Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico
Health & Physical Assessment In Nursing 3rd Edition by Donita T D'Amico
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Chapter 04 Health & Physical Assessment In Nursing 3rd Edition by Donita T D’Amico
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
Question 1
Type: MCSA
The nurse is preparing an educational program for the staff on cultural considerations. The nurse includes the following definition: “The adoption and incorporation of characteristics, customs, and values of the dominant culture by those new to that culture.” Which term is the nurse referring to?
Correct Answer: 2
Rationale 1: Ethnicity is the awareness of belonging to a group in which certain characteristics or aspects of a culture, such as biology, differentiate the members of one group from another.
Rationale 2: Assimilation matches the definition described.
Rationale 3: Ethnocentrism is the tendency to believe that one’s own beliefs, way of life, values, and customs are superior to those of others.
Rationale 4: Culture is the nonphysical traits, such as values, beliefs, attitudes, and customs that are shared by a group of people and passed from one generation to another.
Global Rationale: Assimilation matches the definition described. Ethnicity is the awareness of belonging to a group in which certain characteristics or aspects of a culture, such as biology, differentiate the members of one group from another. Ethnocentrism is the tendency to believe that one’s own beliefs, way of life, values, and customs are superior to those of others. Culture is the nonphysical traits, such as values, beliefs, attitudes, and customs that are shared by a group of people and passed from one generation to another.
Cognitive Level: Remembering
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values,
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice,
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4.1: Examine the components included in the definition of culture.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: p. 73
Question 2
Type: MCSA
The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which response by the nurse is the most appropriate?
Correct Answer: 1
Rationale 1: Some people will report adhering to a particular faith but will not strictly adhere to certain practices. Further assessment is needed to determine this client’s beliefs, desire to adhere to the practice, and extent to which the practice may be altered considering the illness and hospitalization. Making certain assumptions without further assessment would result in actions not respectful of or beneficial to the client.
Rationale 2: Making assumptions such as the healthcare provider discharging this client without further assessment would result in actions not respectful of or beneficial to the client.
Rationale 3: Making assumptions such as fasting being bad for the body without further assessment would result in actions not respectful of or beneficial to the client.
Rationale 4: Making assumptions such as the client being unable to fast during illness without further assessment would result in actions not respectful of or beneficial to the client.
Global Rationale: Many faiths describe circumstances in which fasts may be altered or eliminated during times of illness and hospitalization. Additionally, some people will report adhering to a particular faith but will not strictly adhere to certain practices. Further assessment is needed to determine this client’s beliefs, desire to adhere to the practice, and extent to which the practice may be altered considering the illness and hospitalization. Making certain assumptions without further assessment would result in actions not respectful of or beneficial to the client.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 73–75
Question 3
Type: MCSA
The nurse is caring for an older adult Native American client who is experiencing severe chest pain. The client is accompanied by a tribesman at the insistence of the client. The tribesman tells the nurse that their culture teaches acceptance of death as part of the natural cycle of life and that treatments must be stopped. The client’s son insists that his father be treated, and states he feels the tribe’s teachings are antiquated. Which action by the nurse is the most appropriate?
Correct Answer: 2
Rationale 1: It would be inappropriate to call a family meeting, with or without an interested second party, if the client is competent and has not asked for such a meeting.
Rationale 2: The client is an adult and, if capable of expressing his wishes and beliefs, should be encouraged to do so. Sometimes the client must be interviewed alone to be sure the client is actually stating his own wishes and not those of family members who may be present for the interview. Unless an adult is not competent to make and express his own decisions, or is impaired in some way and cannot express his own wishes, then the adult client’s wishes are honored over all others who may try to exert influence.
Rationale 3: At this time, there is not enough data to ask the hospital ethics committee to render an opinion.
Rationale 4: There is, at the moment, no behavior exhibited that would warrant notifying hospital administration.
Global Rationale: The client is an adult and, if capable of expressing his wishes and beliefs, should be encouraged to do so. Sometimes the client must be interviewed alone to be sure the client is actually stating his own wishes and not those of family members who may be present for the interview. Unless an adult is not competent to make and express his own decisions, or is impaired in some way and cannot express his own wishes, then the adult client’s wishes are honored over all others who may try to exert influence. It would be inappropriate to call a family meeting, with or without an interested second party, if the client is competent and has not asked for such a meeting. There is, at the moment, no behavior exhibited that would warrant notifying hospital administration, nor is there enough data to ask the hospital ethics committee to render an opinion.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.
NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.5: Formulate strategies to promote cultural competence when assessing patients from specific cultural groups.
MNL Learning Outcomes: 1.5.3. Perform a cultural assessment.
Page Number: pp. 80–82
Question 4
Type: MCSA
The nurse is assessing an adolescent client who is fluent in English, participates in high school sports, values riding dirt bikes, and plans to go to college after graduating from high school. The client’s health history indicates birth in China and immigrating to the United States at age 4. When asked where he is from, he says “the United States.” What does the client’s behavior and statements indicate to the nurse?
Correct Answer: 3
Rationale 1: There is no evidence that this client is bored with the interview.
Rationale 2: There is no evidence that this client is embarrassed.
Rationale 3: The teen’s answers indicate characteristics and behaviors of the American culture.
Rationale 4: There is no evidence that this client wishes to deny Asian heritage.
Global Rationale: The teen’s answers indicate characteristics and behaviors of the American culture. Often, those who have not assimilated are not fluent in the language of the new culture and do not display certain behaviors and characteristics of the new culture. There is no evidence to support other assumptions, such as that he wishes to deny his heritage, that he is embarrassed about his appearance, or that he is bored with the interview.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: p. 73
Question 5
Type: MCMA
The nurse manager is discussing cultural considerations with a group of staff nurses. Which statements by the staff nurses indicate an appropriate understanding of cultural concepts?
Standard Text: Select all that apply.
Correct Answer: 2, 5
Rationale 1: Ethnicity is the awareness of belonging to a group in which certain characteristics differentiate the members of one group from another.
Rationale 2: Culture is the socially transmitted beliefs, behaviors, values, customs, lifestyles, and ways of thinking of a specific population that guides worldview and decision-making.
Rationale 3: Ethnocentrism is the tendency to believe that one’s own beliefs, way of life, values, and customs are superior to others.
Rationale 4: Race is the identification of an individual or group by shared genetic heritage and biologic or physical characteristics.
Rationale 5: Decision-making is guided by one’s beliefs, values, customs and way of thinking, which is culture.
Global Rationale: Ethnicity is the awareness of belonging to a group in which certain characteristics differentiate the members of one group from another. Culture is the socially transmitted beliefs, behaviors, values, customs, lifestyles, and ways of thinking of a specific population that guides worldview and decision making. Ethnocentrism is the tendency to believe that one’s own beliefs, way of life, values, and customs are superior to others. Race is the identification of an individual or group by shared genetic heritage and biologic or physical characteristics. Decision making is guided by one’s beliefs, values, customs and way of thinking, which is culture.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.1: Examine the components included in the definition of culture.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 70–73
Question 6
Type: MCSA
The nurse is completing a self-assessment to determine cultural competence. Which behavior indicates cultural competence?
Correct Answer: 3
Rationale 1: Most Jewish people do not eat pork.
Rationale 2: Referring to an Asian as an “Oriental” is offensive.
Rationale 3: Bedouin immigrants from Arabia are nomads who are used to sleeping on the ground.
Rationale 4: Attending Mass is an obligation of Catholics and takes priority over lunchtime assignments, which can be revised.
Global Rationale: Bedouin immigrants from Arabia are nomads who are used to sleeping on the ground. Attending Mass is an obligation of Catholics and takes priority over lunchtime assignments, which can be revised. Most Jewish people do not eat pork. Referring to an Asian as an “Oriental” is offensive.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4.2: Practice using terms related to culture.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: p. 73
Question 7
Type: MCMA
The nurse is studying matriarchal cultures and needs to complete a report on how this aspect affects health care within the culture. Which cultures will the nurse explore as being matriarchal?
Standard Text: Select all that apply.
Correct Answer: 2, 3
Rationale 1: Patriarchal groups are those that are largely headed by a male family figure. Appalachian families are most likely to be patriarchal.
Rationale 2: Native American cultures are matrilineal with grandmothers and mothers being most important.
Rationale 3: Patriarchal groups are those that are largely headed by a male family figure. African American groups are most likely to be matriarchal.
Rationale 4: Patriarchal groups are those that are largely headed by a male family figure. Italian groups are most likely to be patriarchal.
Rationale 5: Patriarchal groups are those who are largely headed by a male family figure. Arab American groups are most likely to be patriarchal.
