the nurse is caring for a newly admitted patient which intervention is the best example of a culturally appropriate nursing intervention
Logo

Nursing Elites

NCLEX-RN

NCLEX Psychosocial Questions

1. The nurse is caring for a newly admitted patient. Which intervention is the best example of a culturally appropriate nursing intervention?

Correct answer: C

Rationale: Culturally appropriate nursing care requires sensitivity to the beliefs and practices of diverse cultural groups. Asking permission before touching a patient during a physical assessment is a universally respectful practice, as many cultures consider it disrespectful to touch a person without consent. This approach demonstrates respect for the patient's autonomy and cultural preferences. Maintaining a personal space of at least 2 feet can be a good practice for infection control or personal comfort but may not be culturally significant for all patients. Insisting that family members provide most of the patient's personal care may not align with the patient's cultural norms or preferences. Considering a patient's ethnicity as the most important factor in care planning overlooks the individuality of the patient and may lead to stereotyping or assumptions that are not accurate or helpful in providing tailored care.

2. Which of the following outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence?

Correct answer: D

Rationale: During the crisis stage of caring for a victim of domestic violence, the immediate priority is ensuring the client's safety and providing treatment for any injuries sustained. This focuses on addressing the urgent physical and emotional needs of the victim. While options like verbalizing community resources or creating safety plans are important for long-term support, they are not the primary concerns during the crisis phase. Contacting an attorney for legal assistance, though vital in the future, is not the immediate priority during the crisis stage when the client's safety and health are at the forefront.

3. What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?

Correct answer: D

Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.

4. The client has a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?

Correct answer: B

Rationale: The most crucial client outcome for successful adjustment to a new colostomy is the readiness to accept an altered body function. Acceptance of changes in body image and function is essential to facilitate mastery of colostomy care techniques and optimal utilization of community resources. Without readiness to accept the altered body function, the client may not be open to learning and adopting necessary changes, hindering the achievement of long-term goals. Understanding dietary modifications, while important, is secondary to the fundamental acceptance of the altered body function in the process of adjusting to a new colostomy.

5. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next?

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to inform the surgeon that the operative permit is not signed and that the client has questions about the surgery. It is the responsibility of the surgeon to explain the procedure to the client and obtain the client's signature on the permit. While the nurse can witness the client's signature on the permit, the procedure must first be explained by the healthcare provider or surgeon, including addressing the client's questions. Therefore, informing the surgeon is the priority to ensure proper communication and consent before the surgery. Answering the client's questions about the surgery (Choice B) may not provide accurate information and could lead to misunderstanding. Reassuring the client (Choice D) is important, but obtaining proper consent and addressing concerns should come first. Witnessing the client's signature (Choice A) is not sufficient if the client has unanswered questions and the permit is not signed.

Similar Questions

Which behavior indicates that the client has learned the most effective method to cope with anger?
What is the nurse's initial plan for providing pain relief measures during labor for a pregnant client with a history of opioid abuse?
Which priority action would the nurse manager use to help the nurse who may be experiencing burnout?
A 30-year-old woman is scheduled for a total abdominal hysterectomy due to noninvasive endometrial cancer. The nurse anticipates the client may have difficulty adjusting emotionally to this type of surgery. Which concern would be the cause of this anticipated difficulty?
Which client is most likely to be at risk for spiritual distress?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses