Question 1

The nurse is caring for a client who only speaks Spanish. Which intervention by the nurse would be most appropriate?&#10;A) Ask the client's daughter to interpret information.&#10;B) Use a certified interpreter with a health care background.&#10;C) Ask the client's friend who teaches Spanish.&#10;D) Ask a nurse who took a Spanish class in high school.&#10;

Accepted Answer

1.This is incorrect. The nurse would not use the client's daughter to interpret information; the daughter may not interpret information correctly or may leave out information she does not want her mother to know.
2.This is correct. The nurse would use a certified Spanish interpreter with a health care background to ensure the client is receiving correct information.
3.This is incorrect. The nurse would not use a client's friend to interpret. The friend may not explain the information the nurse would want the patient to know or leave information out they don't want their friend to know.
4.This is incorrect. A nurse who took one Spanish class in high school likely did not learn health care Spanish and probably did not learn enough Spanish to interpret an entire conversation.

Question 2

Which statement made by the nursing student is an example of stereotyping and requires correction?&#10;A) &#34;Do you have any dietary restrictions based on cultural or spiritual beliefs we need to be aware of?&#34;&#10;B) &#34;Are there any spiritual practices important for you to continue during your stay?&#34;&#10;C) &#34;Do you have any cultural practices you would like us to be aware of?&#34;&#10;D) &#34;Since you are Hispanic, I will call the priest and have him come bring you communion.&#34;&#10;

Accepted Answer

1.This is incorrect. This statement does not require correction. This is an appropriate statement to assess cultural and spiritual beliefs related to dietary restrictions.
2.This is incorrect. This statement does not require correction. This is part of a cultural and spiritual assessment.
3.This is incorrect. This statement does not require correction. This is an appropriate question to assess cultural and spiritual beliefs.
4.This is correct. This statement stereotypes Hispanic individuals as being Catholic and requires correction.

Question 3

A client's wife tells the nurse that her husband strongly believes that he is Jesus. She states that she tells her husband that he is not Jesus, but he truly believes that he is and that he can perform miracles. Which disorder does the nurse suspect the client has?

A) Attention deficit-hyperactivity disorder (ADHD)
B) Schizophrenia
C) Major depressive disorder (MDD)
D) Anxiety

Schizophrenia

Accepted Answer

1.This is incorrect. ADHD does not lead to religious delusions.
2.This is correct; 25% of clients with schizophrenia experience religious delusions.
3.This is incorrect. MDD does not lead to religious delusions.
4.This is incorrect. Anxiety does not lead to religious delusions.

Question 4

The nurse notices the Filipino client has not been eating. The client moves food around the plate. Which nursing diagnosis would be appropriate for this client?&#10;A) Anxiety (moderate to severe) related to entry into an unfamiliar health care system and separation from support systems, evidenced by apprehension and suspicion, restlessness, and trembling&#10;B) Imbalanced nutrition, less than body requirements, related to refusal to eat unfamiliar foods provided in the health care setting, evidenced by loss of weight&#10;C) Impaired verbal communication related to cultural differences, evidenced by inability to speak the predominant language&#10;D) Spiritual distress related to inability to participate in usual religious practices because of hospitalization, evidenced by alterations in mood (e.g., anger, crying, withdrawal, preoccupation, anxiety, hostility, apathy)&#10;

Accepted Answer

1.This is incorrect. Anxiety is not the reason for the client not eating.
2.This is correct. The client is of another culture and is likely not used to the food provided by the facility. This nursing diagnosis is appropriate.
3.This is incorrect. There is nothing to indicate the client does not speak English; in addition, this would have no effect on the client not eating.
4.This is incorrect. This diagnosis would not have any effect on the client not eating.

Question 5

The nurse is assessing a new client. Which strategy indicates an understanding of appropriate cultural considerations?&#10;A) The nurse addresses the client by their first name.&#10;B) The nurse obtains smoking cessation brochures in English.&#10;C) The nurse sits in chair next to the client and makes eye contact.&#10;D) The nurse speaks slowly and clearly and repeats questions if needed.&#10;

Accepted Answer

1.This is incorrect. This strategy is incorrect and does not indicate an understanding of cultural considerations. The nurse would ask the client what they would prefer to be called and not just address them by their first name.
2.This is incorrect. This strategy is incorrect and does not indicate an understanding of cultural considerations. The nurse would ask the client in which language they would prefer written brochures.
3.This is incorrect. This strategy is incorrect and does not indicate an understanding of cultural considerations. The nurse would not just sit next to the client and make eye contact. This is inappropriate for some cultures.
4.This is correct. This statement indicates an understanding of cultural considerations. The nurse would speak slowly and clearly and repeat questions if needed.

Question 6

A Filipino client refusing to eat has a nursing diagnosis of imbalanced nutrition, less than body requirements, related to refusal to eat unfamiliar foods provided in the health care setting. Which nursing intervention would the nurse implement to ensure the client maintains weight?

A) Allow the client's family to bring the client's favorite food.
B) Tell the client they must eat or they cannot go home.
C) Recommend to the health care provider insertion of a feeding tube.
D) Suggest to the client to pretend they are eating their favorite foods.

Accepted Answer

1.This is correct. The client will most likely eat if they have access to familiar foods.
2.This is incorrect. The client will not eat if it is unfamiliar food, even if they are threatened.
3.This is incorrect. A feeding tube would not be necessary unless all other options are exhausted. The nurse should try having family members bring food for the client. If the client still does not eat, there may be another reason for their refusal to eat.
4.This is incorrect. It is unlikely the client will eat unfamiliar foods by pretending they are their favorite foods.

