Nursing Elites

1. A healthcare provider is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the provider identify as examples of cultural variables?

• A. Health literacy, income, gender
• B. Eye contact, personal space, touch
• C. Physical activity, ethnicity, eye contact
• D. Body language, facial expressions, religion

Correct answer: B

Rationale: The correct answer is B: Eye contact, personal space, and touch are cultural variables that can influence healthcare interactions. These factors vary across cultures and can impact how individuals perceive communication and interactions. Choices A, C, and D include elements that are not specifically cultural variables affecting communication and interactions in the same way as eye contact, personal space, and touch.

2. A nurse enters a client's room and sees smoke coming from the trash can. What action should the nurse take first?

• A. Call for assistance
• B. Evacuate the room
• C. Attempt to put out the fire
• D. Turn off the oxygen supply

Correct answer: B

Rationale: In the event of a fire, the priority is to ensure everyone's safety. Therefore, the nurse's initial action should be to evacuate the room. Calling for assistance can be done while evacuating, ensuring help is on the way. Attempting to put out the fire can be dangerous and may delay evacuation. Turning off the oxygen supply is not the first step in this situation, as the immediate concern is to remove individuals from the potential danger.

3. When performing an abdominal assessment on a client, what action should the nurse take first?

• A. Palpate the abdomen
• B. Auscultate bowel sounds
• C. Inspect the abdomen
• D. Percuss the abdomen

Correct answer: B

Rationale: The correct answer is to auscultate bowel sounds. This action should be taken first because it ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen (choice C) may provide visual cues but does not address functional assessment. Palpating the abdomen (choice A) should follow auscultation to prevent altering bowel sounds. Percussing the abdomen (choice D) is typically done after auscultation and palpation.

4. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?

• A. Reposition the client every 4 hours
• B. Use a special mattress for the client
• C. Keep the client on bedrest
• D. Encourage the client to remain in one position

Correct answer: B

Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.

5. A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?

• A. Verbal self-report
• B. Pain scale
• C. Behavioral indicators
• D. Observing facial expressions

Correct answer: C

Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.

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