Global Rationale: Native American and African American families are most likely to be matriarchal, or lead by a female member of the family. Patriarchal groups are those who are largely headed by a male family figure. Appalachian families, Italian families, and Arab American families are most likely to be patriarchal.
Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.2: Practice using terms related to culture.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 70–73
Question 8
Type: MCMA
The nurse is interviewing a client and wishes to determine the roles of various members of an extended family living together in one household. Which statements would be helpful for the nurse to use to obtain this information?
Standard Text: Select all that apply.
Correct Answer: 3, 4
Rationale 1: The language spoken in the home will not help in the identification of roles within the household members.
Rationale 2: Open-ended questions are needed to obtain the most accurate and comprehensive information. This question is closed and would provide the nurse with little information other than a “yes” or “no” response, and no information about roles.
Rationale 3: The responsibilities of the family members will allow the nurse to hear the various roles each of them holds.
Rationale 4: Identification of decision-making roles will aid the nurse in determining roles of the members.
Rationale 5: Closed questions will do little to obtain information from the client. Happiness will not reflect roles of family members.
Global Rationale: The responsibilities of the family members will allow the nurse to hear the various roles each of them holds. Identification of decision-making roles will aid the nurse in determining roles of the members. The language spoken in the home will not help in the identification of roles within the household members. Open-ended questions are needed to obtain the most accurate and comprehensive information. Asking if all of the family members are working and if the client is happy with his or her place in the family are closed questions and would provide the nurse with little information other than a “yes” or “no” response.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.
NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.5: Formulate strategies to promote cultural competence when assessing patients from specific cultural groups.
MNL Learning Outcomes: 1.5.3. Perform a cultural assessment.
Page Number: pp. 78, 80–82
Question 9
Type: MCSA
The nurse manager is preparing for an accreditation visit and wants to assure that the unit is delivering culturally appropriate health care. Which action would demonstrate this approach by the nurse manager?
Correct Answer: 3
Rationale 1: Requiring English be taught to clients admitted to the hospital does not promote the value of other cultures and promotes a sense of ethnocentrism.
Rationale 2: The process used to admit clients may be included in the road to accreditation but does not directly address the delivery of culturally responsible care.
Rationale 3: The National Standards for Culturally and Linguistically Appropriate Services in Healthcare outlines 14 valid approaches for health care to assure that cultural competency is provided, including this approach.
Rationale 4: Nurses at the bedside require education to maintain competency and learn new skills.
Global Rationale: The National Standards for Culturally and Linguistically Appropriate Services in Healthcare outlines 14 valid approaches for health care to assure that cultural competency is provided. Requiring English be taught to clients admitted to the hospital does not promote the value of other cultures and promotes a sense of ethnocentrism. The process used to admit clients may be included in the road to accreditation but does not directly address the delivery of culturally responsible care. Nurses at the bedside require education to maintain competency and learn new skills.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.9. Discuss principles of effective communication.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4.4: Demonstrate culturally sensitive methods of communication when interacting with patients.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 75–78
Question 10
Type: MCSA
The nurse is interviewing a client and wishes to determine health practices that are important to the client’s beliefs. Which statement would be appropriate for the nurse to use to obtain this information?
Correct Answer: 2
Rationale 1: Asking about nontraditional medicine practices is too focused for the data the nurse is seeking.
Rationale 2: The nurse should use open-ended questions when interviewing clients. This choice provides direction for the client, and allows verbalization of information to clarify health beliefs for the nurse.
Rationale 3: Asking about how many times the client has been ill over a lifetime is too focused for the data the nurse is seeking.
Rationale 4: Asking about whether the client has medical insurance is too focused for the data the nurse is seeking.
Global Rationale: The nurse should use open-ended questions when interviewing clients. This choice provides direction for the client, and allows verbalization of information to clarify health beliefs for the nurse. Asking about nontraditional medicine practices, how many times the client has been ill over a lifetime, and whether the client has medical insurance are too focused for the data the nurse is seeking.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.
NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.5: Formulate strategies to promote cultural competence when assessing patients from specific cultural groups.
MNL Learning Outcomes: 1.5.3. Perform a cultural assessment.
Page Number: pp. 80–82
Question 11
Type: MCSA
The nurse is caring for a client who insists on having food very hot and very cold at each meal. The nurse correctly recognizes this as a health belief in which cultural group?
Correct Answer: 3
Rationale 1: The belief in yin and yang supports the request for the two temperature variations in the client’s meals. Cuban Americans do not support this practice.