Question 7

The psychiatric-mental health nurse is performing the admission assessment of a client who is being admitted for depression and anxiety. The client reports a long history of excessive alcohol use and the recent loss of her job. When the nurse asks whether she has a religious preference or affiliation, the client states, "I used to believe in God, but I don't anymore. I don't understand how God can allow bad things to keep happening to me." Which nursing diagnoses will the nurse include in the client's care plan?

A) Risk for lack of faith
B) Risk for spiritual distress
C) Risk for impaired religiosity
D) Risk for impaired spirituality

Accepted Answer

1.This is incorrect. Risk for lack of faith is not a nursing diagnosis.
2.This is correct. NANDA International defines risk for spiritual distress as "vulnerable to an impaired ability to experience and integrate meaning and purpose in life through connectedness within self, literature, nature, and/or a power greater than oneself which may compromise health." Risk factors include substance abuse, depression, anxiety, and life changes.
3.This is incorrect. Risk factors for impaired religiosity are only illness/hospitalization and pain. Substance abuse and alcoholism are not risk factors.
4.This is incorrect. Risk for impaired spirituality is not a nursing diagnosis.

Question 8

The nurse is caring for a client who speaks Japanese. Which actions are appropriate by the nurse when using an interpreter to relay information? Select all that apply.&#10;A) Make eye contact with the interpreter when speaking.&#10;B) Speak to the interpreter separately.&#10;C) Use lay terms when speaking.&#10;D) Discuss the interview questions with the interpreter ahead of time.&#10;E) Use relatives of the client as interpreters when possible.&#10;

Accepted Answer

1.This is incorrect. The nurse should make eye contact with the client, not the interpreter.
2.This is incorrect. The nurse should not speak separately to the interpreter. This may cause the client to lose trust in the nurse.
3.This is correct. The nurse should avoid using medical jargon and instead use lay terms.
4.This is correct. The nurse should discuss interview questions with the interpreter ahead of time to ensure the interpreter is prepared or give them the opportunity to ask questions.
5.This is incorrect. The nurse should avoid using friends or relatives of the client. A certified interpreter with a health care background should be used when available.

Question 9

A 12-year-old client becomes hysterical every time when striking out in a ball game, falling down while roller-skating, or losing board or card games. Using Peplau's interpersonal theory, the nurse should identify that the client needs improvement in which stage of development?

A) Learning to count on others
B) Learning to delay satisfaction
C) Identifying oneself
D) Developing skills in participation

Accepted Answer

1.This is incorrect. The client needs to improve in the "developing skills in participation" stage of Peplau's interpersonal theory. During this stage, the child develops the capacity to compromise, compete, and cooperate with others. During the "learning to count on others" stage of infancy, a child learns to communicate feelings in a way that results in the fulfillment of comfort needs by the mothering figure.
2.This is incorrect. The client needs to improve in the "developing skills in participation" stage of Peplau's interpersonal theory. During this stage, the child develops the capacity to compromise, compete, and cooperate with others. During the "learning to delay satisfaction" stage of toddlerhood, the child begins to develop interdependent social relations and learns cultural norms.
3.This is incorrect. The client needs to improve in the "developing skills in participation" stage of Peplau's interpersonal theory. During this stage, the child develops the capacity to compromise, compete, and cooperate with others. During the "identifying oneself" stage of early childhood, a child learns to structure self-concept by observing how others interact with them.
4.This is correct. The client needs to improve in the "developing skills in participation" stage of Peplau's interpersonal theory. During this stage, the child develops the capacity to compromise, compete, and cooperate with others. This stage should be completed during late childhood.

Question 10

A client complains about a &#34;selfish&#34; spouse, a person only meeting their own sexual needs and never the client's needs. According to Freud, which personality structure should the nurse identify is predominantly driving the spouse's actions?&#10;A) The id&#10;B) The superid&#10;C) The ego&#10;D) The superego&#10;

Accepted Answer

1.This is correct. The spouse's actions are driven by the predominance of the id, the part of the personality that is identified as the pleasure principle and is the locus of instinctual drives.
2.This is incorrect. The spouse's actions are driven by the predominance of the id, the part of the personality that is identified as the pleasure principle and is the locus of instinctual drives. Freud did not identify a superid.
3.This is incorrect. The spouse's actions are driven by the predominance of the id, the part of the personality that is identified as the pleasure principle and is the locus of instinctual drives. The ego, also called the rational self or the reality principle, functions as the mediator to maintain harmony among the external world, the id, and the superego.
4.This is incorrect. The spouse's actions are driven by the predominance of the id, the part of the personality that is identified as the pleasure principle and is the locus of instinctual drives. The superego internalizes the values and morals set forth by primary caregivers. It is composed of the conscious and ego-ideal.

Question 11

A parent of a 5-year-old child curses at the child for disobedience. In turn, when upset, the child uses swear words in kindergarten. After the second occurrence, the teacher asks the child to again take a time-out in the corner of the classroom. Afterward, the verbal outbursts are not repeated. How would Kohlberg categorize the motivation for this changed behavior?

A) Respect for authority
B) Desire for approval
C) Fear of punishment
D) Internal set of values

Accepted Answer

The answer of A parent of a 5-year-old child curses...

Question 12

A 29-year-old client living with parents has few interpersonal relationships. The client states, "I have trouble finding romantic partners. No one wants to date me." Based on Sullivan's stages of personality development, which should the nurse recognize as a true statement about this client?

A) The client is struggling with getting a sense of identity separate from parents.
B) Developmental deficits in the life stage of early adolescence have impaired the client's current functioning.
C) An adult client can skip satisfaction of the developmental tasks of early adolescence.
D) The client's developmental problems began in the preadolescence stage.

Accepted Answer

The answer of A 29-year-old client living with parents has...

Deck 21: Theoretical Models of Personality Development, Cultural and Spiritual Concepts Relevant to Psychiatric-Mental Health Nursing