A community health nurse is caring for a client in a culturally diverse community. Which of the following actions demonstrates accurate cultural knowledge about a specific cultural group?

Touching the hair of an African American client during an assessment

Offering to shake hands when meeting an Asian client of the opposite gender

Maintaining eye contact when interviewing a Native American client

Including both hot and cold food items on a Hispanic client's menu

Answer and Explanation

The Correct Answer is D

Choice A reason: Touching the hair of an African American client during an assessment does not demonstrate accurate cultural knowledge, as it may be considered disrespectful or intrusive. Hair is a sensitive and personal topic for many African Americans, who may have experienced discrimination or stigma based on their hair texture or style¹. The nurse should ask for permission before touching the client's hair and explain the purpose of the assessment.

Choice B reason: Offering to shake hands when meeting an Asian client of the opposite gender does not demonstrate accurate cultural knowledge, as it may be considered inappropriate or offensive. In some Asian cultures, physical contact between men and women who are not related or married is discouraged or prohibited². The nurse should observe the client's body language and follow the client's lead in greeting gestures.

Choice C reason: Maintaining eye contact when interviewing a Native American client does not demonstrate accurate cultural knowledge, as it may be considered rude or aggressive. In some Native American cultures, eye contact is a sign of disrespect or challenge, especially when talking to elders or authority figures³. The nurse should avoid direct eye contact and use a respectful tone of voice when interviewing the client.

Choice D reason: Including both hot and cold food items on a Hispanic client's menu demonstrates accurate cultural knowledge, as it reflects the concept of balance and harmony in Hispanic culture. Many Hispanics believe that health and illness are influenced by the balance between hot and cold forces in the body and the environment⁴. The nurse should respect the client's food preferences and beliefs and provide a variety of food options.

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Correct Answer is A

Explanation

Choice A reason: Koplik spots are small, white, bluish-gray spots that appear on the inner cheeks, gums, or roof of the mouth before the rash develops. They are a characteristic sign of measles and can help to distinguish it from other viral infections.

Choice B reason: Persistent low-grade temperature is not a finding that the nurse should expect in a client who has measles. Measles typically causes a high fever that can reach up to 40°C (104°F) and lasts for four to seven days. The fever may spike when the rash appears and subside when the rash fades.

Choice C reason: Muscle aches and tenderness are not findings that the nurse should expect in a client who has measles. Measles mainly affects the respiratory system and the skin, and does not cause significant muscle involvement. The client may experience fatigue, weakness, or malaise, but not muscle pain or soreness.

Choice D reason: Rash confined to the trunk of the body is not a finding that the nurse should expect in a client who has measles. Measles causes a red, blotchy rash that usually starts on the face and spreads to the rest of the body, including the arms, legs, and feet. The rash may last for up to a week and may cause itching or peeling of the skin.

A. The need for supplemental folic acid is greatest during the third trimester. B. The incidence of high birth weight infants is higher in adolescent pregnancy. C. Pregnant adolescents need to gain less weight than adult mothers. D. Caffeinated beverages should be replaced with caffeine-free beverages.

Correct Answer is D

Explanation

The correct answer is D.

Caffeinated beverages should be replaced with caffeine-free beverages. High levels of caffeine can cause low birth weight and may increase the chance of miscarriage. Pregnant women metabolize caffeine more slowly, which can affect the fetus.

Choice A reason: The need for supplemental folic acid is greatest during the first trimester to prevent neural tube defects. The recommended daily dose is 600 mcg.

Choice B reason: Adolescent pregnancy is associated with a higher risk of low birth weight infants, not high birth weight.

Choice C reason: Pregnant adolescents generally need to gain an appropriate amount of weight, similar to adult mothers, to support the growth and development of the fetus. The weight gain recommendations during pregnancy are based on the mother's pre-pregnancy BMI.

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A community health nurse is caring for a client in a culturally diverse community. Which of the following actions demonstrates accurate cultural knowledge about a specific cultural group?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A clinic nurse is assessing a client who has measles. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is providing education to a group of adolescents who are pregnant and attending high school. Which of the following information should the nurse include in their teaching?

Correct Answer is D

Explanation

A nurse should expect which of the following conditions in a client who has hypoglycemia?

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A nurse of a community clinic is preparing an educational guide about cultural variances in expression of pain. Which of the following information should the nurse include?

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