Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis -Test Bank
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Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 3: Culturally Competent Care
MULTIPLE CHOICE
1. A
Hispanic patient complains of abdominal cramping caused by empacho. The nurse’s
first action should be to
|
a. |
ask the patient what
treatments are likely to help. |
|
b. |
give the patient medication
to decrease the cramping. |
|
c. |
offer to contact a curandero(a) to
make a visit to the patient. |
|
d. |
massage the patient’s
abdomen until the pain is gone. |
Correct Answer: A
Rationale: Further assessment of
the patient’s cultural beliefs is appropriate before implementing any
interventions for a culture-bound syndrome such as empacho. Although
medication, a visit by a curandero(a), or
massage may be helpful, more information about the patient’s beliefs is needed
to determine which intervention(s) will be most helpful.
Cognitive Level: Application Text Reference: p.
35
Nursing Process: Assessment NCLEX: Psychosocial
Integrity
2. When
performing a cultural assessment with a patient of a different culture, the
nurse’s first action should be to
|
a. |
tell the patient what the
nurse already knows about the patient’s culture. |
|
b. |
wait until a cultural
healer is available to help with the assessment. |
|
c. |
obtain a list of any
cultural remedies that the patient currently uses. |
|
d. |
ask the patient about any
affiliation with a particular cultural group. |
Correct Answer: D
Rationale: An early step in
performing a cultural assessment is to determine whether the patient feels an
affiliation with any cultural group. The other actions may be appropriate if
the patient does identify with a particular culture.
Cognitive Level: Application Text Reference: p.
29
Nursing Process: Assessment NCLEX: Psychosocial
Integrity
3. A
family member of an elderly Hispanic patient admitted to the hospital tells the
nurse that the patient has traditional beliefs about health and illness. The
best action by the nurse is to
|
a. |
avoid asking any questions
unless the patient initiates conversation. |
|
b. |
ask the patient whether it
is important that cultural healers are contacted. |
|
c. |
obtain further information
about the patient’s cultural beliefs from the daughter. |
|
d. |
explain the usual hospital
routines for meal times, care, and family visits. |
Correct Answer: B
Rationale: Because the patient has
traditional health care beliefs, it is appropriate for the nurse to ask whether
the patient would like a visit by a curandero(a). There
is no cultural reason for the nurse to avoid asking the patient questions, and
questions may be necessary to obtain necessary health information. The patient
(rather than the daughter) should be consulted about personal cultural beliefs.
The hospital routines for meals, care, and visits should be adapted to the
patient’s preferences rather than expecting the patient to adapt to the
hospital schedule.
Cognitive Level: Application Text Reference: p.
30
Nursing Process: Implementation NCLEX: Psychosocial
Integrity
4. To
determine a patient’s cultural practices regarding communication and eye
contact, the nurse should
|
a. |
ask the patient what
silence means when communicating with others. |
|
b. |
avoid all eye contact
unless the patient establishes eye contact with the nurse. |
|
c. |
observe the behaviors and
interactions between the patient and other members of the culture. |
|
d. |
use eye contact and
communication techniques that are most comfortable for the nurse. |
Correct Answer: C
Rationale: Observation of the
patient’s interactions with visitors will provide the most useful information.
Asking about the meaning of silence will not be helpful in assessing the
patient’s cultural values regarding eye contact. Avoiding eye contact may not
be appropriate for interactions with some patients. The nurse should attempt to
adapt communication to the patient’s communication style.
Cognitive Level: Comprehension Text Reference: p.
31
Nursing Process: Implementation NCLEX: Psychosocial
Integrity
5. A new
RN graduate is assessing a newly admitted non–English-speaking Chinese patient.
The charge nurse should intervene if the new RN’s first action is to
|
a. |
call for a medical interpreter. |
|
b. |
palpate the patient’s
scalp. |
|
c. |
sit down at the bedside. |
|
d. |
avoid eye contact with the
patient. |
Correct Answer: B
Rationale: Many people of Asian
ethnicity believe that touching a person’s head is disrespectful; the RN should
ask permission before touching the patient’s head. The other actions are
appropriate.
