A novice nurse is beginning work on a behavioral health unit and states to the preceptor, "What if I encounter a client that is sexually aggressive? Which is the appropriate response by the preceptor?

"Set firm limits and boundaries for the client."

“Tell the client that you are going to report to the director of the unit.”

"Walk away and have someone else take care of the client."

"It happens frequently so just ignore it they will stop."

Answer and Explanation

The Correct Answer is A

When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.

the other choices are incorrect:

1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.

2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.

3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.

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Correct Answer is B

Explanation

Nurses should focus on clients' cultures, rather than their ethnicity, when providing care: Cultural competence involves understanding and respecting the beliefs, values, practices, and customs of different cultures. It is important for nurses to recognize that culture extends beyond ethnicity and encompasses various aspects such as religion, language, socioeconomic status, and more. By focusing on clients' cultures, nurses can provide care that is sensitive and tailored to their unique needs and preferences.

The following are incorrect:

Nonverbal communication is important in many cultures: Nonverbal communication, including body language, facial expressions, and gestures, plays a significant role in communication across cultures. Different cultures may have specific nonverbal cues and interpretations. Nurses

should be aware of these variations and understand how nonverbal communication impacts their interactions with clients. By being attentive to nonverbal cues, nurses can enhance communication, build trust, and promote effective care.

Nurses should not expect clients to adapt to the care provided regardless of culture: Culturally competent care acknowledges and respects the diversity of clients' cultural backgrounds. It is important for nurses to recognize that clients' cultural beliefs, values, and practices may influence their healthcare preferences and decisions. Nurses should strive to provide care that is congruent with clients' cultural values and preferences, rather than expecting them to adapt entirely to a standardized approach. This promotes patient-centered care and enhances client satisfaction and outcomes.

"Culture plays no role in determining when a client will seek medical care" is incorrect. Culture significantly influences an individual's healthcare-seeking behaviors, including beliefs about illness, preventive care practices, and help-seeking patterns. Understanding these cultural factors is essential for nurses to provide appropriate and effective care.

A. Validate knowledge about culture through continuing education. B. Know what to expect from many cultural groups. C. Find out as much as possible about a client's cultural values, beliefs, and health practices. D. Behave as appropriate for the nurse's culture.

Correct Answer is C

Explanation

Culturally competent care involves understanding and respecting the diverse cultural backgrounds of clients. It requires the nurse to acquire knowledge about the client's specific culture and how it influences their healthcare preferences and practices. By taking the time to learn about the client's cultural background, the nurse can better understand their unique needs, beliefs, and values related to health and healthcare.

While continuing education and gaining knowledge about different cultures are important aspects of providing culturally competent care, it is essential to go beyond generalized expectations about cultural groups. Each individual within a culture can have unique beliefs and preferences, so it is crucial to approach each client as an individual rather than relying solely on broad cultural stereotypes.

Behaving as appropriate for the nurse's own culture may lead to misunderstandings or misinterpretations of the client's needs and preferences. It is important for the nurse to be aware of their own cultural biases and to approach care in a culturally sensitive and respectful manner.

Therefore, the best approach for the nurse to provide culturally competent care is to find out as much as possible about the client's specific cultural values, beliefs, and health practices. This

knowledge can guide the nurse in tailoring care that is respectful, responsive, and appropriate for the client's cultural background.

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A novice nurse is beginning work on a behavioral health unit and states to the preceptor, "What if I encounter a client that is sexually aggressive? Which is the appropriate response by the preceptor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?

Correct Answer is B

Explanation

The nurse is taking care of a client from a culture different from the nurse's culture. How might the nurse best provide culturally competent care?

Correct Answer is C

Explanation

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