TEST BANK For Family Practice Guidelines, 5th Edition by Jill C. Cash; Cheryl A. Glass, Verified Chapters 1 - 23, Complete Newest Version.pdf

TEST BANKS For Family Practice Guidelines
5th Edition by Jill C. Cash; Cheryl A. Glass;
Jenny Mullen||Chapters 1 - 23

Chapter 1. Health Maintenance Guidelines
Multiple Choice
Identify the choice that best completes the statement or answers the question.
1. The nurse is preparing to teach a patient of the Asian culture to perform
postoperative dressing changes at home after discharge. Which statement made by the
nurse indicates cultural competence?
a. Tell me how you feel about your surgery.
b. Asian people are smart, so this should be easy for you to understand.
c. American surgeons are highly qualified; Im sure you will heal quickly.
d. Will you tell me about any traditional healing practices that you would like to use?
2. An unconscious victim of a house fire is brought to the emergency department by
the paramedics. Tied to the right wrist is an emblem that appears be a religious talisman.
Which action should the nurse take?
a. Tape it in place.
b. Do nothing with it.
c. Remove it and lock it up for safekeeping.
d. Place it in a clothing bag with the rest of the patients belongings.
3. A 43-year-old patient of Arab descent is admitted to the hospital. To comply with
the state laws of the organization, the nurse offers the patient a Papanicolaou smear,
which she refuses. Which action should the nurse take first?
a. Notify the physician.
b. Report the refusal to the supervisor.
c. Explain the rationale for and benefits of the test.
d. Tell her it is state law and that she does not have a choice.
4. A patient who is a Jehovahs Witness has severe gastrointestinal bleeding and a
dangerously low hemoglobin level. The patient is fully alert and competent and refuses to
accept the blood transfusion ordered by the physician. Which action by the nurse is most
appropriate?
a. Obtain a court order to give the blood.
b. Administer the blood while the patient is sleeping.

c. Have the patients spouse sign the consent to have the blood administered.

d. Ensure the patient understands possible consequences and then respect the patients wishes.
5. A patient of Mexican descent sees a curandero for asthma; the curandero has
prescribed a special tea to be taken four times a day to open the airways. How should the
nurse respond to this situation?
a. Encourage the patient to continue drinking the tea.
b. Encourage the patient to drink only one cup of the tea each day.
c. Ask the patient to bring in the tea package and have the pharmacist check the ingredients.
d. Advise the patient to stop drinking the tea because of potential interactions with
other medications.
6. The nurse is caring for a young adult male patient who refuses personal care
from a female nursing assistant. Which approach by the nurse is best?
a. Encourage the patients family to talk with him about his care.
b. Have a registered nurse (RN) help with his personal care.
c. Assign a male assistant to help with his personal care if one is available.
d. Explain to him that males and females take care of both genders in this hospital.
7. The nurse is providing medication instructions to a 45-year-old patient who does
not maintain eye contact. What should this patients behavior indicate to the nurse?
a. The patient is not interested.
b. The nurse threatens the patients ego.
c. The nurse is in a hierarchical position.
d. The patient does not intend to follow the instructions.
8. The nurse is caring for a patient of Spanish descent who is experiencing pain, but
does not speak English. An interpreter is located to help with the assessment. What should
the nurse do to facilitate communication with this patient?
a. Use hand signals to determine the cause of the pain.
b. Ensure the interpreter is not left alone with the patient.
c. Maintain eye contact with the patient and the interpreter.
d. Use only physical examination data; do not rely on verbal communication.
9. A new mother of Guatemalan descent brings her 10-day-old infant to a clinic for a
well- baby checkup. To promote healing, she has a coin taped to the infants umbilicus.
What should the nurse do about this situation?
a. Teach the mother how to clean the coin daily and reapply it.

b. Explain to the mother that the coin is not necessary for healing.

c. Tell the mother to remove the coin, because it could cause an infection.
d. Teach the mother how to apply a dry sterile dressing in place of the coin.
10. An older patient who follows the Muslim religion is approaching death. The
family says the patients bed should be turned toward the opposite wall, so it can face
Mecca to ensure an easier passage into the next life. The wall they want the bed to face
has wall suction and oxygen, which the patient is using. Which action by the nurse is
appropriate?
a. Get permission from the physician to move the bed.
b. Rearrange the furniture to accommodate the request.
c. Tell them you will move the bed when the patient is closer to death.
d. Tell them it is impossible because of the short tubing on the oxygen and suction.
11. A patient of northern European descent recovering from surgery denies
postoperative pain; however, vital signs indicate an elevated pulse and blood pressure.
The patient refuses to move in bed. Which nursing action would best ensure comfort and
timely discharge?
a. Give the pain medicine as prescribed.
b. Ask the physician to prescribe the analgesics around the clock.
c. Explain that the pain medicine will help prevent complications.
d. Respect the patients denial of pain, and do not encourage the pain medicine.
12. A nurse who emigrated from China begins working on a medical unit. The preceptor
explains the unit routines, including the medication administration system. When the
preceptor asks if the nurse understands, the answer is always: Yes, I understand. What
should the preceptor do to measure the nurses comprehension?
a. Give the nurse a medication quiz.
b. Have the nurse repeat the instructions.
c. Have the nurse demonstrate the procedures.
d. Ask the nurse which information is hard to understand.
13. A 52-year-old from Haiti is hospitalized with heart failure and wants to have a
voodoo practitioner visit to say prayers. How should the nurse respond to this request?
a. Report the request to the physician immediately.
b. Tell the patient that this is not permitted during hospitalization.
c. Tell the patient it is okay for the voodoo practitioner to say prayers.
d. Have the patient meet with the voodoo practitioner in the hospital lobby.
14. The nurse is caring for a patient from a non-English speaking culture. While
providing care, the nurse shows an appreciation for and attention to arts, music, crafts,

belonging to the patients culture. What did the nurse demonstrate while caring for this
patient?
a. Cultural beliefs
b. Cultural awareness
c. Cultural sensitivity
d. Cultural competence
15. A female Caucasian nurse, overhead discussing a patient from another culture, asks
why the patient wants to see a practitioner from his own culture, since everyone sees
physicians when they are ill. What characteristic is the nurse exhibiting?
a. Stereotyping
b. Ethnocentrism
c. Cultural sensitivity
d. Cultural generalization
16. During an assessment, the nurse determines that a patient from a non-English
speaking culture practices activities that are past-oriented. What behavior did the nurse
assess in this patient?
a. Investing time and money
b. Enjoying each day as it comes
c. Worshipping ancestors and maintaining traditions
d. Learning from the past to avoid making the same mistakes in the future
17. The nurse notes that a patient of Arab descent is not eating anything on the meal
trays. What should the nurse do about this situation?
a. Wait for the patient to ask for specific foods.
b. Ask if the patient has special food preferences.
c. Consult with a physician of Arab descent on staff.
d. Contact the dietitian to find out what patients of Arab descent patients like to eat.
18. The mother of a 6-year-old Vietnamese child admitted with pneumonia is
rubbing a coin on the childs back. The coin leaves red marks. What should the nurse do
about this observation?
a. Report the possibility of child abuse.
b. Do not allow the mother to be alone with her child.
c. Explain to the mother that she cannot do this in the hospital.
d. Add a statement to the care plan that the family practices coining.
19. The family of an older Arab-American patient does not want the patient to be
informed

