during an assessment the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck which action by the nu
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Nursing Elites

HESI A2

HESI A2 Practice Test Anatomy and Physiology

1. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate?

Correct answer: A

Rationale: The appropriate action for the nurse in this situation is to ask the patient about the charm and its significance. This helps the nurse understand the patient's cultural beliefs, personal values, and any potential significance the charm holds for the patient. It also shows respect for the patient's personal belongings. Asking about the charm can help establish rapport and cultural competence in the nurse-patient relationship. Choices B and C do not address the patient's attachment to the charm or provide an opportunity for cultural understanding. Choice D is incorrect as it dismisses the importance of acknowledging and respecting the patient's personal belongings.

2. Among many Asians there is a belief in the yin\yang theory, rooted in the ancient Chinese philosophy of Tao. The nurse recognizes which statement that most accurately reflects "health" in an Asian with this belief?

Correct answer: C

Rationale: In Asian belief systems like the yin\yang theory rooted in Tao philosophy, health is seen as existing when all aspects of a person are in perfect balance. This means that physical, mental, emotional, and spiritual elements need to be harmonized for an individual to be considered healthy. The other statements do not encapsulate this holistic perspective on health.

3. What would be an appropriate nursing response when a mother reports that her 16-month-old toddler has an earache?

Correct answer: B

Rationale: The appropriate nursing response would be to assess the toddler's ear to determine if there is indeed an ear infection causing the earache. It is crucial to provide timely and suitable care for the child's pain and discomfort. Checking for an ear infection is a necessary step in evaluating the source of the toddler's earache. Choice A is incorrect as it assumes the earache is due to teething without proper assessment. Choice C questions the mother's report rather than focusing on the child's condition. Choice D is not as direct and focused as directly examining the ear for a possible infection.

4. When a nurse is performing a health interview on a patient with a language barrier and no interpreter is available, which of the following is the best example of an appropriate question for the nurse to ask?

Correct answer: A

Rationale: The best example of an appropriate question for the nurse to ask in this situation is 'Do you take medicine?' This question is clear, simple, and focused on one topic at a time, which is essential when there is a language barrier and no interpreter available. It follows the recommendation to use simple words, avoid medical jargon, contractions, and pronouns in such situations. Choices B, C, and D involve more complex language, unrelated topics, or assumptions about the patient's actions, making them less suitable for effective communication in this context.

5. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this is true, probably because Mexican-Americans:

Correct answer: B

Rationale: In Mexican-American culture, coughing, sweating, and diarrhea are often considered normal bodily functions and not necessarily indicative of illness. This cultural perspective shapes their understanding of health and illness, leading them to view these symptoms differently than the majority culture in America. Choice A is incorrect because it generalizes Mexican-Americans as having less efficient immune systems, which is not supported by evidence. Choice C is incorrect as it oversimplifies by attributing the perception solely to coming from Mexico. Choice D is incorrect as it makes unwarranted assumptions about the socioeconomic status and health status of Mexican-Americans.

Similar Questions

When planning a cultural assessment, which component should be included?
An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by:
During an interview, the nurse states, 'You mentioned shortness of breath. Tell me more about that.' Which verbal skill is used with this statement?
An elderly Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally-sensitive nurse would:
When an American Indian seeks help at the clinic for regulating her diabetes, the nurse can expect that she:

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