The nurse provides care to a Muslim client who presents to the emergency department with abdominal pain and vaginal bleeding. The client's spouse asks that only a female examines the client. Which is the most culturally appropriate statement by the nurse in response to the request?

"The male and female providers here both respect privacy."

"Your spouse will be covered so it will not matter what the gender of the examiner is."

"Every attempt will be made to honor your request regarding the care of your spouse."

"Your request is unreasonable and cannot be honored at this time."

Answer and Explanation

The Correct Answer is C

Rationale:

A. Although emphasizing privacy is important, this statement does not directly address the client’s cultural or religious preference for a female examiner. Simply stating that all providers respect privacy may be perceived as dismissive, and it fails to reassure the client that their specific request will be honored. Cultural sensitivity requires recognizing and validating the client’s values, not just general privacy assurances.

B. This statement minimizes the client’s cultural and religious beliefs by suggesting that covering the client compensates for the presence of a male examiner. In many Muslim traditions, modesty and gender-specific care are critical. Ignoring these preferences can cause distress, reduce trust in healthcare providers, and potentially discourage the client from seeking care in the future.

C. This response acknowledges and respects the client’s religious and cultural values. It communicates that the healthcare team is willing to accommodate the client’s preference for a female examiner whenever possible, without guaranteeing it in situations where staffing limitations may exist. This approach promotes cultural competence, patient-centered care, and trust in the healthcare relationship, while balancing clinical needs and practical limitations.

D. This response is culturally insensitive, dismissive, and likely to create conflict or distress for the client and their family. It fails to recognize the importance of religious beliefs in patient care, which is essential in culturally competent nursing practice. Such a statement can damage the nurse-client relationship and reduce patient cooperation.

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Correct Answer is D

Explanation

Rationale:

A. While informing the family is an important aspect of care, it is not an immediate life-saving intervention. In emergency situations, the nurse must prioritize interventions that address threats to life before attending to family notifications. Delaying airway management to notify next of kin could result in deterioration or death.

B. Chest tube insertion may be required if the penetrating neck injury leads to a pneumothorax or hemothorax. However, in this scenario, the most pressing concern is airway compromise, as indicated by the client’s dyspnea, cyanosis, and cervical subcutaneous emphysema. While a chest tube addresses a potentially life-threatening condition, it does not take priority over securing the airway, which is the immediate determinant of survival.

C. Lumbar imaging is irrelevant in this situation. The client’s clinical presentation—dyspnea, cyanosis, and subcutaneous emphysema of the neck—indicates airway and respiratory compromise, not a spinal fracture. Pursuing imaging before airway stabilization would delay critical intervention and put the client at risk of respiratory arrest.

D. The client exhibits dyspnea (difficulty breathing), cyanosis (hypoxia), and cervical subcutaneous emphysema (air trapped in subcutaneous tissue), which are classic signs of a compromised airway, possibly due to tracheal or laryngeal injury. These conditions can rapidly progress to respiratory failure. Immediate airway management—including preparing for intubation or a surgical airway (cricothyrotomy)—is the highest priority to maintain oxygenation and prevent death.

A. "Furosemide will help to reduce the amount of abdominal fluid B. "My cirrhosis was caused from too much alcohol I plan to stop drinking" C. "Propranolol has been ordered to decrease my blood pressure." D. "I need to rest more: I plan on only going to work on a part-time basis."

Correct Answer is C

Explanation

Rationale:

A. Furosemide is a diuretic commonly prescribed to manage ascites in clients with cirrhosis. The statement demonstrates understanding of the medication’s purpose and indicates proper discharge teaching.

B. Abstaining from alcohol is a critical component of cirrhosis management. This statement reflects appropriate understanding and a commitment to lifestyle modification, which reduces further liver damage.

C. This statement indicates a misunderstanding. In cirrhosis, propranolol is often prescribed to reduce portal hypertension and prevent variceal bleeding, not primarily to manage systemic blood pressure. Teaching is needed to clarify the medication’s purpose in preventing complications of cirrhosis, rather than solely controlling blood pressure.

D. Rest is important in managing cirrhosis-related fatigue and supporting recovery. This statement shows an understanding of energy conservation and activity modification, which is appropriate.

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The nurse provides care to a Muslim client who presents to the emergency department with abdominal pain and vaginal bleeding. The client's spouse asks that only a female examines the client. Which is the most culturally appropriate statement by the nurse in response to the request?

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Naxlex Comprehensive Predictor Exams

A client is brought to the emergency department with a penetrating wound to the neck. The client is dyspneic and cyanotic and has evidence of cervical subcutaneous emphysema. What should the nurse prioritize in the plan of care?

Correct Answer is D

Explanation

The nurse participates in the discharge plans for a client with cirrhosis. Which statement by the client indicates the need for further instruction?

Correct Answer is C

Explanation

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