of a diagnosis of cancer. What should the nurse do?
a. Call a religious counselor.
b. Respect the familys wishes.
c. Insist that the family tell the patient about the diagnosis.
d. Tell the patient anyway, because patients have a right to know.
20. A patient with diabetes mellitus who comes to the clinic for a routine examination
agrees to have a diagnostic test, but is concerned that her transportation will not wait for
the test to be performed. What should the nurse do?
a. Contact the department to have the test done now.
b. Ask the patient to schedule an appointment for the test.
c. Refer the patient to the community health nurse practitioner.
d. Schedule the test for the next time the patient comes to the clinic.
21. The nurse is assessing a patient who believes in a balance of yin and yang in the
body, has a brother with stomach cancer, and frequently uses acupuncture for headache
treatment. The nurse should validate that the patient is a member of which cultural group?
a. Hispanic/Latino
b. Asian American
c. African American
d. American Indian/Native Alaskan
22. An older patient is observed wearing a copper bracelet to relieve the pain of
arthritis. What type of practice should the nurse realize this patient is demonstrating?
a. Allopathy
b. Acupressure
c. Reflexology
d. Folk medicine
23. The nurse is preparing discharge teaching for an older patient who immigrated to
the United States a few years ago. What should the nurse remember when preparing these
instructions?
a. The patient most likely has limited financial resources.
b. The patient will prefer to follow cultural medical practices.
c. The patient will most likely live with other family members.
d. The patient will attend all follow-up appointments as needed.
24. During a home visit to a family of a non-English speaking culture, the nurse observes

the male parent becoming upset when the youngest child refuses to speak the native
language in the home. What should the nurse realize is occurring within the family at this
time?
a. Ethnocentrism
b. Cultural shock
c. Cultural conflict
d. Cultural assimilation
25. An older male patient is admitted to the hospital for treatment of a chronic disease.
The spouse is at the bedside for most hours of the day, and the patients children come to
visit every day after work to discuss activities and ask for advice. What should the nurse
realize about the social organization of this family?
a. The male patient is the head of the household.
b. The spouse does not trust health care providers.
c. The children want to learn everything before the patient dies.
d. The children are concerned that the patient is not receiving adequate
care. Multiple Response
Identify one or more choices that best complete the statement or answer the question.
26. The nurse is planning care for a patient from a non-English speaking culture.
Which cultural factors should the nurse be aware of in order to provide culturally competent
care to this patient? (Select all that apply.)
a. The patients nutritional habits
b. The patients communication style
c. The patients sense of personal space
d. Complementary therapies the patient is using
e. The prescribed medications the patient is taking
27. A female nurse is providing smoking cessation counseling and education during a
community health fair. The nurse should avoid physical closeness, shaking hands, or
touching during instruction with which of the following? (Select all that apply.)
a. A 35-year-old man of Asian descent
b. A 45-year-old woman of Arab descent
c. A 28-year-old man of Hispanic descent
d. A 52-year-old woman of African American descent
e. A 41-year-old woman of American Indian descent
28. The nurse is providing care in a clinic with a culturally diverse patient population.

Which actions should the nurse take to ensure care is culturally appropriate? (Select all that
apply.)
a. Awareness of cultural bias
b. Desire to be culturally competent
c. Educational training related to world politics
d. Awareness of personal communication patterns
e. Number of face-to-face encounters with people from various cultural backgrounds
29. The staff development instructor is planning a seminar on improving cultural
sensitivity when providing patient care. What should the instructor include in this seminar?
(Select all that apply.)
a. Information about different cultural groups
b. Recognition that patient are unique and not defined by their culture
c. Ways to enhance cultural assimilation in the health care environment
d. The importance of nurses knowing information about their own cultural group
e. Strategies to incorporate patients cultural values and practices into the plan of care
30. The nurse is visiting the home of a patient who recently immigrated to the United
States from Buenos Aires. Which observations in the patients home should the nurse
question to determine the patients health beliefs? (Select all that apply.)
a. Black bracelet woven with a cross being worn on the patients left wrist
b. A lit candle burning near a picture of a saint on a side table in the living room
c. Cup of hot black liquid that the patient is sipping from periodically during the visit
d. A copy of a magazine printed in Spanish sitting on the coffee table in the living room
e. A pillow placed between the patient and the nurse after the nurse sits down on the couch
Chapter 4. Cultural Influences on Nursing Care
Answer Section
MULTIPLE CHOICE
1. ANS: D
D. Cultural sensitivity is using language and statements that do not offend another persons
cultural beliefs. Cultural competence includes the skills and knowledge required to provide
effective nursing care. The use of traditional healers and healing therapies is common for
Asian individuals, and assessing the patients desire to use such healers or therapies shows the
nurse is

culturally sensitive and competent to provide care. B. This statement represents a
stereotypean opinion or belief about a group of people which is ascribed to an individual. C.
This statement exemplifies ethnocentrism or the tendency for people to think that their
ways of thinking, acting, and believing are the only right, proper, and natural ways. A. This
is an assessment designed to elicit the patients emotional reaction to the surgery. This may
be an important part of adult learning, but it is not the best option to represent cultural
competence.
PTS: 1 DIF: Moderate
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Analysis
2. ANS: A
A. Often folk practices are not harmful and can be added to the patients plan of care.
Tape the emblem in place to keep it from getting lost or damaged. C. D. Removing it
could be very distressing to the patient. B. The item could get lost if nothing is done with
it.
KEY: Client Need: Psychosocial Integrity | Cognitive Level: Application
3. ANS: C
C. A Pap smear can provide important health information. The patient may refuse it,
because she does not understand what it is. A. B. Teaching is a nursing action and does not
need to be approved by a physician or supervisor. D. The state law simply says the patient
must be offered the test, not that she must accept it.
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
4. ANS: D
D. Patients beliefs should be respected, even when their decisions go against medical advice.
The patient needs to understand the consequences of his decision. A. B. C. Administering the
blood without the patients knowledge or consent is unethical.

5. ANS: C
C. Often, folk practices are not harmful and may even be helpful; they may be incorporated
into the patients plan of care. Checking with the pharmacist ensures that the tea is safe and
will not interact with other essential medications. A. B. D. As long as it is safe, there is no
reason to have the patient stop or limit tea intake.
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control |
Cognitive Level: Analysis
6. ANS: C
C. It is important to respect differences in gender relationships when providing care. Some
people may be especially modest because of their religion, seeking out same-gender nurses
and physicians for intimate care. Respect these patients modesty by providing privacy and
assigning a same-gender care provider when possible. A. B. D. Having a registered nurse
(unless male) provide care and talking to his family do not solve the problem or respect the
patients preferences.
7. ANS: C
C. Use and degree of eye contact is culturally influenced. Many cultures view health care
workers as having higher status, making it rude to maintain eye contact. A. B. D. The nurse
should not make assumptions about the patients level of interest, intent to follow
instructions, or ego.
8. ANS: C
C. The use of eye contact can help the nurse interpret the information that is being
exchanged between the interpreter and patient. A. B. D. There is no reason to avoid leaving
the interpreter with the patient, to rely on hand signals, or to avoid verbal communication
when an interpreter is available.