Rationale 2: The belief in yin and yang supports the request for the two temperature variations in the client’s meals. Jewish Americans do not support this practice.
Rationale 3: Chinese Americans believe that health is maintained by the balance of two forces, yin and yang. This belief supports the request for the two temperature variations in the client’s meals.
Rationale 4: The belief in yin and yang supports the request for the two temperature variations in the client’s meals. Native Americans do not support this practice.
Global Rationale: Chinese Americans believe that health is maintained by the balance of two forces; yin and yang. This belief supports the request for the two temperature variations in the client’s meals. None of the other choices (Cuban Americans, Jewish Americans, and Native Americans) support this practice.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: p. 76
Question 12
Type: MCSA
The female nurse is examining a Vietnamese male and notes that he will not make eye contact with her during the assessment. The client appears very uncomfortable and is sweating and flushed. Which action by the nurse would be appropriate in this situation?
Correct Answer: 2
Rationale 1: Continuing the delivery of care by obtaining a blood sugar reading is inappropriate as it does not address the client’s feelings of discomfort.
Rationale 2: The Vietnamese culture prefers same-sex health care providers and the client may be extremely uncomfortable when the nurse does not provide this. The nurse needs to gather additional data by asking the client his preferences and allowing verbalization of his discomfort.
Rationale 3: Continuing the delivery of care by offering reassurance about the examination being over quickly is inappropriate as it does not address the client’s feelings of discomfort.
Rationale 4: Continuing the delivery of care by continuing the examination is inappropriate as it does not address the client’s feelings of discomfort.
Global Rationale: The Vietnamese culture prefers same-sex health care providers and the client may be extremely uncomfortable when the nurse does not provide this. The nurse needs to gather additional data by asking the client his preferences and allowing verbalization of his discomfort. Continuing the delivery of care by obtaining a blood sugar reading, offering reassurance about the examination being over quickly, or continuing the examination are all inappropriate as they do not address the client’s feelings of discomfort.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 73–79
Question 13
Type: MCSA
The nurse is admitting a client and asks to see all medications taken on a routine basis. The client offers a long list containing prescription medications and a variety of herbal preparations that are unfamiliar names to the nurse. Which action by the nurse would be appropriate at this time?
Correct Answer: 4
Rationale 1: Looking up the herbal preparations will enhance the level of knowledge by the nurse but is not the priority action.
Rationale 2: Asking the client to throw the items away will not address potential impact of their past ingestion.
Rationale 3: This step should be done only after the nurse has completed the assessment as associated with these substances.
Rationale 4: The nurse must assess prior to intervening, and must understand that some cultures use herbal preparations in their health practices. The nurse needs to obtain additional data from the client about what the herbals are used for and how often they are taken. This information should be documented in the client’s record and thus be available to the healthcare provider.
Global Rationale: The nurse must assess prior to intervening, and must understand that some cultures use herbal preparations in their health practices. The nurse needs to obtain additional data from the client about what the herbals are used for and how often they are taken. This information should be documented in the client’s record and thus be available to the healthcare provider. It will enhance the level of knowledge by the nurse to look up the herbal preparations but is not the priority action. Asking the client to throw the items away will not address potential impact of their past ingestion. The remaining choices are not appropriate at this time.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches.
NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.5: Formulate strategies to promote cultural competence when assessing patients from specific cultural groups.
MNL Learning Outcomes: 1.5.3. Perform a cultural assessment.
Page Number: pp. 80–82
Question 14
Type: MCSA
The nurse is setting up a meal tray and notes that the client refuses to look at the food and asks the nurse to take it away. The meal contains a chicken breast, green beans, fruit cocktail, and cottage cheese. Which response by the nurse is the most appropriate?
Correct Answer: 3
Rationale 1: While the patient may not be hungry, the nurse must determine if this is indeed the case.
Rationale 2: Telling the patient the food is horrible is inappropriate and does not promote the dietary intake of the client.
Rationale 3: The nurse must be alert and aware of cultural preferences related to dietary habits. Further assessment in this situation is needed to obtain data about the client’s inability to look at or eat the food.
Rationale 4: Offering other food options may be an option once the underlying cause for the client’s refusal is determined. Offering juice and crackers is not appropriate for the situation.