Cognitive Level: Application Text Reference: p.
33
Nursing Process: Implementation NCLEX: Psychosocial
Integrity
6. If an
interpreter is not available when a patient speaks a language different from
the nurse’s language, it is appropriate for the nurse to
|
a. |
use specific medical terms
in the Latin form. |
|
b. |
talk slowly so that each
word is clearly heard. |
|
c. |
repeat important words so that
the patient recognizes their importance. |
|
d. |
use gestures to demonstrate
what is to be communicated to the patient. |
Correct Answer: D
Rationale: The use of gestures
will enable some information to be communicated to the patient. The other
actions will not improve communication with the patient.
Cognitive Level: Comprehension Text Reference: p.
37
Nursing Process: Implementation NCLEX: Psychosocial
Integrity
7. When
planning care for a hospitalized patient who uses culturally based treatments,
the most appropriate action by the nurse is to
|
a. |
discourage the use of
culturally based treatments for Western diseases. |
|
b. |
teach the patient that folk
remedies will interfere with Western treatments. |
|
c. |
ask the patient to
discontinue the cultural treatments during hospitalization. |
|
d. |
coordinate the use of folk
treatments with ordered medical therapies. |
Correct Answer: D
Rationale: Many culturally based
therapies can be accommodated along with the use of Western treatments and
medications. The nurse should attempt to use both traditional folk treatments
and the ordered Western therapies as much as possible. Some culturally based
treatments can be effective in treating “Western” diseases. Not all folk remedies
interfere with Western therapies. It may be appropriate for the patient to
continue some culturally based treatments while he or she is hospitalized.
Cognitive Level: Comprehension Text Reference: p.
35
Nursing Process: Planning NCLEX: Psychosocial
Integrity
8. The
best example of culturally appropriate nursing care when caring for a newly
admitted patient is
|
a. |
asking permission before
touching a patient during the physical assessment. |
|
b. |
having family members
provide most of the patient’s personal care. |
|
c. |
maintaining a personal
space of at least 2 feet when assessing the patient. |
|
d. |
considering the patient’s
ethnicity as the most important factor in planning care. |
Correct Answer: A
Rationale: Many cultures consider
it disrespectful to touch a patient without asking permission, so asking a
patient for permission is culturally appropriate. The other actions may be
appropriate for some patients but are not appropriate across all cultural groups
or for all individual patients.
Cognitive Level: Comprehension Text Reference: p.
33
Nursing Process: Implementation NCLEX: Psychosocial
Integrity
9. While
talking with the nursing supervisor, a staff nurse expresses frustration that a
Native American patient always has several family members at the bedside. The
most appropriate action by the nursing supervisor is to
|
a. |
remind the nurse that this
cultural practice is important to the family and the patient. |
|
b. |
suggest that the nurse ask
family members to leave the room during patient care. |
|
c. |
have the nurse explain to
the family that too many visitors will tire the patient. |
|
d. |
ask about the nurse’s
personal beliefs about family support during hospitalization. |
Correct Answer: D
Rationale: The first step in
providing culturally competent care is to understand one’s own beliefs and
values related to health and health care. Asking the nurse about personal
beliefs will help to achieve this step. Reminding the nurse that this cultural
practice is important to the family and patient will not decrease the nurse’s
frustration. The remaining responses (suggest that nurse ask family members to
leave the room, and have the nurse explain to family that too many visitors
will tire the patient) are not culturally appropriate for this patient.
Cognitive Level: Application Text Reference: pp.