9. ANS: A
A. Often, folk practices are not harmful and can be added to the patients plan of care. In the
case of the coin, it should be cleaned daily to keep the area clean and free of infection. B. C.
D. There is no reason to tell the mother to remove it or to apply a sterile dressing in place of
the coin.
Cognitive Level: Application
10. ANS: B
B. Often, folk practices are not harmful and can be added to the patients plan of care. There
is no reason not to move the patients bed. A. There is no reason to involve the physician. C.
There is no way to know the exact time the patient will die, so waiting to move the bed is
not appropriate.
D. Oxygen and suction tubing can have extensions added.
11. ANS: C
C. Explaining that pain control can help prevent complications allows the patient to make
an informed decision. A. B. The patients wishes must be respected, so giving the medication
without the patients consent is not appropriate. D. Respecting the patients denial of pain
and not encouraging the pain medication may not necessarily support the patients comfort
and allow for appropriate healing of the incision.
PTS: 1 DIF: Difficult
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level: Analysis
12. ANS: C
C. The best measure of learning is observing the nurse demonstrate the procedures. A. B. D.
Having the nurse talk about the instructions or fill out a quiz may be helpful, but the only
way to know for sure if the teaching has been effective is to observe the behavior.

Cognitive Level: Application
13. ANS: C
C. Often, folk practices are not harmful and can be added to the patients plan of care. A.
There is no reason to involve the physician in non-harmful folk practices. B. A patient should
only be told that something is not permitted if it is prohibited by policy. D. Allowing the
practice to occur in the lobby may be unsafe for the patient and confusing to other patients
and visitors.
14. ANS: B
B. Cultural awareness focuses on history and ancestry and emphasizes an appreciation for and
attention to arts, music, crafts, celebrations, foods, and traditional clothing. A. Beliefs are
assertions that are based on assumptions. C. Cultural sensitivity is using politically correct
language and not making statements that may offend another persons cultural beliefs. D.
Cultural competence includes the skills and knowledge required to provide effective nursing
care.
15. ANS: B
B. Ethnocentrism is the tendency for human beings to think that their ways of thinking,
acting, and believing are the only right ways. A. A stereotype is an opinion or belief about a
group of people, which is ascribed to an individual from that group. C. Cultural sensitivity is
using politically correct language and not making statements that may offend another
persons cultural beliefs. D. A generalization, or assumption, may be true for the group, but
it does not necessarily fit an individual.

16. ANS: C
C. Past-oriented individuals maintain traditions that were meaningful in the past, and
they may worship ancestors. A. Future-oriented people may invest time and money in the
future. B. Present-oriented people accept the day as it comes, with little regard for the
past. D. Some cultures combine all three.
17. ANS: B
B. Cultural assessment must provide the basis for nursing care. This should include a review
of food preferences. A, C, and D are insensitive actions and risk stereotyping and providing
inappropriate care to the patient.
KEY: Client Need: Physiological IntegrityBasic Care and Comfort | Cognitive Level:
Application
18. ANS: D
D. Individuals from Asian cultures may practice coining. This is an example of a cultural
practice that is harmless and may be included in the patients care. A, B, and C are
culturally insensitive responses.
19. ANS: B
B. Initially, the familys wishes should be respected. This may be important in their culture.
An ethics committee may be contacted for further input if the situation warrants it. A, C,
and D are culturally insensitive responses.

20. ANS: A
A. Because it may be difficult for the patient to obtain transportation, the test
should be performed now. B, C, and D risk further delay of the test.
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level:
Application
21. ANS: B
B. Asian-Americans hold these beliefs. A. C. D. Individuals from the other cultural groups
do not believe in yin and yang and do not practice acupuncture. African Americans may
have an increased risk for stomach cancer, but they do not believe in yin and yang or
acupuncture.
22. ANS: D
C. Examples of folk medicines include covering a boil with axle grease, wearing copper
bracelets for arthritic pain, and drinking herbal teas. A. Allopathy is another name for
traditional Western medicine.
B. C. Acupressure and reflexology are complementary therapies.
23. ANS: A
A. Compared with white or European American older adults, ethnic minorities are more
likely to live in poverty. The nurse needs to take the patients finances into consideration
when preparing discharge instructions. B. The nurse needs to assess the patients preference
for using cultural or Western medicine practices. C. There is no information to support that
the patient lives with other family members. D. The patient may have difficulty accessing
health care, so it is incorrect to assume that the patient will attend all follow-up
appointments.

24. ANS: D
D. Cultural assimilation occurs when a new member takes on the dominant cultures values,
beliefs, and practices, sometimes at the cost of losing some of his or her cultural heritage.
This process is often viewed as negative as evidenced by the male parent becoming upset
with the youngest child refusing to speak the native language in the home. A.
Ethnocentrism is the tendency for humans to think that their ways of thinking, acting, and
believing are the only right, proper, and natural ways. B. Cultural shock is when values,
beliefs, and practices sanctioned by the new culture are very different from the ones of the
native culture. There is no evidence that cultural shock is occurring within the family. C.
Cultural conflict is when one culture conflicts with another. There is no evidence that
cultural conflict is occurring within the family.
25. ANS: A
A. Family organization includes the perceived head of the household, gender roles, and roles
of the elderly and extended family members. Because the spouse stays at the bedside and
the children visit every day to discuss events and ask advice, this household is most likely
patriarchal. B. There is no evidence to suggest that the spouse does not trust health care
providers. C. Although the patient has a chronic disease, there is no evidence to suggest that
death is imminent. D. There is no evidence to support that the children are concerned that
the patient is not receiving adequate care.
MULTIPLE RESPONSE
26. ANS: A, B, C, D
A, B, C, and D describe characteristics of cultural diversity of which the nurse should be
aware.
E. Prescribed medications are related to physiological needs, not cultural needs.

27. ANS: A, E
A. E. For American Indians/Native Alaskans, touch is not acceptable from strangers. Asians
and Pacific Islanders avoid physical closeness and touching. B. Touch between persons of
the same gender is acceptable, and personal space is very close for Arab Americans. C.
Hispanics/Latinos/Spanish individuals value touching and closeness. D. African Americans
have close personal space and touch frequently, although less with strangers.
28. ANS: A, B, D, E
A. B. D. E. Cultural competence requires self-awareness and a desire to provide culturally
competent care. The number of encounters and experience with various groups can be helpful
as is knowledge of your own communication patterns. C. Educational training on world
politics is not required to provide culturally competent care.
29. ANS: A, B, D, E
A. B. D. E. The staff development instructor can help nurses improve cultural sensitivity by
using the acronym BALI or 1) be aware of your personal cultural heritage; 2) appreciate that
each patient is unique, influenced but not defined by his or her culture; 3) learn about the
patients cultural groups; and 4) incorporate the patients cultural values, beliefs, and
practices into their plan of care. C. Cultural assimilation is a personal endeavor, one in which
the nurse may have little influence.
30. ANS: A, B, C
A. B. C. To determine health beliefs the nurse should ask about the practice of special rituals
or prayers to maintain health, the wearing of bracelets to ward off illnesses and the
drinking of herbs or special teas when ill. D. A copy of a magazine printed in Spanish would
help indicate

the patients communication style. E. The use of a pillow between the nurse and patient could
be identifying a boundary for personal space.
31. Pertussis vaccination should begin at which age?
a. Birth
b. 2 months
c. 6 months
d. 12 months
ANS: B
The acellular pertussis vaccine is recommended by the American Academy of Pediatrics
beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The
vaccine is not given after age 7 years, when the risks of the vaccine become greater than those
of pertussis. The first dose is usually given at the 2-month well-child visit. Infants are highly
susceptible to pertussis, which can be a life-threatening illness in this age group.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity
32. A mother tells the nurse that she does not want her infant immunized because of
the discomfort associated with injections. What should the nurse explain?
a. This cannot be prevented.
b. Infants do not feel pain as adults do.
c. This is not a good reason for refusing immunizations.
d. A topical anesthetic can be applied before injections are given.
ANS: D
To minimize the discomfort associated with intramuscular injections, a topical anesthetic
agent can be used on the injection site. These include EMLA (eutectic mixture of local
anesthetic) and vapor coolant sprays. Pain associated with many procedures can be
prevented or minimized by using the principles of atraumatic care. Infants have neural
pathways that will indicate pain.

