the nurse is caring for a native american patient who has traditional beliefs about health and illness which action by nurse is most appropriate

NCLEX-RN

NCLEX Psychosocial Questions

1. The nurse is caring for a Native American patient who has traditional beliefs about health and illness. Which action by the nurse is most appropriate?

A. Avoid asking questions unless the patient initiates the conversation.
B. Ask the patient whether it is important that cultural healers are contacted.
C. Explain the usual hospital routines for meal times, care, and family visits.
D. Obtain further information about the patient's cultural beliefs from a family member.

Correct answer: B

Rationale: When caring for a patient with traditional health beliefs, it is essential to respect and address their cultural practices. Asking the patient whether it is important to involve cultural healers, such as a shaman, aligns with providing culturally sensitive care. Avoiding asking questions unless initiated by the patient may hinder effective communication and understanding of the patient's needs. Consulting a family member for cultural beliefs assumes that all family members share the same beliefs, which may not be accurate. Additionally, the patient's personal beliefs should be prioritized over family input. Explaining hospital routines without considering the patient's cultural preferences may lead to a lack of patient-centered care. Therefore, the most appropriate action is to inquire about the patient's preference regarding cultural healers.

2. The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?

A. Place the client in a high Fowler position.
B. Assist the client in assuming a left side-lying position.
C. Measure the tube from the tip of the nose to the xiphoid process.
D. Assist the client in flexing the neck forward to facilitate tube insertion.

Correct answer: A

Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.

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 of the following individuals is at the highest risk of suicide?

A. An 80-year-old man who lost his wife last year
B. A 36-year-old woman whose former neighbor committed suicide
C. A 40-year-old married businessman
D. A 46-year-old former alcoholic who has been sober for 12 years

Correct answer: A

Rationale: The correct answer is an 80-year-old man who lost his wife last year. Certain factors increase the risk of suicide, such as recent loss of a loved one, in this case, the man's wife. The elderly are a high-risk group due to factors like social isolation, physical health issues, and bereavement. While experiencing a loss can affect anyone, the combination of age, loss of a spouse, and the associated emotional impact elevates the risk significantly. The other choices are not at the highest risk of suicide. A former alcoholic who has been sober for 12 years has taken steps towards recovery, reducing the immediate risk. A 40-year-old married businessman and a 36-year-old woman whose former neighbor committed suicide do not have the same level of immediate risk as the elderly man who recently lost his wife.

5. Under what patient conditions or situations are restraints sometimes used?

A. As punishment when the patient is uncontrollable
B. To prevent the patient from pulling their IV out
C. When a patient is a danger to self and others
D. Both B and C

Correct answer: D

Rationale: Restraints are sometimes used to prevent a patient from pulling out their IV or another life-saving tube and when the person poses a serious danger to themselves and/or others. Restraints are never used as a form of punishment. Choice A is incorrect because restraints are not utilized for punishment but for patient safety and care. Choice B and C are correct because they reflect the appropriate and necessary situations where restraints may be used in healthcare settings.