28, 36
Nursing Process: Implementation NCLEX: Psychosocial
Integrity
10. An
82-year-old Asian American patient tells the nurse that she has lived in the
United States for 50 years. The patient speaks English but lives in a
predominantly Asian neighborhood. The nurse will need to
|
a. |
include a folk healer when
planning the patient’s care. |
|
b. |
ask the patient about any
special cultural beliefs or practices. |
|
c. |
involve the patient’s
oldest son in making health care decisions. |
|
d. |
avoid making direct eye
contact with the patient during care. |
Correct Answer: B
Rationale: Further assessment of
the patient’s health care preferences is needed before making further plans for
culturally appropriate care. The other responses indicate stereotyping of the
patient based on ethnicity and would not be appropriate initial actions.
Cognitive Level: Application Text Reference: pp.
29-30, 36
Nursing Process: Planning NCLEX: Psychosocial
Integrity
11. When
planning health care for a community with a large number of recent immigrants
from Asia, the most important intervention for the nurse to include is
|
a. |
contraceptive teaching. |
|
b. |
colonoscopy information. |
|
c. |
tuberculosis screening. |
|
d. |
pregnancy testing |
Correct Answer: C
Rationale: Tuberculosis (TB) is
endemic in many parts of Asia, and the incidence of TB is much higher in
immigrants from Asia than in the general US population. Teaching about
contraceptive use, colonoscopy, and testing for pregnancy may also be
appropriate for some patients but is not generally indicated for all members of
this community.
Cognitive Level: Application Text Reference: p.
34
Nursing Process: Planning NCLEX: Physiological
Integrity
12. When
doing an admission assessment for a patient, the nurse notices that the patient
pauses before answering questions about the health history. The most
appropriate action by the nurse is to
|
a. |
ask the patient why the
questions require so much time to answer. |
|
b. |
stop doing the assessment
and return later. |
|
c. |
give the patient an
assessment form listing the questions and a pen. |
|
d. |
wait for the patient to
answer the questions. |
Correct Answer: D
Rationale: Patients from some
cultures take time to consider a question carefully before answering. The nurse
will show respect for the patient and help to develop a trusting relationship
by allowing the patient time to give a thoughtful answer. Asking the patient
why the answers are taking so much time, stopping the assessment, and handing
the patient a form indicate that the nurse does not have time for the patient.
Cognitive Level: Application Text Reference: p.
36
Nursing Process: Assessment NCLEX: Psychosocial
Integrity
Lewis: Medical-Surgical Nursing, 7th Edition
Test Bank
Chapter 4: Health History and Physical Examination
MULTIPLE CHOICE
1. A
patient having difficulty breathing is admitted to the hospital. The best
approach for the nurse to use to obtain a complete health history is to
|
a. |
use the health care provider’s
medical history to obtain subjective data. |
|
b. |
obtain subjective data
about the patient from family members. |
|
c. |
delay subjective data
collection and focus only on the physical examination. |
|
d. |
schedule several short
sessions with the patient to gather subjective data. |
Correct Answer: D
Rationale: In an emergency
situation, the nurse may need to ask only the most pertinent questions for a
specific problem and obtain more information later. A complete health history
will include subjective information that is not available in the health care
provider’s medical history. Family members may be able to give some subjective
data, but only the patient will be able to give subjective information about
the shortness of breath. The physical examination will not provide a complete
health history.
Cognitive Level: Application Text Reference: p.
40
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
2. When
the nurse is gathering information of a personal nature, the question that best
communicates acceptance of the patient is,
|
a. |
“Individuals going through
a divorce have many emotional problems. What kind of problems are you
having?” |
|
b. |
“Many older people have
limited financial resources for food and medications. Is this a problem in
your case?” |
|
c. |
“A lot of people drink
alcohol in excessive amounts. How much alcohol do you drink in a day?” |
|
d. |
“Many drugs used for
hypertension cause sexual dysfunction. What type of problems are you having?” |
Correct Answer: B
Rationale: When asking personal or
potentially sensitive questions, prefacing the question with phrases such as
“many people” indicates that the patient’s situation is normal. Therefore, the
best response is that where the nurse asks whether the patient actually has the
problem of limited resources but does not imply any judgments about the patient
in his regard. The response beginning, “Individuals going through a divorce
have many emotional problems” implies that the nurse has already decided the
patient must be having emotional problems. The response beginning, “A lot of
people drink alcohol in excessive amounts” indicates that the nurse thinks the
patient does drink alcohol daily. And the response beginning, “Many drugs used
for hypertension cause sexual dysfunction” indicates that the nurse is sure
that the patient is having problems.