Numerous research studies have indicated that infants perceive and react to pain in the same
manner as do children and adults. The mother should be allowed to discuss her concerns and
the alternatives available. This is part of the informed consent process.
TOP: Integrated Process: Teaching/Learning
MSC: Client Needs: Physiological Integrity
33. A 4-month-old infant comes to the clinic for a well-infant checkup. Immunizations she
should receive are DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated
poliovirus vaccine). She is recovering from a cold but is otherwise healthy and afebrile. Her
older sister has cancer and is receiving chemotherapy. Nursing considerations should include
which?
a.
b. DTaP and IPV are contraindicated because she has a cold.
c. IPV is contraindicated because her sister is immunocompromised.
d. DTaP and IPV are contraindicated because her sister is immunocompromised.
ANS: A
These immunizations can be given safely. Serious illness is a contraindication. A mild illness
with or without fever is not a contraindication. These are not live vaccines, so they do not
pose a risk to her sister.
34. Which serious reaction should the nurse be alert for when administering vaccines?
a. Fever
b. Skin irritation
c. Allergic reaction
DTaP and IPV can be safely given.

d. Pain at injection site
ANS: C
Each vaccine administration carries the risk of an allergic reaction. The nurse must be
prepared to intervene if the child demonstrates signs of a severe reaction. Mild febrile
reactions do occur after administration. The nurse includes management of fever in the
parent teaching. Local skin irritation may occur at the injection site after administration.
Parents are informed that this is expected. The injection can be painful. The nurse can
minimize the discomfort with topical analgesics and nonpharmacologic measures.
35. Which muscle is contraindicated for the administration of immunizations in infants
and young children?
a. Deltoid
b. Dorsogluteal
c. Ventrogluteal
d. Anterolateral thigh
ANS: B
The dorsogluteal site is avoided in children because of the location of nerves and veins. The
deltoid is recommended for 12 months and older. The ventrogluteal and anterolateral thigh
sites can safely be used for the administration of vaccines to infants.
36. Which is described as an elevated, circumscribed skin lesion that is less than 1 cm
in diameter and filled with serous fluid?
a. Cyst

b. Papule
c. Pustule
d. Vesicle
ANS: D
A vesicle is elevated, circumscribed, superficial, smaller than 1 cm in diameter, and filled
with serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with
liquid or semisolid material. A papule is elevated; palpable; firm; circumscribed; smaller
than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A pustule is elevated,
superficial, and similar to a vesicle but filled with purulent fluid.
37. Which vitamin supplementation has been found to reduce both morbidity and
mortality in measles?
a. A
b. B1
c. C
d. Zinc
ANS: A
Evidence suggests that vitamin A supplementation reduces both morbidity and mortality
in measles.
38. What does impetigo ordinarily results in?
a. No scarring
b. Pigmented spots
c. Atrophic white scars

Streptococci or staphylococci
d. Slightly depressed scars
ANS: A
Impetigo tends to heal without scarring unless a secondary infection occurs.
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological
Integrity
39. What often causes cellulitis?
a. Herpes zoster
b. Candida albicans
c. Human papillomavirus
d.
ANS: D
Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually
responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C.
albicans is associated with candidiasis, or thrush. Human papillomavirus is associated with
various types of human warts.
40. Lymphangitis (streaking) is frequently seen in what?
a. Cellulitis
b. Folliculitis
c. Impetigo contagiosa
d. Staphylococcal scalded
skin ANS: A

Lymphangitis is frequently seen in cellulitis. If it is present, hospitalization is usually
required for parenteral antibiotics. Lymphangitis is not associated with folliculitis,
impetigo, or staphylococcal scalded skin.
41. What is most important in the management of cellulitis?
a. Burow solution compresses
b. Oral or parenteral antibiotics
c. Topical application of an antibiotic
d. Incision and drainage of severe lesions
ANS: B
Oral or parenteral antibiotics are indicated depending on the extent of the cellulitis. Warm
water compresses may be indicated for limited cellulitis. The antibiotic needs to be
administered systemically. Incision and drainage of severe lesions presents a risk of
spreading infection or making the lesion worse.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
42. What causes warts?
a. A virus
b. A fungus
c. A parasite
d. Bacteria
ANS: A
Human warts are caused by the human papillomavirus. Infection with fungus, parasites, or
bacteria does not result in warts.

43. What is the primary treatment for warts?
a. Vaccination
b. Local destruction
c. Corticosteroids
d. Specific antibiotic therapy
ANS: B
Local destructive therapy is individualized according to location, type, and number;
surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray
treatment, and laser therapies are used. Vaccination is prophylaxis for warts, not a
treatment. Corticosteroids and specific antibiotic therapy are not effective in the
treatment of warts.
44. Herpes zoster is caused by the varicella virus and has an affinity for which?
a. Sympathetic nerve fibers
b. Parasympathetic nerve fibers
c. Lateral and dorsal columns of the spinal cord
d. Posterior root ganglia and posterior horn of the spinal cord
ANS: D
The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the
spinal cord, and the skin. The zoster virus does not involve the nerve fibers listed.
45. Treatment for herpes simplex virus (type 1 or 2) includes which?
a. Corticosteroids
b. Oral griseofulvin

d. Topical or systemic antibiotic
ANS: C
Oral antiviral agents are effective for viral infections such as herpes simplex. Corticosteroids,
antibiotics, and griseofulvin (an antifungal agent) are not effective for viral infections.
TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity
46. What should the nurse explain about ringworm?
a. It is not contagious.
b. It is a sign of uncleanliness.
c. It is expected to resolve spontaneously.
d. It is spread by both direct and indirect contact.
ANS: D
Ringworm is spread by both direct and indirect contact. Infected children should wear
protective caps at night to avoid transfer of ringworm to bedding. Ringworm is infectious.
Because ringworm is easily transmitted, it is not a sign of uncleanliness. It can be
transmitted by seats with head rests, gym mats, and animal-to-human transmission. The
drug griseofulvin is indicated for a prolonged course, possibly several months.
47. When giving instructions to a parent whose child has scabies, what should the nurse
include?
a. Treat all family members if symptoms develop.
b. Be prepared for symptoms to last 2 to 3 weeks.
c. Carefully treat only areas where there is a rash.
d. Notify practitioner so an antibiotic can be prescribed.