Global Rationale: The nurse must be alert and aware of cultural preferences related to dietary habits. Further assessment in this situation is needed to obtain data about the client’s inability to look at or eat the food. While the patient may not be hungry, the nurse must determine if this is indeed the case. Telling the patient the food is horrible is inappropriate and does not promote the dietary intake of the client. Offering other food options may be an option once the underlying cause for the client’s refusal is determined. Offering juice and crackers is not appropriate for the situation.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.9. Discuss principles of effective communication.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4.4: Demonstrate culturally sensitive methods of communication when interacting with patients.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 75–77
Question 15
Type: MCMA
Which questions will the nurse plan to ask when assessing a client’s ethnicity, which may impact their healthcare needs?
Standard Text: Select all that apply.
Correct Answer: 1, 2, 3
Rationale 1: Religious preference determination is a component of the cultural assessment.
Rationale 2: Dietary preferences are deeply ingrained into cultural beliefs and preferences. Assessment of dietary restrictions or preferences is a component of the cultural assessment.
Rationale 3: Ethnicity involves both internal and external identification practices. The nurse must ask what the client prefers.
Rationale 4: Although families frequently practice the same religion, it is not appropriate to make this inquiry.
Rationale 5: Politics are a component of ethnicity but are not a requirement nor an appropriate question for the admission assessment.
Global Rationale: Religious preference determination is a component of the cultural assessment. Dietary preferences are deeply ingrained in cultural beliefs and preferences. Assessment of dietary restrictions or preferences is a component of the cultural assessment. Ethnicity involves both internal and external identification practices. The nurse must ask what the client prefers. Although families frequently practice the same religion, it is not appropriate to make this inquiry. Politics are a component of ethnicity but are not a requirement nor an appropriate question for the admission assessment.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.2: Practice using terms related to culture.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 70–73
Question 16
Type: MCSA
A seasoned nurse notes that a novice nurse voices frustration and a lack of appreciation for clients with differing health care beliefs and practices. Which action will best assist the seasoned nurse to improve the novice nurse’s practice?
Correct Answer: 2
Rationale 1: Simply reducing the comments and displays of frustration will not address the root cause of the problem. The underlying cause must be handled to resolve the issue.
Rationale 2: Ethnocentrism is the belief of one’s personal beliefs to be superior to those held by others. The best manner in which to begin to manage and reduce these feelings is to begin the process of self-awareness.
Rationale 3: Administering a written reprimand will not handle the existing problem. The underlying cause must be handled to resolve the issue.
Rationale 4: Counseling and discipline may be warranted later in the process if the behaviors continue or worsen.
Global Rationale: Ethnocentrism is the belief of one’s personal beliefs to be superior to those held by others. The best manner in which to begin to manage and reduce these feelings is to begin the process of self-awareness. Simply reducing the comments and displays of frustration will not address the root cause of the problem. The underlying cause must be handled to resolve the issue. Administering a written reprimand will not handle the existing problem. Counseling and discipline may be warranted later in the process if the behaviors continue or worsen.
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A.9. Discuss principles of effective communication.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4.4: Demonstrate culturally sensitive methods of communication when interacting with patients.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 73–75
Question 17
Type: MCSA
The nurse is assigned to provide care to a Muslim client who is diagnosed with diabetes. When planning the care for the shift, which factor may have the greatest impact on the care?
Correct Answer: 3
Rationale 1: The respect for elders in the family has no impact on the successful plan of care.
Rationale 2: The lack of pork in the diet does not hinder dietary planning.
Rationale 3: During special religious events Muslims participate in fasting during the daylight hours. The diabetic client who engages in fasting and the nurse providing care will face unique challenges.
Rationale 4: Lamb and chicken provide adequate, healthful alternatives.
Global Rationale: During special religious events Muslims participate in fasting during the daylight hours. The diabetic client who engages in fasting and the nurse providing care will face unique challenges. The lack of pork in the diet does not hinder dietary planning. Lamb and chicken provide adequate, healthful alternatives. The respect for elders in the family has no impact on the successful plan of care.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 78–79
Question 18
Type: MCSA
The charge nurse is making assignments for the next shift. Three of the staff members are female and one is male. Which client should be assigned to a female staff member?
Correct Answer: 4
Rationale 1: The African American female would likely not have difficulty being assigned to the patient load of the male staff nurse.
Rationale 2: The African American male would likely not have difficulty being assigned to the patient load of the male staff nurse.
Rationale 3: The Arab American male would likely not have difficulty being assigned to the patient load of the male staff nurse.