Cognitive Level: Application Text Reference: p.
41
Nursing Process: Assessment NCLEX: Psychosocial
Integrity
3. A
patient is admitted to the orthopedic unit with a fractured right elbow
following a skiing accident. During the initial nursing assessment, the
subjective information the nurse obtains from the patient about how the injury
occurred and what treatments have been implemented is related to the functional
health pattern of
|
a. |
activity-exercise. |
|
b. |
cognitive-perceptual. |
|
c. |
health perception-health
maintenance. |
|
d. |
self-perception–self-concept. |
Correct Answer: C
Rationale: In a hospitalized
patient, the health perception-health maintenance pattern includes information
about the patient’s understanding of the onset and treatment of the current
health problem. The activity-exercise pattern will include questions about how
often the patient skis. The cognitive-perceptual pattern question may address
how much pain the patient is experiencing. The self-perception–self-concept
pattern may include questions such as how skiing impacts the patient’s
self-concept.
Cognitive Level: Application Text Reference: pp.
44-45
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
4. Immediate
surgery is planned for a patient with acute abdominal pain. The question used
by the nurse that will elicit the most complete information about the patient’s
coping-stress tolerance pattern is
|
a. |
“What do you think caused
this abdominal pain?” |
|
b. |
“Are there any other major
problems that are a concern right now?” |
|
c. |
“How do you feel about
yourself and your hospitalization?” |
|
d. |
“Can you tell me how
intense your pain is now?” |
Correct Answer: B
Rationale: The coping-stress
tolerance pattern includes information about other major stressors confronting
the patient. The health perception-health management pattern includes
information about the patient’s ideas about risk factors. Feelings about self
and the hospitalization are assessed in the self-perception–self concept
pattern. Intensity of pain is part of the cognitive-perceptual pattern.
Cognitive Level: Application Text Reference: pp.
45-46
Nursing Process: Assessment NCLEX: Psychosocial
Integrity
5. During
the health history interview, a patient tells the nurse about periodic fainting
spells. In gathering more specific information, the question that will best
assist in determining the setting where the fainting spells occur is,
|
a. |
“Do the spells tend to
occur at any special time of day?” |
|
b. |
“How frequently do you have
the fainting spells?” |
|
c. |
“Where are you when you
have the fainting spells?” |
|
d. |
“Do you have any other
symptoms along with the spells? |
Correct Answer: C
Rationale: Information about the
setting is obtained by asking where the patient was and what the patient was
doing when the symptom occurred. The other questions from the nurse are
appropriate for obtaining information about chronology, frequency, and
associated clinical manifestations.
Cognitive Level: Application Text Reference: p.
41
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
6. The
nurse records the following general survey of a patient: “The patient is a
68-year-old male Asian attended by his wife and two daughters. Alert and
oriented. Does not make eye contact with the nurse and responds slowly, but
appropriately, to questions. No apparent disabilities or distinguishing
features.” Additional information that should be added to this general survey
includes
|
a. |
reasons for contact with
the health care system. |
|
b. |
comments of family members
about his condition. |
|
c. |
nutritional status. |
|
d. |
intake and output. |
Correct Answer: C
Rationale: The general survey also
describes the patient’s general nutritional status. The other information will
be obtained when doing the complete nursing history and examination but is not
obtained through the initial scanning of a patient.
Cognitive Level: Application Text Reference: p.
46
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
7. Following
knee surgery, the patient has an elastic bandage applied to the surgical site.