ANS: B
The mite responsible for the scabies will most likely be killed with the administration of
medications. It will take 2 to 3 weeks for the stratum corneum to heal. That is when the
symptoms will abate. Initiation of therapy does not wait for clinical symptom development.
All individuals in close contact with the affected child need to be treated. Permethrin, a
scabicide, is the preferred treatment and is applied to all skin surfaces.
48. Which is usually the only symptom of pediculosis capitis (head lice)?
a. Itching
b. Vesicles
c. Scalp rash
d. Localized inflammatory response
ANS: A
Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is
made by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and
localized inflammatory response are not symptoms of head lice.
49. The school reviewed the pediculosis capitis (head lice) policy and removed the no nit
requirement. The nurse explains that now, when a child is found to have nits, the parents
must do which before the child can return to school?
a. No treatment is necessary with the policy change.
b. Shampoo and then trim the childs hair to prevent reinfestation.
c. The child can remain in school with treatment done at home.

d. Treat the child with a shampoo to treat lice and comb with a fine-tooth
comb every day until nits are eliminated.
ANS: C
Many children have missed significant amounts of school time with no nit policies. The child
should be appropriately treated with a pediculicide and a fine-tooth comb. The environment
needs to be treated to prevent reinfestation. The treatment with the pediculicide will kill the
lice and leave nit casings. Cutting the childs hair is not recommended; lice infest short hair
as well as long. With a no nit policy, treating the child with a shampoo to treat lice and
combing the hair with a fine-tooth comb every day until nits are eliminated is the correct
treatment. The policy change recognizes that most nits do not become lice.
50. The nurse should know what about Lyme disease?
a. Very difficult to prevent
b. Easily treated with oral antibiotics in stages 1, 2, and 3
c. Caused by a spirochete that enters the skin through a tick bite
d. Common in geographic areas where the soil contains the mycotic spores
that cause the disease
ANS: C
Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early
characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-
infested areas with caution. Light-colored clothing should be worn to identify ticks easily.
Long-sleeve shirts and long pants tucked into socks should be the attire. Early treatment of
erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is
caused by a spirochete, not mycotic spores.

51. The nurse is teaching a nursing student about standard precautions. Which statement
made by the student indicates a need for further teaching?
a. I will use precautions when I give an infant oral care.
b. I will use precautions when I change an infants diaper.
c. I will use precautions when I come in contact with blood and body fluids.
d. I will use precautions when administering oral medications to a school-age child.
ANS: D
Standard precautions involve the use of barrier protection (personal protective equipment
[PPE]), such as gloves, goggles, a gown, or a mask, to prevent contamination from (1)
blood; (2) all body fluids, secretions, and excretions except sweat, regardless of whether they
contain visible blood; (3) nonintact skin; and (4) mucous membranes. Precautions should be
taken when giving oral care, when changing diapers, and when coming in contact with blood
and body fluids.
Further teaching is needed if the student indicates the need to use precautions when
administering an oral medication to a school-age child.
Chapter 2. Public Health Guidelines
MULTIPLE CHOICE
1. Children are taught the values of their culture through observation and feedback
relative to their own behavior. In teaching a class on cultural competence, the nurse
should be aware that which factor may be culturally determined?
a. Ethnicity
b. Racial variation
c. Status
d. Geographic
boundaries ANS: C

Status is culturally determined and varies according to each culture. Some cultures ascribe
higher status to age or socioeconomic position. Social roles also are influenced by the culture.
Ethnicity is an affiliation of a set of persons who share a unique cultural, social, and
linguistic heritage. It is one component of culture. Race and culture are two distinct
attributes. Whereas racial grouping describes transmissible traits, culture is determined by
the pattern of assumptions, beliefs, and practices that unconsciously frames or guides the
outlook and decisions of a group of people. Cultural development may be limited by
geographic boundaries, but the boundaries are not culturally determined.
MSC: Client Needs: Psychosocial Integrity
2. The nurse is aware that if patients different cultures are implied to be inferior, the
emotional attitude the nurse is displaying is what?
a. Acculturation
b. Ethnocentrism
c. Cultural shock
d. Cultural sensitivity
ANS: B
Ethnocentrism is the belief that ones way of living and behaving is the best way. This
includes the emotional attitude that the values, beliefs, and perceptions of ones ethnic group
are superior to those of others. Acculturation is the gradual changes that are produced in a
culture by the influence of another culture that cause one or both cultures to become more
similar. The minority culture is forced to learn the majority culture to survive. Cultural
shock is the helpless feeling and state of disorientation felt by an outsider attempting to
adapt to a different culture group.
Cultural sensitivity, a component of culturally competent care, is an awareness of cultural
similarities and differences.

3. Which term best describes the sharing of common characteristics that differentiates one
group from other groups in a society?
a. Race
b. Culture
c. Ethnicity
d. Superiority
ANS: C
Ethnicity is a classification aimed at grouping individuals who consider themselves, or are
considered by others, to share common characteristics that differentiate them from the
other collectivities in a society, and from which they develop their distinctive cultural
behavior. Race is a term that groups together people by their outward physical appearance.
Culture is a pattern of assumptions, beliefs, and practices that unconsciously frames or
guides the outlook and decisions of a group of people. A culture is composed of individuals
who share a set of values, beliefs, and practices that serve as a frame of reference for
individual perception and judgments. Superiority is the state or quality of being superior; it
does not apply to ethnicity.
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
4. After the family, which has the greatest influence on providing continuity
between generations?
a. Race
b. School
c. Social class
d. Government
ANS: B
Schools convey a tremendous amount of culture from the older members to the younger
members of society. They prepare children to carry out the traditional social roles that will
be expected of them as adults. Race is defined as a division of humankind possessing traits
that are

transmissible by descent and are sufficient to characterize race as a distinct human type;
although race may have an influence on childrearing practices, its role is not as significant
as that of schools. Social class refers to the familys economic and educational levels. The
social class of a family may change between generations. The government establishes
parameters for children, including amount of schooling, but this is usually at a local level.
The school culture has the most significant influence on continuity besides family.
5. The nurse is planning care for a patient with a different ethnic background. Which
should be an appropriate goal?
a. Adapt, as necessary, ethnic practices to health needs.
b. Attempt, in a nonjudgmental way, to change ethnic beliefs.
c. Encourage continuation of ethnic practices in the hospital setting.
d. Strive to keep ethnic background from influencing health needs.
ANS: A
Whenever possible, nurses should facilitate the integration of ethnic practices into health
care provision. The ethnic background is part of the individual; it should be difficult to
eliminate the influence of ethnic background. The ethnic practices need to be evaluated
within the context of the health care setting to determine whether they are conflicting.
6. The nurse discovers welts on the back of a Vietnamese child during a home health visit.
The childs mother says she has rubbed the edge of a coin on her childs oiled skin. The nurse
should recognize this as what?
a. Child abuse
b. Cultural practice to rid the body of disease
c. Cultural practice to treat enuresis or temper tantrums
d. Child discipline measure common in the Vietnamese culture

ANS: B
This is descriptive of coining. The welts are created by repeatedly rubbing a coin on the
childs oiled skin. The mother is attempting to rid the childs body of disease. Coining is a
cultural healing practice. Coining is not specific for enuresis or temper tantrums. This is not
child abuse or discipline.
7. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds
the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O,
Popsicles, and juices, are left. Which statement best explains this?
a. The parent is trying to feed the child only what the child likes most.
b. Hispanics believe the evil eye enters when a person gets cold.
c. The parent is trying to restore normal balance through appropriate hot remedies.
d. Hispanics believe an innate energy called chi is strengthened by eating soup.
ANS: C
In several cultures, including Filipino, Chinese, Arabic, and Hispanic, hot and cold describe
certain properties completely unrelated to temperature. Respiratory conditions such as
pneumonia are cold conditions and are treated with hot foods. The child may like broth but
is unlikely to always prefer it to Jell-O, Popsicles, and juice. The evil eye applies to a state
of imbalance of health, not curative actions. Chinese individuals, not Hispanic individuals,
believe in chi as an innate energy.
8. How is family systems theory best described?
a. The family is viewed as the sum of individual members.
b. A change in one family member cannot create a change in other members.
c. Individual family members are readily identified as the source of a problem.

