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
Explanation
Choice A rationale
The client reports mild pain in the upper left arm at 2/10 on a scale of 0 to 10. This indicates that the interventions were effective in managing the pain associated with the infection and cellulitis.
Choice B rationale
The client’s early morning finger stick blood glucose (FSBG) was 97 mg/dL (5.4 mmol/L). This is within the normal range, indicating that the interventions were effective in maintaining the client’s blood glucose levels within the normal range.
Choice C rationale
The client’s left upper arm is slightly reddened when compared with the right upper arm. This could be a sign of inflammation or infection, suggesting that the interventions were ineffective in completely resolving the infection and cellulitis.
Choice D rationale
The client reports that her back is more achy since she came to the hospital. This could be due to a variety of factors, including the hospital bed or a lack of physical activity. It is unrelated to the expected outcomes of the interventions for the infection and cellulitis.
Correct Answer is D
Explanation
Choice A rationale
Subjective documentation cannot be quantified. It is based on the patient’s personal experiences and perceptions, which can vary greatly among individuals.
Choice B rationale
A patient’s description is an example of subjective data, not objective data. Subjective data is information that comes directly from the patient and includes their feelings, perceptions, and reported symptoms.
Choice C rationale
Subjective data can incorporate a patient’s emotions. Emotions can provide valuable insights into a patient’s mental and emotional health, which is an important aspect of overall health.
Choice D rationale
A 2-centimeter red wound with exudate is an example of objective data. Objective data is measurable, observable, and can be verified by more than one person.
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