. Ethnocentrism is the tendency for human beings to think that their ways of thinking, acting,
and believing are the only right ways. A. A stereotype is an opinion or belief about a group of
people, which is ascribed to an individual from that group. C. Cultural sensitivity is using
politically correct language and not making statements that may offend another persons cultural
beliefs. D. A generalization, or assumption, may be true for the group, but it does not necessarily
fit an individual.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
11 | P a g e16. ANS: C
C. Past-oriented individuals maintain traditions that were meaningful in the past, and they may
worship ancestors. A. Future-oriented people may invest time and money in the future. B.
Present-oriented people accept the day as it comes, with little regard for the past. D. Some
cultures combine all three.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
17. ANS: B
B. Cultural assessment must provide the basis for nursing care. This should include a review of
food preferences. A, C, and D are insensitive actions and risk stereotyping and providing
inappropriate care to the patient.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level:
Application
18. ANS: D
D. Individuals from Asian cultures may practice coining. This is an example of a cultural
practice that is harmless and may be included in the patients care. A, B, and C are culturally
insensitive responses.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
19. ANS: B
B. Initially, the familys wishes should be respected. This may be important in their culture. An
ethics committee may be contacted for further input if the situation warrants it. A, C, and D are
culturally insensitive responses.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
20. ANS: A
A. Because it may be difficult for the patient to obtain transportation, the test should
be performed now. B, C, and D risk further delay of the test.
PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
12 | P a g eApplication
21. ANS: B
B. Asian-Americans hold these beliefs. A. C. D. Individuals from the other cultural groups do
not believe in yin and yang and do not practice acupuncture. African Americans may have an
increased risk for stomach cancer, but they do not believe in yin and yang or acupuncture.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
22. ANS: D
C. Examples of folk medicines include covering a boil with axle grease, wearing copper bracelets
for arthritic pain, and drinking herbal teas. A. Allopathy is another name for traditional Western
medicine.
B. C. Acupressure and reflexology are complementary therapies.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
23. ANS: A
A. Compared with white or European American older adults, ethnic minorities are more likely to
live in poverty. The nurse needs to take the patients finances into consideration when preparing
discharge instructions. B. The nurse needs to assess the patients preference for using cultural or
Western medicine practices. C. There is no information to support that the patient lives with
other family members. D. The patient may have difficulty accessing health care, so it is incorrect
to assume that the patient will attend all follow-up appointments.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
24. ANS: D
D. Cultural assimilation occurs when a new member takes on the dominant cultures values,
beliefs, and practices, sometimes at the cost of losing some of his or her cultural heritage. This
process is often viewed as negative as evidenced by the male parent becoming upset with the
youngest child refusing to speak the native language in the home. A. Ethnocentrism is the
tendency for humans to think that their ways of thinking, acting, and believing are the only right,
proper, and natural ways. B. Cultural shock is when values, beliefs, and practices sanctioned by
the new culture are very different from the ones of the native culture. There is no evidence that
cultural shock is occurring within the family. C. Cultural conflict is when one culture conflicts
with another. There is no evidence that cultural conflict is occurring within the family.
13 | P a g ePTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
25. ANS: A
A. Family organization includes the perceived head of the household, gender roles, and roles of
the elderly and extended family members. Because the spouse stays at the bedside and the
children visit every day to discuss events and ask advice, this household is most likely
patriarchal. B. There is no evidence to suggest that the spouse does not trust health care
providers. C. Although the patient has a chronic disease, there is no evidence to suggest that
death is imminent. D. There is no evidence to support that the children are concerned that the
patient is not receiving adequate care.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis MULTIPLE
RESPONSE
26. ANS: A, B, C, D
A, B, C, and D describe characteristics of cultural diversity of which the nurse should be aware.
E. Prescribed medications are related to physiological needs, not cultural needs.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
27. ANS: A, E
A. E. For American Indians/Native Alaskans, touch is not acceptable from strangers. Asians and
Pacific Islanders avoid physical closeness and touching. B. Touch between persons of the same
gender is acceptable, and personal space is very close for Arab Americans. C.
Hispanics/Latinos/Spanish individuals value touching and closeness. D. African Americans have
close personal space and touch frequently, although less with strangers.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
28. ANS: A, B, D, E
A. B. D. E. Cultural competence requires self-awareness and a desire to provide culturally
competent care. The number of encounters and experience with various groups can be helpful as
is knowledge of your own communication patterns. C. Educational training on world politics is
not required to provide culturally competent care.
14 | P a g ePTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 29. ANS: A, B, D, E A. B. D. E. The staff development instructor can help nurses improve cultural sensitivity by using the acronym BALI or 1) be aware of your personal cultural heritage; 2) appreciate that each patient is unique, influenced but not defined by his or her culture; 3) learn about the patients cultural groups; and 4) incorporate the patients cultural values, beliefs, and practices into their plan of care. C. Cultural assimilation is a personal endeavor, one in which the nurse may have little influence.
PTS: 1 DIF: Moderate KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application 30. ANS: A, B, C A. B. C. To determine health beliefs the nurse should ask about the practice of special rituals or prayers to maintain health, the wearing of bracelets to ward off illnesses and the drinking of herbs or special teas when ill. D. A copy of a magazine printed in Spanish would help indicate the patients communication style. E. The use of a pillow between the nurse and patient could be identifying a boundary for personal space.
31. Pertussis vaccination should begin at which age?
a. Birth b. 2 months c. 6 months d. 12 months
ANS: B
The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The first dose is usually given at the 2-month well-child visit. Infants are highly susceptible to pertussis, which can be a life-threatening illness in this age group.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 32. A mother tells the nurse that she does not want her infant immunized because of
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