Rationale 4: The teachings and beliefs of Arab Americans restrict physical touch between unmarried males and females.
Global Rationale: The teachings and beliefs of Arab Americans restrict physical touch between unmarried males and females. The African American female and male and the Arab American male would likely not have difficulty being assigned to the patient load of the male staff nurse.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 78–79
Question 19
Type: MCSA
When providing an in-service to new staff nurses, the nurse educator discusses expectations concerning the acceptance of client cultural beliefs. Which statement by a participant indicates the need for further teaching?
Correct Answer: 3
Rationale 1: Failure to have self-awareness can result in ethnocentrism.
Rationale 2: The cultural values and beliefs of the client may require “sensitive” scheduling.
Rationale 3: The knowledge and acceptance of one’s own cultural values is essential to the acceptance and awareness of the values of the client.
Rationale 4: Time does allow the nurse to develop additional knowledge of many issues in nursing, including cultural considerations.
Global Rationale: The knowledge and acceptance of one’s own cultural values is essential to the acceptance and awareness of the values of the client. Failure to have self-awareness can result in ethnocentrism. The cultural values and beliefs of the client may require “sensitive” scheduling. Time does allow the nurse to develop additional knowledge of many issues in nursing, including cultural considerations.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 78–79
Question 20
Type: MCSA
The nurse is collecting data concerning the client’s chief complaint. The client reports having attempted to manage the illness using herbs. Which response by the nurse is most therapeutic?
Correct Answer: 1
Rationale 1: The comprehensive assessment of health requires the nurse to obtain as much information as possible. The nurse will need to determine the herbs in use to ensure there are not adverse interactions between the treatments that may be ordered by the healthcare provider.
Rationale 2: Asking about the healthcare provider’s knowledge of the remedies and the implications made concerning the potential damage caused by the herbs are presented in closed questions. Further, they may imply to clients that they have engaged in wrongdoing.
Rationale 3: Asking about the healthcare provider’s knowledge of the remedies and the implications made concerning the potential damage caused by the herbs are presented in closed questions. Further, they may imply clients that they have engaged in wrongdoing.
Rationale 4: The last dosage of the herbal remedies may be beneficial; however, it is not the most therapeutic question to be asked.
Global Rationale: The comprehensive assessment of health requires the nurse to obtain as much information as possible. The nurse will need to determine the herbs in use to ensure there are not adverse interactions between the treatments that may be ordered by the healthcare provider. Asking about the healthcare provider’s knowledge of the remedies and the implications made concerning the potential damage caused by the herbs are presented in closed questions. Closed questions limit the amount of information obtained. Further, they may imply to the client they have engaged in wrongdoing. The last dosage of the herbal remedies may be beneficial; however, it is not the most therapeutic question to be asked.
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 78–79
Question 21
Type: MCSA
The nurse is preparing to perform an assessment of the client’s social support and organization. Which question will provide the needed information?
Correct Answer: 4
Rationale 1: Finding out the location of the client’s birth provides information concerning ethnicity.
Rationale 2: The primary language spoken in the home is of importance but does not determine the client’s social support.
Rationale 3: Political association may be influenced by culture and ethnicity, but this question does not assess social support or organization.
Rationale 4: During the data collection phase, data are collected to determine the social organization of the client. Assessment of religious affiliation/cultural affiliation will provide information concerning the social organization of the client.
Global Rationale: During the data collection phase, data are collected to determine the social organization of the client. Assessment of religious affiliation/cultural affiliation will provide information concerning the social organization of the client. Finding out the location of the client’s birth provides information concerning ethnicity. The primary language spoken in the home is of importance but does not determine the client’s social support. Political association may be influenced by culture and ethnicity, but this question does not assess social support or organization.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.2: Practice using terms related to culture.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 70–73
Question 22
Type: MCSA
While working in an ambulatory care clinic, a Hispanic client who speaks limited English seeks care. When preparing to provide the discharge instructions to the client, which is a responsibility of the nurse?
Correct Answer: 3
Rationale 1: Providing a translation dictionary does not ensure the client has adequate information to understand the plan of care.
Rationale 2: The types of resources available will vary depending upon the geographical area of the clinic as well as the language spoken and understood by the client. Translator availability will vary.
Rationale 3: The nurse has the responsibility to seek available resources to ensure the client understands the care and treatment being provided.
