A nurse is caring for a client whose cultural beliefs prohibit certain foods. The client is on a hospital diet. What should the nurse do first?
Refuse to provide the restricted foods
Explain that the client must follow the standard hospital diet
Ask the client to ignore their cultural beliefs while in the hospital
Document the client's cultural preferences and consult the dietary team
The Correct Answer is D
Choice A reason: Simply refusing to provide restricted foods without offering a culturally appropriate alternative is a failure of patient-centered care. It ignores the client's nutritional needs and personal autonomy, potentially leading to malnutrition or a breakdown in the therapeutic relationship between the healthcare provider and the client.
Choice B reason: Insisting that a client strictly follow a standard hospital diet regardless of their cultural or religious constraints is culturally insensitive. Such a rigid approach fails to account for holistic nursing care and may result in the client refusing to eat entirely, which negatively impacts their recovery.
Choice C reason: Asking a client to temporarily abandon their cultural beliefs is unprofessional and unethical. Respecting cultural diversity is a core competency in nursing. Disregarding these beliefs can cause significant psychological distress and violates the principle of respect for the individual's identity and heritage during treatment.
Choice D reason: The nurse's priority is to provide culturally competent care by first identifying and documenting the specific dietary restrictions. Collaborating with the dietary department ensures that the client receives meals that are both nutritionally adequate and compliant with their cultural values, thereby promoting safety and adherence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A reason: The procedure for detecting orthostatic (postural) hypotension requires sequential blood pressure and pulse measurements in three distinct positions: supine, sitting, and standing. This allow the nurse to observe how the cardiovascular system compensates for the gravitational shifts in blood volume during position changes.
Choice B reason: Orthostatic hypotension is clinically defined as a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within three minutes of standing. Recording these specific drops is essential for a definitive diagnosis of the condition.
Choice C reason: Providing water before the test could artificially inflate the blood volume and mask orthostatic hypotension. The goal of the test is to evaluate the body's baseline compensatory mechanisms. Adding fluids would interfere with the accuracy of the assessment by temporarily correcting potential dehydration-induced hypotension.
Choice D reason: The client must remain still during each measurement to ensure an accurate blood pressure reading. Walking or physical activity during the test would stimulate the sympathetic nervous system and muscular pump, which could falsely elevate the blood pressure and invalidate the results of the orthostatic assessment.
Choice E reason: A brief rest period of 1 to 2 minutes (sometimes up to 3 minutes) between each position change is necessary to allow the blood to redistribute and the baroreceptor reflex to respond. Taking the measurement too quickly would not give the body enough time to show a true postural reaction.
Correct Answer is A
Explanation
Choice A reason: The rectal route is widely recognized as the gold standard for core temperature measurement because the rectum is a highly vascularized, closed cavity. It is least affected by external factors like ambient air or oral intake, providing the most reliable reflection of internal metabolic heat.
Choice B reason: Axillary temperature is considered the least accurate method because it measures skin surface temperature rather than internal core temperature. It is highly susceptible to environmental interference and peripheral vasoconstriction, often resulting in readings that are significantly lower and less consistent than other anatomical sites.
Choice C reason: Tympanic temperature measurement utilizes infrared technology to detect heat from the eardrum, which shares blood supply with the hypothalamus. While convenient and fast, accuracy can be compromised by the presence of cerumen, improper probe positioning, or the anatomical curvature of the individual's ear canal.
Choice D reason: Oral temperature measurement is common but subject to several variables that can skew results. Recent ingestion of hot or cold liquids, smoking, or mouth breathing can temporarily alter the sublingual environment, leading to inaccurate readings that do not truly represent the patient's systemic core temperature.
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