When assessing the circulation to the lower leg, the first action the nurse
will take is to
|
a. |
visually inspect the color
of the foot. |
|
b. |
palpate the temperature of
the foot. |
|
c. |
use a stethoscope to
auscultate ankle blood pressure. |
|
d. |
check the patient’s pedal
pulses using the fingertips. |
Correct Answer: A
Rationale: Inspection is the first
of the major techniques used in the physical examination. Palpation and
auscultation are used later in the examination.
Cognitive Level: Application Text Reference: p.
47
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
8. All
the following information is obtained by the nurse while performing a health
history and physical examination from a patient with right-sided rib fractures.
The pertinent negative finding is that the patient
|
a. |
states that there have been
no other health problems recently. |
|
b. |
refuses to take a deep
breath because of the associated chest pain. |
|
c. |
has several bruised and
swollen areas on the right anterior chest. |
|
d. |
denies having pain when the
area over the fractures is palpated. |
Correct Answer: D
Rationale: The nurse expects that
a patient with rib fractures will have pain over the fractured area. The first
statement is neither a positive nor a negative finding with regard to the rib
fractures. The pain with breathing and the bruising and swelling are positive
findings.
Cognitive Level: Application Text Reference: p.
47
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
9. As
the nurse assesses the patient’s neck, the patient says, “My neck is so stiff I
can hardly move it.” This finding indicates the nurse should perform a(n)
|
a. |
specific examination. |
|
b. |
screening examination. |
|
c. |
focused examination. |
|
d. |
extensive examination. |
Correct Answer: C
Rationale: The focused examination is
needed when a patient has clinical manifestations that indicate a problem. The
term specific
examination is not a commonly used term. The screening examination is
a general check to determine any possible problems. Extensive examination is
another term that is not generally used and would not be clearly understood by
other members of the health care team.
Cognitive Level: Comprehension Text Reference: p.
47
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
10. In
performing a physical examination, it is most important for the nurse to use
|
a. |
the head-to-toe approach. |
|
b. |
a consistent, systematic
approach. |
|
c. |
the body-systems model. |
|
d. |
a model based on a nursing
theory. |
Correct Answer: B
Rationale: The nurse is less
likely to omit a needed part of the examination if a consistent approach is
followed every time. Either a head-to-toe approach or a body-systems approach
may be used. Nursing theories do not describe the approach to the physical
examination.
Cognitive Level: Comprehension Text Reference: p.
48
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
11. The
nurse is preparing to perform a screening physical examination for a patient.
The assessment technique that will require a stethoscope is
|
a. |
inspection. |
|
b. |
percussion. |
|
c. |
auscultation. |
|
d. |
palpation. |
Correct Answer: C
Rationale: A stethoscope is used
to auscultate sounds produced by various parts of the body. Inspection,
percussion, and palpation do not require a stethoscope.
Cognitive Level: Knowledge Text Reference: p.
48
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
12. Adaptations
used by the nurse when performing a physical examination on an 86-year-old
patient will include
|
a. |
avoiding the use of touch
as much as possible. |
|
b. |
organizing the sequence to
minimize position changes. |
|
c. |
using slightly more
pressure for palpation of the liver. |
|
d. |
speaking slowly when
directing the patient. |
Correct Answer: B
Rationale: Older patients may have
age-related changes in mobility that make it more difficult to change position.
There is no need to avoid the use of touch when examining older patients. Less
pressure should be used over the liver. There is no indication that the patient
has any age-related difficulty in understanding directions from the nurse.
Cognitive Level: Application Text Reference: p.
50
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
13. While
the nurse is taking the health history, a patient states, “My father and
grandfather both had heart attacks and were unable to be very active
afterwards.” This statement is related to the functional health pattern of
|
a. |
health perception-health
management. |
|
b. |
activity-exercise. |
|
c. |
cognitive-perceptual. |
|
d. |
coping-stress tolerance. |
Correct Answer: A
Rationale: The information in the
patient statement relates to risk factors that may cause cardiovascular
problems in the future. Identification of risk factors falls into the health
perception-health maintenance pattern.
Cognitive Level: Application Text Reference: p.
44
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
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