The nurse is caring for a newly admitted client.
Which intervention is the best example of a culturally appropriate nursing intervention?
Insist family members provide most of the client’s personal care.
Maintain a personal space of at least 2 feet when assessing the client.
Ask permission before touching a client during the physical assessment.
Consider the client’s ethnicity as the most important factor in planning care.
The Correct Answer is C
Choice A rationale
Insisting that family members provide most of the client’s personal care may not be culturally appropriate. It may place undue burden on the family and may not respect the client’s autonomy or preferences.
Choice B rationale
Maintaining a personal space of at least 2 feet when assessing the client may not be culturally appropriate. Different cultures have different norms and expectations about personal space, and this distance may be seen as too distant or impersonal in some cultures.
Choice C rationale
Asking permission before touching a client during the physical assessment is a culturally appropriate nursing intervention. It shows respect for the client’s personal space and autonomy, and acknowledges cultural differences in norms about touch.
Choice D rationale
Considering the client’s ethnicity as the most important factor in planning care is not a culturally appropriate nursing intervention. While a client’s ethnicity can influence their health beliefs and behaviors, it is only one aspect of their identity and should not be the sole basis for planning care. Hildegard Peplau Hildegard Peplau Explore
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Using a sterile technique when packing the wound and changing the dressing twice a day is crucial to prevent further infection.
Choice B rationale
It is important to complete the full course of antibiotics, even if symptoms improve, to ensure the infection is fully treated and to prevent antibiotic resistance.
Choice C rationale
Diarrhea can be a side effect of some antibiotics. If it gets worse, it could be a sign of an infection such as Clostridium difficile, which requires immediate medical attention.
Choice D rationale
Rest is important for recovery. Strenuous activity could delay healing and increase the risk of complications.
Correct Answer is A
Explanation
Choice A rationale
Fatigue is a subjective symptom because it is experienced and reported by the patient. Patients with left-sided heart failure often experience fatigue due to the heart’s inability to pump sufficient blood to meet the body’s needs.
Choice B rationale
Elevated pulmonary capillary wedge pressure is an objective symptom that can be measured and observed by healthcare professionals. It is not something that a patient can directly experience or report.
Choice C rationale
Orthopnea, or difficulty breathing when lying flat, is a subjective symptom as it is based on the patient’s personal experience. However, it is not the best answer in this case because the question asks for the “subjective symptoms,” and fatigue is a more common subjective symptom of left-sided heart failure.
Choice D rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective symptom that can be observed by healthcare professionals. It is not something that a patient can directly experience or report.
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