Rationale 4: The types of resources available will vary depending upon the geographical area of the clinic as well as the language spoken and understood by the client.
Global Rationale: The nurse has the responsibility to seek available resources to ensure the client understands the care and treatment being provided. The types of resources available will vary depending upon the geographical area of the clinic as well as the language spoken and understood by the client. Providing a translation dictionary does not ensure the client has adequate information to understand the plan of care. Translator availability will vary.
Cognitive Level: Analyzing
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A.9. Discuss principles of effective communication.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Conduct population-based transcultural health assessments and interventions.
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4.4: Demonstrate culturally sensitive methods of communication when interacting with patients.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 75–78
Question 23
Type: MCSA
The nurse is providing postoperative care to a Chinese American client. Which traditional Chinese cultural concepts may impact the nurse-client interaction?
Correct Answer: 1
Rationale 1: The Chinese American client may dislike being touched by strangers.
Rationale 2: The association of health and being overweight is a traditional belief of the Cuban American client.
Rationale 3: The use of herbs is a traditional belief of the Cuban American client.
Rationale 4: The use of ceremonies is a traditional belief of the Cuban American client.
Global Rationale: The Chinese American client may dislike being touched by strangers. The association of health and being overweight, and the use of herbs and ceremonies are the traditional beliefs of the Cuban American client.
Cognitive Level: Understanding
Client Need: Safe and Effective Care Environment
Client Need Sub: Management of Care
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 74–78
Question 24
Type: MCSA
The nurse is discharging a Chinese American client the hospital. The nurse notes the client is nodding in agreement in response to the nurse’s statements during discharge teaching. After completing the exchange of information, which is the priority action by the nurse?
Correct Answer: 3
Rationale 1: The client’s nodding may simply indicate hearing the information being provided.
Rationale 2: Asking the client if she understands is a closed question and may not determine adequate information.
Rationale 3: The client’s nodding may simply indicate hearing the information being provided. The nurse should ask questions to assess understanding.
Rationale 4: The client’s signature on the discharge paperwork may be indicated as a part of the discharge plan but is not the next step that should be taken by the nurse.
Global Rationale: The client’s nodding may simply indicate hearing the information being provided. The nurse should ask questions to assess understanding. Asking the client if she understands is a closed question and may not determine adequate information. The client’s signature on the discharge paperwork may be indicated as a part of the discharge plan but is not the next step that should be taken by the nurse.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 74–78
Question 25
Type: MCSA
When planning care to manage osteoporosis in an African American client, which must be taken into consideration?
Correct Answer: 3
Rationale 1: Bread and pork are factors to be considered when providing nutritional care to the Arab American.
Rationale 2: Snacking during adolescence is a health concern for the Appalachian population.
Rationale 3: Lactose intolerance is estimated to affect 75% of the African American population. This factor may impact dietary choices available and recommended to manage osteoporosis.
Rationale 4: Bread and pork are factors to be considered when providing nutritional care to the Arab American.
Global Rationale: Lactose intolerance is estimated to affect 75% of the African American population. This factor may impact dietary choices available and recommended to manage osteoporosis. Bread and pork are factors to be considered when providing nutritional care to the Arab American. Snacking during adolescence is a health concern for the Appalachian population. In addition, bread, pork, and snacks do not relate to osteoporosis.
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 78–79
Question 26
Type: MCSA
The nurse must order a meal tray for a Jewish client who is off the unit for testing and will require insulin administration immediately upon returning to the unit. Which dietary selection is the most appropriate for this client?
Correct Answer: 3
Rationale 1: The Jewish client is least likely to be accepting of meals containing pork.
Rationale 2: Meat and milk are not served in the same meal.
Rationale 3: The Jewish client is least likely to be accepting of meals containing pork. The menu of egg salad, a side salad, applesauce, and diet soda does not violate Jewish religious customs.
Rationale 4: The Jewish client is least likely to be accepting of meals containing pork. In addition, meat and milk are not served in the same meal.
Global Rationale: The menu of egg salad, a side salad, applesauce, and diet soda does not violate Jewish religious customs. The Jewish client is least likely to be accepting of the meal containing pork. In addition, meat and milk are not served in the same meal.
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 78–79
Question 27
Type: MCSA
A Filipino American client is discussing concerns related to osteoporosis with the nurse educator. Which concept related to cultural nutrition may pose problems for this client’s plan of care and will need to be incorporated into the information provided?
