The nurse is interviewing a recent immigrant from Mexico. During the course of the interview, the man leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse's. The nurse begins to feel uncomfortable with his proximity. Which of the following statements describes the most appropriate response by the nurse?- Skildor

Question 1 of 5

The nurse is interviewing a recent immigrant from Mexico. During the course of the interview, the man leans forward and then finally moves his chair close enough that his knees are nearly touching the nurse's. The nurse begins to feel uncomfortable with his proximity. Which of the following statements describes the most appropriate response by the nurse?

A. Try to relax; this behaviour is culturally appropriate for this person. B. Discreetly move the chair back to a more comfortable distance, and then continue with the interview. C. These behaviours are indicative of sexual aggression, and the nurse should confront this person about them. D. The nurse should laugh but tell him that he or she is uncomfortable with the proximity and ask the person to move away.

Correct Answer: A

Rationale: The correct answer is A: "Try to relax; this behavior is culturally appropriate for this person." In Mexican culture, close proximity during conversations is common and signifies engagement and trust. By understanding cultural differences, the nurse can avoid misinterpreting the behavior. Moving the chair back (choice B) may be seen as rude. Assuming sexual aggression (choice C) without evidence is inappropriate. Laughing and asking to move away (choice D) may embarrass the individual. Understanding and respecting cultural norms is crucial in providing effective care.

Question 2 of 5

A nurse is teaching a patient with diabetes about blood glucose management. Which of the following statements by the patient indicates proper understanding?

A. I should check my blood glucose levels regularly and adjust my insulin as needed. B. I can stop taking my insulin if my blood glucose is normal. C. I should skip meals if my blood sugar is high. D. I should only use my insulin when my blood sugar is over 200 mg/dL.

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Regular blood glucose monitoring helps in understanding patterns and making informed decisions. 2. Adjusting insulin based on blood glucose levels is crucial for effective diabetes management. 3. This statement shows the patient's understanding of the need for personalized insulin adjustments. 4. It promotes self-management and proactive approach to blood sugar control. Summary: B: Stopping insulin abruptly can lead to dangerous complications. C: Skipping meals can disrupt blood sugar levels and is not recommended. D: Waiting for high blood sugar to use insulin can result in uncontrolled levels and complications.

Question 3 of 5

Which of the following is an example of a first-level priority problem?

A. A patient with postoperative pain. B. A patient newly diagnosed with diabetes who needs teaching about diabetes. C. An individual with a small laceration on the sole of the foot. D. An individual with shortness of breath and respiratory distress.

Correct Answer: D

Rationale: The correct answer is D because shortness of breath and respiratory distress indicate a potentially life-threatening emergency requiring immediate intervention. This problem falls under the first-level priority as it addresses airway, breathing, and circulation, which are essential for survival. Choices A, B, and C are not first-level priorities as they do not pose an immediate threat to the patient's life or require urgent intervention. Postoperative pain, diabetes teaching, and a small foot laceration are important but can be addressed at a later time without immediate harm to the patient.

Question 4 of 5

The review of systems provides the nurse with:

A. physical findings related to each system. B. information regarding health promotion practices. C. an opportunity to teach the patient medical terms. D. information necessary for the nurse to diagnose the patient's medical problem.

Correct Answer: B

Rationale: Step 1: The review of systems is a systematic approach to assessing the patient's overall health. Step 2: It gathers information about symptoms across different body systems. Step 3: This information helps identify potential health risks and guide health promotion practices. Step 4: Choice B is correct as it aligns with the purpose of the review of systems. Summary: - Choice A is incorrect because it focuses on physical findings only, not the comprehensive assessment. - Choice C is incorrect as the review of systems is not primarily for teaching medical terms. - Choice D is incorrect as it does not provide enough information for diagnosing specific medical problems.

Question 5 of 5

A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. Which of the following is the best action for the nurse to take?

A. Count the respirations, and call a physician immediately. B. Percuss the thorax bilaterally, noting any differences in percussion tones. C. Inspect the thorax for any masses and bleeding associated with respirations. D. Call for a chest x-ray examination, and wait for the results before beginning an assessment.

Correct Answer: B

Rationale: The correct answer is B: Percuss the thorax bilaterally, noting any differences in percussion tones. This is the best action because it allows the nurse to assess for potential underlying issues such as pneumothorax or pleural effusion which could be causing the respiratory distress. Percussion can help identify abnormal air or fluid accumulation in the chest. Choice A is incorrect because simply counting respirations does not provide immediate information on the cause of distress. Choice C is incorrect as inspecting for masses and bleeding does not directly address the urgency of the situation. Choice D is incorrect as waiting for a chest x-ray would delay necessary interventions in a critical situation.

jarvis physical examination and health assessment 9th edition test bank

Skildor

ATI RN

ATI RN

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