d. When the family system is disrupted, change can occur at any point in the system.
ANS: D
Family systems theory describes an interactional model. Any change in one member will
create change in others. Although the family is the sum of the individual members, family
systems theory focuses on the number of dyad interactions that can occur. The interactions,
not the individual members, are considered to be the problem.
9. Which family theory is described as a series of tasks for the family throughout its life span?
a. Exchange theory
b. Developmental theory
c. Structural-functional theory
d. Symbolic interactional theory
ANS: B
In developmental systems theory, the family is described as a small group, a semiclosed
system of personalities that interact with the larger cultural system. Changes do not occur
in one part of the family without changes in others. Exchange theory assumes that
humans, families, and groups seek rewarding statuses so that rewards are maximized while
costs are minimized.
Structural-functional theory states that the family performs at least one societal function
while also meeting family needs. Symbolic interactional theory describes the family as a
unit of interacting persons with each occupying a position within the family.
10. Which family theory explains how families react to stressful events and suggests factors
that promote adaptation to these events?
a. Interactional theory
b. Family stress theory

c. Eriksons psychosocial theory
d. Developmental systems theory
ANS: B
Family stress theory explains the reaction of families to stressful events. In addition, the
theory helps suggest factors that promote adaptation to the stress. Stressors, both positive
and negative, are cumulative and affect the family. Adaptation requires a change in family
structure or interaction. Interactional theory is not a family theory. Interactions are the
basis of general systems theory. Eriksons theory applies to individual growth and
development, not families.
Developmental systems theory is an outgrowth of Duvalls theory. The family is described
as a small group, a semiclosed system of personalities that interact with the larger
cultural system. Changes do not occur in one part of the family without changes in others.
11. Historically, what was the justification for the victimization of women?
a. Women were regarded as possessions.
b. Women were the weaker sex.
c. Control of women was necessary to protect them.
d. Women were created subordinate to men.
ANS: A
Misogyny, patriarchy, devaluation of women, power imbalance, a view of women as property,
gender-role stereotyping, and acceptance of aggressive male behaviors as appropriate
contributed and continue to contribute to the subordinate status of women in many of the
worlds societies.
Viewing women as the weaker sex is a cultural and modern stereotype that contributes to
the victimization of women. Control of women to protect them is another cultural and
modern stereotype that contributes to the victimization of women. Yet another cultural
stereotype that contributes to the victimization of women is the idea that women were
created as subordinate to men.

12. What is the primary theme of the feminist perspective regarding violence against women?
a. Role of testosterone as the underlying cause of mens violent behavior
b. Basic human instinctual drive toward aggression
c. Male dominance and coercive control over women
d. Cultural norm of violence in Western society
ANS: C
The contemporary social view of violence is derived from the feminist theory. With the
primary theme of male dominance and coercive control, this view enhances an
understanding of all forms of violence against women, including wife battering, stranger and
acquaintance rape, incest, and sexual harassment in the workplace. The role of testosterone
as an underlying cause of mens violent behavior, the basic human instinctual drive toward
aggression, and the cultural norm of violence in Western society are not associated with the
feminist perspective regarding violence against women.
13. Which trait is least likely to be displayed by a woman experiencing intimate partner
violence (IPV)?
a. Socially isolated
b. Assertive personality
c. Struggling with depression
d. Dependent partner in a relationship
ANS: B
Every segment of society is represented among women who are suffering abuse. However,
traits of assertiveness, independence, and willingness to take a stand have been documented
as more characteristic of women who are in nonviolent relationships. Women who are
financially more dependent have fewer resources and support systems, exhibit symptoms of
depression, and are more often seen as victims.

14. A woman who is 6 months pregnant has sought medical attention, saying she fell down
the stairs. What scenario would cause an emergency department nurse to suspect that the
woman has been a victim of IPV?
a. The woman and her partner are having an argument that is loud and hostile.
b. The woman has injuries on various parts of her body that are in different
stages of healing.
c. Examination reveals a fractured arm and fresh bruises.
d. She avoids making eye contact and is hesitant to answer questions.
ANS: B
The client may have multiple injuries in various stages of healing that indicates a pattern of
violence. An argument is not always an indication of battering. A fractured arm and fresh
bruises could be caused by the reported fall and do not necessarily indicate IPV. It may be
normal for the woman to be reticent and have a dull affect.
15. Which statement is most accurate regarding the reporting of IPV in the United States?
a. Asian women report more IPV than do other minority groups.
b. Caucasian women report less IPV than do non-Caucasians.
c. Native-American women report IPV at a rate similar to other groups.
d. African-American women are less likely to report IPV than Caucasian women.
ANS: B
Caucasian women report less IPV than other ethnic groups. Asian women report
significantly less IPV than do other racial groups. Native-American and Alaska Native
women report significantly more IPV than do women of any other racial background.
African-American women tend to report violence at a slightly higher rate than Caucasian
women.

16. Intervention for the sexual abuse survivor is often not attempted by maternity and
womens health nurses because of the concern about increasing the distress of the woman and
the lack of expertise in counseling. What initial intervention is appropriate and most
important in facilitating the womans care?
a. Initiating a referral to an expert counselor
b. Setting limits on what the client discloses
c. Listening and encouraging therapeutic communication skills
d. Acknowledging the nurses discomfort to the client as an expression of empathy
ANS: C
The survivor needs support on many different levels, and a womens health nurse may be the
first person to whom she relates her story. Therapeutic communication skills and listening
are initial interventions. Referring this client to a counselor is an appropriate measure but
not the most important initial intervention. A client should be allowed to disclose any
information she feels the need to discuss. A nurse should provide a safe environment in
which she can do so. Either verbal or nonverbal shock and horror reactions from the nurse
are particularly devastating.
Professional demeanor and professional empathy are essential.
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
17. A young woman arrives at the emergency department and states that she thinks she has
been raped. She is sobbing and expresses disbelief that this could happen because the
perpetrator was a very close friend. Which statement is most appropriate at this time?
a. Rape is not limited to strangers and frequently occurs by someone who is
known to the victim.
b. I would be very upset if my best friend did that to me; that is very unusual.
c. You must feel very betrayed. In what way do you think you might have led
him on?
d. This does not sound like rape. Didnt you just change your mind about having
sex after the fact?

ANS: A
Acquaintance rape involves individuals who know one another. Sexual assault occurs when
the trust of a relationship is violated. Victims may be less prone to recognize what is
happening to them because the dynamics are different from those of stranger rape. It is not
at all unusual for the victim to know and trust the perpetrator. Stating that the woman
might have led the man to attack her indicates that the sexual assault was somehow the
victims fault. This type of mentality is not constructive. Nurses must first reflect on their
own feelings and learn to be unbiased when dealing with victims. A statement of this type
can be very psychologically damaging to the victim. Nurses must display compassion by
first believing what the victim states. The nurse is not responsible for deciphering the facts
involving the victims claim.
18. Nurses are often the first health care professional with whom a woman comes into
contact after being sexually assaulted. Which statement best describes the initial care of a
rape victim?
a. All legal evidence is preserved during the physical examination.
b. The victim appreciates the legal information; however, decides not to pursue
legal proceedings.
c. The victim states that she is going to advocate against sexual violence.
d. The victim leaves the health care facility without feeling re-victimized.
ANS: D
Nurses can assist clients through an examination that is as nontraumatic as possible with
kindness, skill, and empathy. The initial care of the victim affects her recovery and decision
to receive follow-up care. Preservation of all legal evidence is very important; however, this
may not be the best measure in terms of evaluating the care of a rape victim. Offering legal
information is not the best measure of evaluating the care that this victim received. The
victim may well decide not to pursue legal proceedings. Advocating against sexual violence
may be extremely therapeutic for the client after her initial recovery but not a measure of
evaluating her care.

