the nurse plans care for a hospitalized patient who uses culturally based treatments which action by the nurse is best

NCLEX-RN

NCLEX Psychosocial Questions

1. The nurse plans care for a hospitalized patient who uses culturally based treatments. Which action by the nurse is best?

A. Encourage the use of diagnostic procedures.
B. Coordinate the use of folk treatments with ordered medical therapies.
C. Ask the patient to discontinue the cultural treatments during hospitalization.
D. Teach the patient that folk remedies will interfere with orders by the healthcare provider.

Correct answer: B

Rationale: The best action for the nurse is to coordinate the use of folk treatments with ordered medical therapies. Many culturally based therapies can complement Western treatments and medications. It is essential for the nurse to integrate both traditional folk treatments and Western therapies to provide holistic care. Some culturally based treatments can effectively complement Western medicine in treating diseases. Encouraging the patient to continue some culturally based treatments during hospitalization can enhance their overall well-being. Asking the patient to discontinue cultural treatments or teaching that folk remedies interfere with Western therapies may not align with the patient's beliefs and could hinder their care.

2. Which of the following is a true statement about palliative care?

A. The goal of palliative care is to provide end-of-life care for a client as they transition toward death.
B. Palliative care provides comfort and support for those who may have a terminal illness.
C. Palliative care provides resources for funeral arrangements after death.
D. Palliative care is a support network for family and friends after the death of a loved one.

Correct answer: B

Rationale: Palliative care is a type of care that focuses on providing support and comfort to individuals who may have a terminal illness or severe symptoms. It aims to improve the quality of life for both the individual receiving care and their family. While it can be provided in various settings, including hospitals, homes, or specialized facilities, the primary focus is on symptom management and addressing the physical, emotional, and spiritual needs of the individual. Choice A is incorrect because palliative care is not solely limited to end-of-life care but also includes managing symptoms and improving quality of life. Choice C is incorrect as palliative care is focused on providing care and support during the individual's life, not on funeral arrangements after death. Choice D is incorrect as palliative care is primarily directed towards the individual receiving care, although it may also provide support to their family and friends during the care process.

3. What step should be taken when administering ear drops to an adult client?

A. Place the client in a side-lying position.
B. Hold the dropper 1 cm above the ear canal.
C. Place a cotton ball into the outermost canal.
D. Pull the auricle down and back.

Correct answer: A

Rationale: The correct step when administering ear drops to an adult client is to place the client in a side-lying position (A). This position allows for easier administration of the drops and helps prevent spillage. The dropper should be held approximately 1 cm (� inch) above the ear canal (B) to ensure accurate delivery of the medication. Placing a cotton ball into the outermost canal (C) is unnecessary and may interfere with the absorption of the ear drops. Pulling the auricle down and back (D) is a technique used for children younger than 3 years old to straighten the ear canal, but it is not necessary for adults and may cause discomfort.

4. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

A. Ask whether the voices are male or female and how many there are.
B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
D. Encourage the client to leave the room and keep busy to distract from the voices.

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

5. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

A. At home, I take my pills at 8:00 am.
B. It costs a lot of money to buy all of these pills.
C. I get so tired of taking pills every day.
D. This is a new pill I have never taken before.

Correct answer: D

Rationale: The client stating, 'This is a new pill I have never taken before,' is the correct answer as it indicates a potential discrepancy in the medication order. This statement requires further assessment to ensure the medication is correct, verify if it is a new prescription or a different manufacturer, and determine if the client needs additional instructions. While the timing of medication administration (option A) is important, it may not be as critical as ensuring the accuracy of the medication being administered. Option B, regarding the cost of pills, is relevant for discharge planning but does not directly impact the immediate administration of the medication. Option C, expressing tiredness from taking pills daily, may warrant discussion on adherence or side effects but does not raise immediate concerns about the specific medication being administered.