The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which response by the nurse is the most appropriate?

Fasting is harmful to your body.

You must have food during times of illness.

I will let your healthcare provider know that you need to be discharged.

What can we do to accommodate your needs during your stay here?

Answer and Explanation

The Correct Answer is D

This response demonstrates respect for the client's religious beliefs and a willingness to work with the client to meet their needs. It also opens up a dialogue between the nurse and the client to develop a plan of care that is consistent with the client's beliefs and values.

Option a, "Fasting is harmful to your body," is not an appropriate response as it does not respect the client's religious beliefs and may be perceived as insensitive or disrespectful.

Option b, "You must have food during times of illness," may be accurate in some situations, but it is not relevant to the client's request to fast during Ramadan.

Option c, "I will let your healthcare provider know that you need to be discharged," is not an appropriate response as it does not address the client's request to fast during Ramadan and may be perceived as dismissive or unhelpful.

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Correct Answer is A

Explanation

A. The examiner uses bimanual palpitation to evaluate the tail of spence.

This statement is true. The tail of Spence is the extension of breast tissue into the axilla, and it is important to evaluate this area during a breast examination. Bimanual palpation, which involves using both hands to examine the breast tissue, is commonly used to assess the tail of Spence.

B. The axillae are not palpated if the breast tissue is normal.

This statement is false. The axillae should be palpated during a breast examination, even if the breast tissue is normal. Lymph nodes in the axilla can sometimes be the first site of metastasis for breast cancer, so it is important to check for any abnormalities in this area.

C. Nipple discharge in pregnant women is considered abnormal.

This statement is false. Nipple discharge is a common occurrence during pregnancy and is usually considered normal, especially in the later stages of pregnancy. However, any sudden or persistent discharge should be evaluated by a healthcare provider.

D. The breasts are inspected as the client changes positions to detect abnormal symmetry.

This statement is false. The breasts should be inspected in a consistent position, such as with the patient sitting or lying down. Changing positions can alter the appearance of the breasts and make it difficult to detect any changes or abnormalities. However, it is important to inspect both breasts and compare them for any signs of asymmetry or abnormalities.

A. Test the hypoglossal nerve. B. Evaluate the function of the Cranial nerve XI (11) C. Test the glossopharyngeal nerve. D. Evaluate sensory function.

Correct Answer is D

Explanation

The sense of taste is primarily mediated by the facial nerve (cranial nerve VII) and the glossopharyngeal nerve (cranial nerve IX). However, testing the function of specific cranial nerves such as the hypoglossal nerve (cranial nerve XII) or cranial nerve XI (11) is not directly related to evaluating the patient's ability to taste. Therefore, options a, b, and c would not be the most appropriate actions for the nurse to take in this scenario.

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The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which response by the nurse is the most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements concerning breast examination is true?

Correct Answer is A

Explanation

The patient reports an inability to taste. What is the most appropriate action for the nurse to take?

Correct Answer is D

Explanation

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