19. When the nurse is alone with a battered client, the client seems extremely anxious and
says, It was all my fault. The house was so messy when he got home, and I know he hates
that. What is the most suitable response by the nurse?
a. No one deserves to be hurt. Its not your fault. How can I help you?
b. What else do you do that makes him angry enough to hurt you?
c. He will never find out what we talk about. Dont worry. Were here to help you.
d. You have to remember that he is frustrated and angry so he takes it out on you.
ANS: A
The nurse should stress that the client is not at fault. Asking what the client did to make her
husband angry is placing the blame on the woman and would be an inappropriate statement.
The nurse should not provide false reassurance. To assist the woman, the nurse should be
honest.
Often the batterer will find out about the conversation.
20. Nurses who provide care to victims of IPV should be keenly aware of what?
a. Relationship violence usually consists of a single episode that the couple can
put behind them.
b. Violence often declines or ends with pregnancy.
c. Financial coercion is considered part of IPV.
d. Battered women are generally poorly educated and come from a deprived
social background.
ANS: C
Economic coercion may accompany physical assault and psychologic attacks. IPV almost
always follows an escalating pattern. It rarely ends with a single episode of violence. IPV
often begins with and escalates during pregnancy. It may include both psychologic attacks
and economic coercion. Race, religion, social background, age, and education level are not
significant factors in differentiating women at risk.

21. In 1979, Lenore Walker pioneered the cause of women as victims of violence when she
published her book The Battered Woman. While Walker conducted her research, she found a
similar pattern of abuse among many of the women. This concept is now referred to as the
cycle of violence. Which phase does not belong in this three-cycle pattern of violence?
a. Tension-building state
b. Frustration, followed by violence
c. Acute battering incident
d. Kindness and contrite, loving behavior
ANS: B
Frustration, followed by violence, is not part of the cycle of violence. The tension-building
state is also known as phase I of the cycle. The batterer expresses dissatisfaction and
hostility with violent outbursts. The woman senses anger and anxiously tries to placate him.
An acute battering incident is phase II of the cycle. It results in the mans uncontrollable
discharge of tension toward the woman. Outbursts can last from several hours to several
days and may involve kicking, punching, slapping, choking, burns, broken bones, and the
use of weapons. Phase III of the cycle is sometimes referred to as the honeymoon, kindness
and contrite, and loving behavior phase, during which the batterer feels remorseful and
profusely apologizes. He tries to help the woman and often showers her with gifts.
22. Nurses must remember that pregnancy is a time of risk for all women. Which
condition is likely the biggest risk for the pregnant client?
a. Preeclampsia
b. IPV
c. Diabetes
d. Abnormal Pap test

ANS: B
The prevalence of IPV during pregnancy is estimated at 6% of all pregnant women. The risk
for IPV and even IPV-related homicide is more common than all of the other pregnancy-
related conditions. Although preeclampsia poses a risk to the health of the pregnant client,
it is less common than IPV. Gestational diabetes continues to be a complication of
pregnancy; however, it is less common than IPV during pregnancy. Some women are at risk
for an abnormal Pap screening during pregnancy, but this finding is not as common as IPV.
23. In the 1970s, the rape-trauma syndrome (RTS) was identified as a cluster of symptoms
and related behaviors observed in the weeks and months after an episode of rape.
Researchers identified three phases related to this condition. Which phase is not displayed
in a client with RTS?
a. Acute Phase: Disorganization
b. Outward Adjustment Phase
c. Shock/Disbelief: Disorientation Phase
d. Long-Term Process: Reorganization Phase
ANS: C
Shock, disbelief, or disorientation is a component of the Acute Phase. The rape survivor feels
embarrassed, degraded, fearful, and angry. She may feel unclean and want to bathe and
douche repeatedly, even though doing so may destroy evidence. The victim relives the scene
over and over in her mind, thinking of things she should have done. During the Outward
Adjustment Phase, the victim may appear to have resolved her crisis and return to activities
of daily living and work. Other women may move, leave their job, and buy a weapon to
protect themselves.
Disorientation is a reaction during which the victim may feel disoriented, have difficulty
concentrating, or have poor recall. The Long-Term Process is the reorganization phase. This
recovery phase may take years and may be difficult and painful.

24. Documentation of abuse can be useful to women later in court, should they elect to press
charges. It is of key importance for the nurse to document accurately at the time that the
client is seen. Which entry into the medical record would be the least helpful to the court?
a. Photographs of injuries
b. Clear and legible written documentation
c. Summary of information (e.g., The client is a battered woman.)
d. Accurate description of the clients demeanor
ANS: C
A statement such as, The client is a battered woman lacks the supporting factual
information and will render the report inadmissible. More appropriate documentation would
include exact statements from the woman in quotations (e.g., My husband kicked me in the
stomach). The time and date of the examination should also be included.
25. Which statement regarding human trafficking is correct?
a. Human trafficking is a multibillion-dollar business that primarily exists in
the United States.
b. Victims often experience the Stockholm syndrome.
c. Vast majority of the victims are young boys and girls.
d. Human trafficking primarily refers to commercial sex
work. ANS: B
Although victims of sex trafficking can be young boys and girls, the vast majority are women
and girls. They are often lured by false promises, such as a job or marriage, sold by their
parents, or kidnapped by traffickers. These individuals are forced into sex work, hard labor,
and organ donation. This $32 billion business exists in the United States and internationally.
The Stockholm syndrome occurs when the slaves become attached to their enslavers. Health
care professionals may interact with victims who are in captivity should they require
emergent health care. The

nurse is challenged to find an opportunity to speak with the client alone and assess
for victimization.
26. Which statement is the most comprehensive description of sexual violence?
a. Sexual violence is limited to rape.
b. Sexual violence is an act of force during which an unwanted and
uncomfortable sexual act occurs.
c. Sexual violence encompasses a number of sexual acts.
d. Sexual violence includes degrading sexual comments and
behaviors. ANS: C
Sexual violence is a broad term that includes a range of sexual victimization including sexual
assault, sexual harassment, and rape. It may include but is not limited to rape. Sexual
assault includes unwanted or uncomfortable touches, kisses, hugs, petting, intercourse, or
other sexual acts. It is a component of sexual violence. Unwelcome or degrading e-mail
messages, comments, contact, or behavior, such as exhibitionism, that makes any
environment feel unsafe is known as sexual harassment.
27. Women with severe and persistent mental illness are likely to be more vulnerable to
being involved in controlling and/or violent relationships; however, many women develop
mental health problems as a result of long-term abuse. Which condition is unlikely to be a
psychologic consequence of continued abuse?
a. Substance abuse
b. Posttraumatic stress disorder (PTSD)
c. Eating disorders
d. Bipolar disorder
ANS: D

Bipolar disorder is a specific illness (also known as manic depressive disorder) not related to
abuse. Substance abuse is a common method of coping with long-term abuse. The abuser is
also more likely to use alcohol and other chemical substances. PTSD is the most prevalent
mental health sequela of long-term abuse. The traumatic event is persistently re-
experienced through distress recollection and dreams. Eating disorders, depression,
psychologic-physiologic illness, and anxiety reactions are all mental health problems
associated with repeated abuse.
a. High level of self-esteem
b. High frustration tolerance
c. Substance abuse problems
d. Excellent verbal skills
e. Personality disorders
MULTIPLE RESPONSE
28. The nurse who is evaluating the client for potential abuse should be aware that IPV includes
a number of different forms of abuse, including which of the following? (Select all that apply.)
a. Physical
b. Sexual
c. Emotional
d. Psychologic
e. Financial
ANS: A, B, D, E
Physical, sexual, financial, and psychologic abuse can all be components in a relationship with
IPV. Emotional abuse is a form of psychologic abuse.
MSC: Client Needs: Psychosocial and Physiologic Integrity
29. What are some common characteristics of a potential male batterer? (Select all that apply.)

