Nursing Elites

1. A 17-year-old Asian client is being seen for lower abdominal pain in the right quadrant. The client is accompanied by his parents. The nurse notes that the client's father does not make eye contact and shows little response when told that the client will need surgery. Which of the following is the most appropriate action of the nurse?

• A. Contact an interpreter to give the information again in the father's native language
• B. Continue to provide information about surgery to both the client and his parents
• C. Call social services to evaluate the parent's standard of care
• D. Contact the physician about postponing the surgery

Correct answer: B

Rationale: Nurses may work with clients who have varying cultural beliefs. Because of this, nurses must remain aware of the cultural practices associated with certain ethnic groups. Asian Americans may avoid eye contact as a sign of respect; additionally, emotional responses may be avoided except for in private situations. If this family did not have a language barrier, the nurse should continue to provide appropriate information about the surgery and recognize the cultural differences that exist. Contacting an interpreter is not necessary as there was no mention of a language barrier. Calling social services to evaluate the parent's standard of care is premature and not within the nurse's immediate scope of practice. Contacting the physician about postponing the surgery is not warranted based on the information provided.

2. Which nursing intervention would be provided to a hospitalized client during the identity versus role confusion stage?

• A. Choosing creative ways to promote social participation
• B. Providing information to the client about the treatment plan
• C. Encouraging the client to participate actively in treatment procedures
• D. Involving the client's partners or family members in the caring process

Correct answer: B

Rationale: During the identity versus role confusion stage, which occurs during adolescence or puberty, it is essential for the nurse to empower hospitalized adolescents by providing them with sufficient information about their treatment plan. This approach enables the clients to actively participate in decision-making regarding their care. Choosing creative ways to promote social participation is more aligned with assisting clients during the generativity versus self-absorption and stagnation stage, where fostering social engagement can contribute to a sense of fulfillment. Involving the client's partners or family members in the caring process is typically beneficial during the intimacy versus isolation stage to create a strong support system for the client. Encouraging active participation in treatment procedures is more relevant to the industry versus inferiority stage, ensuring that the hospitalized client engages effectively in their care.

3. A client with generalized anxiety disorder presents with restlessness and fatigue. Which additional clinical manifestation would the nurse monitor for?

• A. Hoarding
• B. Panic attacks
• C. Excessive worry
• D. Fear of leaving the house

Correct answer: C

Rationale: The nurse would monitor for excessive worry. Generalized anxiety disorder is characterized by physical and cognitive symptoms of chronic or excessive anxiety and worry. Excessive worry is a core feature of generalized anxiety disorder. Hoarding is a symptom of hoarding disorder, not generalized anxiety disorder. Panic attacks are typical of panic disorder, not generalized anxiety disorder. Fear of leaving the house is a characteristic of agoraphobia, which is distinct from generalized anxiety disorder.

4. A 28-year-old woman is recovering from her third consecutive spontaneous abortion in 2 years. Which is the most therapeutic nursing intervention for this client at her follow-up appointment?

• A. Focusing on the client's physical needs
• B. Encouraging the client to verbalize her feelings about the loss
• C. Reminding the client that she will be able to become pregnant again
• D. Encouraging the client to think of herself, her husband, and their future

Correct answer: B

Rationale: The most therapeutic nursing intervention for a client recovering from multiple spontaneous abortions is to encourage the client to verbalize her feelings about the loss. This allows the client to express and process her emotions, facilitating the grieving process and emotional healing. Focusing solely on the client's physical needs, as in choice A, overlooks the importance of addressing the emotional aspect of the client's experience. Choice C, reminding the client that she will be able to become pregnant again, fails to acknowledge the current loss and may minimize the client's feelings of grief. Choice D, encouraging the client to think of herself, her husband, and their future, does not directly address the client's immediate emotional needs related to the recent loss. Therefore, choice B is the most appropriate intervention to support the client in coping with her emotional distress.

5. When attempting to incorporate the Latino client's cultural background into the plan of care, which consideration is the most important?

• A. Socioeconomic considerations regarding hospitalization
• B. The meaning and attention the client places on the future
• C. The client's need to control care to ensure desired outcomes
• D. Inclusion of the family in the plan of care with the client's permission

Correct answer: D

Rationale: The most important consideration when incorporating the Latino client's cultural background into the plan of care is the inclusion of the family in the care plan with the client's permission. In Latino cultures, family plays a vital role, and there is a strong emphasis on family support during challenging times. This support can positively impact the client's health outcomes and overall well-being. Socioeconomic status, although relevant, does not carry more weight than usual in healthcare decisions. Latino clients typically focus on the present rather than the future, and they often attribute outcomes to external factors like fate or divine intervention. While the client's need for control is important, involving the family aligns more closely with the cultural values and preferences of Latino clients.

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