Correct Answer: 1
Rationale 1: The Filipino American has a higher than average risk to be lactose intolerant. Lactose intolerance may make ingestion of dairy products challenging.
Rationale 2: The client’s preferred sources of protein are not a source of concern.
Rationale 3: The use of salt and vinegar for seasoning are not issues for the client who has concerns related to osteoporosis.
Rationale 4: The client’s preferred sources of protein are not a source of concern.
Global Rationale: The Filipino American has a higher than average risk to be lactose intolerant. Lactose intolerance may make ingestion of dairy products challenging. The client’s preferred sources of protein are not a source of concern. The use of salt and vinegar for seasoning are not issues for the client who has concerns related to osteoporosis.
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 78–79
Question 28
Type: MCSA
The nurse is caring for a Vietnamese client. When providing care, the nurse should include which action?
Correct Answer: 2
Rationale 1: The culture often does not engage in direct eye contact as it is deemed disrespectful.
Rationale 2: The traditional Vietnamese client will appreciate an increase allowance of personal space.
Rationale 3: Periods of silence are used to demonstrate negative emotion, not positive emotion.
Rationale 4: Discussion of personal feelings is discouraged.
Global Rationale: The traditional Vietnamese client will appreciate an increase allowance of personal space. The culture often does not engage in direct eye contact as it is deemed disrespectful. Periods of silence are used to demonstrate negative emotion. Discussion of personal feelings is discouraged.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 74–79
Question 29
Type: MCSA
The nurse caring for a Navajo client notes a lack of verbal communication when attempting to interact with the client. Which inference can be made about this behavior?
Correct Answer: 4
Rationale 1: There is no indication the client is having difficulty understanding the interaction.
Rationale 2: There is no indication the client is failing to agree with the nurse.
Rationale 3: There is no indication the client is having difficulty speaking with the nurse without the male head of her household.
Rationale 4: The use of silence in the Navaho culture indicates agreement. In differing cultures silence may indicate a lack of understanding, disapproval, or discomfort.
Global Rationale: The use of silence in the Navaho culture indicates agreement. In differing cultures silence may indicate a lack of understanding, disapproval, or discomfort. There is no indication the client is having difficulty understanding the interaction, is failing to agree with the nurse, or is having difficulty speaking with the nurse without the male head of her household.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: VII.7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion, and disease and injury prevention interventions.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 4.3: Describe the impact of cultural phenomena on health and wellness.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 74–78
Question 30
Type: MCMA
The nurse educator is discussing culture and ethnicity with a group of student nurses. Which student statements indicate appropriate understanding of the material presented?
Standard Text: Select all that apply.
Correct Answer: 4, 5
Rationale 1: The United States represents a population of diverse individuals. There has been an increase in blending races. Many individuals now classify themselves as biracial or multiracial.
Rationale 2: The use of skin tone or facial features is not an acceptable means to determine racial or cultural heritage. This method of assessment and classification is shortsighted and may result in errors.
Rationale 3: Genetic heritage and biologic and physiologic characteristics may not all be shared between all members of the same race.
Rationale 4: The awareness of belonging to a group in which certain characteristics or aspects such as culture and biology differentiate the members of one group from another is the concept of ethnicity. It is defined by a shared interest, heritage, religion, food, politics, or geography and nationality.
Rationale 5: Inclusion in an ethnic group may be self-directed. An individual may share the viewpoints, geography, and nationality of an ethnic group by personal choice.
Global Rationale: The awareness of belonging to a group in which certain characteristics or aspects such as culture and biology differentiate the members of one group from another is the concept of ethnicity. It is defined by a shared interest, heritage, religion, food, politics, or geography and nationality. Inclusion in an ethnic group may be self-directed. An individual may share the viewpoints, geography, and nationality of an ethnic group by personal choice. The United States represents a population of diverse individuals. There has been an increase in blending races. Many individuals now classify themselves as biracial or multiracial. The use of skin tone or facial features is not an acceptable means to determine racial or cultural heritage. This method of assessment and classification is shortsighted and may result in errors. Genetic heritage and biologic and physiologic characteristics may not all be shared between all members of the same race.
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values.
AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice.
NLN Competencies: Context and Environment: Transcultural approaches to health.
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 4.2: Practice using terms related to culture.
MNL Learning Outcomes: 1.5.1. Consider the different aspects of culture to provide culturally competent nursing care to clients.
Page Number: pp. 70–73
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