ANS: C, E
Substance abuse and personality disorders are often observed in batterers. Typically, the
batterer has low self-esteem. Batterers usually have a low frustration level (i.e., they easily
lose their temper). Batterers characteristically have poor verbal skills and can especially
have difficulty expressing their feelings.
30. Which nursing diagnoses would be most applicable for battered women? (Select all
that apply.)
a. Loss of trust
b. Ineffective family coping
c. Situational low self-esteem
d. Risk for self-directed violence
e. Enhanced communication
ANS: A, B, C, D
Loss of trust, ineffective family coping, situational low self-esteem, and risk for self-
directed violence are potential nursing diagnoses associated with battered women. A more
appropriate nursing diagnosis for a battered woman would be impaired communication.
31. A thorough abuse assessment screen should be completed on all female clients. This
screen should include which components? (Select all that apply.)
a. Asking the client if she has ever been slapped, kicked, punched, or physically
hurt by her partner
b. Asking the client if she is afraid of her partner
c. Asking the client if she has been forced to perform sexual acts
d. Diagramming the clients current injuries on a body map
e. Asking the client what she did wrong to elicit the abuse

ANS: A, B, C, D
Asking the client if she has been slapped, kicked, punched, or physically hurt by her partner,
if she is afraid of her partner, or if she has been forced to perform sexual acts are questions
that should be posed to all clients. If any physical injuries are present, then they should be
marked on a form that indicates their locations on the body. Implying that a client did
something wrong can be very emotionally damaging. Many victims of violence are not
aware that they are in an abusive relationship. They may not respond to questions about
abuse. Using general descriptive words such as slap, kick, or punch to elicit information is
best.
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
32. What are the responsibilities of the nurse who suspects or confirms any type of
violence against a woman? (Select all that apply.)
a. Report the incident to legal authorities.
b. Provide resources for domestic violence shelters.
c. Call a client advocate who can assist in the clients decision about what actions
to take.
d. Accurately and concisely document the incident (or findings) in the
clients record.
e. Reassure and support the client.
ANS: B, C, D, E
Domestic violence is considered a crime in all states; however, mandatory reporting remains
controversial. Nurses must become knowledgeable on the laws that apply in the state in
which they practice. Caring for a client who may be a victim of domestic abuse is an ideal
opportunity to provide the woman with information for safe houses or support groups for
herself and her children. The nurse may assist in reaching out to a client advocate, which
often occurs when potential legal action is taken or if the woman is seeking shelter.
Documentation must be accurate and timely to be useful to the client later in court if she
chooses to press charges. The

primary functions for the nurse are to reassure the client and to provide her with emotional
support.
31. The alcoholic patient says to the nurse, I am not an alcoholic. I can quit any time I
want to. The nurse recognizes the defense mechanism of:
a. repression.
b. denial.
c. rationalization.
d. intellectualization.
ANS: B
Denial is ignoring reality in spite of hard evidence. Denial is a mechanism frequently used by
substance abusers. Repression refers to unconsciously blocking an unwanted thought or
memory from open expression. Rationalization attempts to justify a behavior or action by
making an excuse or an explanation. Intellectualization is the excessive reasoning and logic
to counter emotional distress.
TOP: Alcoholism: Defense Mechanism KEY: Nursing Process Step:
Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
34. The wife of an alcoholic tells the nurse, My husband only drinks on the weekends to
relax. He has a very stressful job. The nurse recognizes the defense mechanism of:
a. repression.
b. denial.
c. rationalization.
d. identification.
ANS: C

Rationalization is a justification for an unreasonable act to make it appear reasonable.
Rationalization is used by many families to allay their own anxiety about the substance
abuse of a family member. Repression refers to unconsciously blocking an unwanted thought
or memory from open expression. Denial is ignoring reality in spite of hard evidence. Denial
is a mechanism frequently used by substance abusers. Identification refers to modeling
behaviors after another individual.
TOP: Family Reaction to Substance Abuse: Rationalization
KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity
35. The nurse explains the difference between an enabler and a co-dependent is that a
co- dependent:
a. covers up the behavior of the substance abuser.
b. rationalizes the behavior of the substance abuser.
c. uses the behavior of the substance abuser to build up his or her own self-esteem.
d. is also a substance abuser.
ANS: A
The co-dependent fixes things by overcompensating to prevent the abuser from facing
reality. Enabling refers to helping a person so that the persons consequences from
unhealthy behavior are less severe; thus enabling helps the unhealthy behavior to
continue.
TOP: Co-dependent vs. Enabler KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
36. The nurse explains that, no matter whether you drink a 12-ounce beer, a 6-ounce
glass of wine, or 1.5 ounces of straight liquor, it takes approximately minutes for the
body to metabolize it.
a. 20
b. 30

c. 40
d. 60
ANS: D
The metabolization of any amount of alcohol takes approximately 1 hour.
TOP: Alcohol: Metabolization Time KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
37. A person in jail for public intoxication has been without alcohol for 12 hours. The jail
nurse would be alert for withdrawal signs of:
a.
b. nausea and vomiting.
c. hallucinations.
d. seizures.
ANS: A
Marked irritability is the early sign (6 to 12 hours after last drink) of alcohol withdrawal.
TOP: Alcohol Withdrawal: Signs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
38. A patient who is still intoxicated has been admitted for detoxification at the treatment
center. The nurse takes into consideration that the patient will be supported in his
withdrawal with the use of:
a. psychotherapy support only.
b. heavy doses of opioids to keep the patient sedated for 72 hours.
c. symptomatic relief until substance has cleared from his system.
d. titrated amounts of alcohol until severe withdrawal is over.
irritability.

ANS: C
The alcoholic in withdrawal is supported with symptomatic relief for nausea and vomiting,
cramps, and possible seizure.
TOP: Alcoholism: Detoxification KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
39. After detoxification from substance abuse, the patient says, I feel better than I have in
years! All I needed was some rest. I am not an alcoholic. The nurse should respond to this
by saying:
a. What were you doing that got you admitted to the detoxification center?
b. Alcoholism has many definitions. What is yours?
c. Admitting to alcoholism is hard.
d. Alcoholism has ruined your life. How can you say you are not an alcoholic?
ANS: A
Confronting denial and encouraging self-diagnosis is the point of the treatment phase after
detoxification. Asking for the patients definition of alcoholism allows for the patient to
intellectualize the problem. Stating that alcoholism is hard is a sympathetic and unhelpful
response. Alcoholism has ruined your life is accusatory and counterproductive.
TOP: Alcoholism: Post-detoxification KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
40. The nurse explains that an alternative to disulfiram (Antabuse) is the drug
naltrexone (ReVia), which can:
a. cause severe headaches if alcohol is consumed while using the drug.
b. cause a dependence on ReVia rather than on alcohol.
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TEST BANK For Family Practice Guidelines, 5th Edition by Jill C. Cash; Cheryl A. Glass, Verified Chapters 1 - 23, Complete Newest Version.pdf