Chapter 5

Question 1

1. Which Western cultural feature may result in establishing unrealistic outcomes for patients of other cultural groups?
   a. Interdependence
   b. Present orientation
   c. Flexible perception of time
   d. Direct confrontation to solve problems

Answer 1

ANS: D
Directly confronting problems is a highly valued approach in the American culture but not part of many other cultures in which harmony and restraint are valued. American nurses sometimes mistakenly think that all patients should take direct action. Patients with other values will be unable to meet this culturally inappropriate outcome. Present orientation, interdependence, and a flexible perception of time are not valued in Western culture. These views are more predominant in other cultures. See relationship to audience response question.

Question 2

2. A psychiatric nurse leads a medication education group for Hispanic patients. This nurse holds a Western worldview and uses pamphlets as teaching tools. Groups are short and concise. After the group, the patients are most likely to believe:
   a. the nurse was uncaring. c. the teaching was efficient.
   b. the session was effective. d. they were treated respectfully.

Answer 2

ANS: A
Hispanic individuals usually value relationship behaviors. Their needs are for learning through verbal communication rather than reading and for having time to chat before approaching the task.

Question 3

3. To provide culturally competent care, the nurse should:
   a. accurately interpret the thinking of individual patients.
   b. predict how a patient may perceive treatment interventions.
   c. formulate interventions to reduce the patient’s ethnocentrism.
   d. identify strategies that fit within the cultural context of the patient.

Answer 3

ANS: D
The correct answer is the most global response. Cultural competence requires ongoing effort. Culture is dynamic, diversified, and changing. The nurse must be prepared to gain cultural knowledge and determine nursing care measures that patients find acceptable and helpful. Interpreting the thinking of individual patients does not ensure culturally competent care. Reducing a patient’s ethnocentrism may not be a desired outcome.

Question 4

4. A black patient, originally from Haiti, has a diagnosis of depression. A colleague tells the nurse, “This patient often looks down and is reluctant to share feelings. However, I’ve observed the patient spontaneously interacting with other black patients.” Select the nurse’s best response.
   a. “Black patients depend on the church for support. Have you consulted the patient’s pastor?”
   b. “Encourage the patient to talk in a group setting. It will be less intimidating than one-to-one interaction.”
   c. “Don’t take it personally. Black patients often have a resentful attitude that takes a long time to overcome.”
   d. “The patient may have difficulty communicating in English. Have you considered using a cultural broker?”

Answer 4

ANS: D
Society expects a culturally diverse patient to accommodate and use English. Feelings are abstract, which requires a greater command of the language. This may be especially difficult during episodes of high stress or mental illness. Cultural brokers can be helpful with language and helping the nurse to understand the Haitian worldview and cultural nuances.

Question 5

5. A Haitian patient diagnosed with depression tells the nurse, “There’s nothing you can do. This is a punishment. The only thing I can do is see a healer.” The culturally aware nurse assesses that the patient:
   a. has delusions of persecution.
   b. has likely been misdiagnosed with depression.
   c. may believe the distress is the result of a curse or spell.
   d. feels hopeless and helpless related to an unidentified cause.

Answer 5

ANS: C
Individuals of African American or Caribbean cultures who have a fatalistic attitude about illness may believe they are being punished for wrongdoing or are victims of witchcraft or voodoo. They may be reticent to share information about curses with therapists. No data are present in the scenario to support delusions. Misdiagnosis more often labels a patient with depression as having schizophrenia.

Question 6

6. A group activity on an inpatient psychiatric unit is scheduled to begin at 1000. A patient, who was recently discharged from United States Marine Corps, arrives at 0945. Which analysis best explains this behavior?
   a. The patient wants to lead the group and give directions to others.
   b. The patient wants to secure a chair that will be close to the group leader.
   c. The military culture values timeliness. The patient does not want to be late.
   d. The behavior indicates feelings of self-importance that the patient wants others to appreciate.

Answer 6

ANS: C
Culture is more than ethnicity and social norms; it includes religious, geographic, socioeconomic, occupational, ability- or disability-related, and sexual orientation-related beliefs and behaviors. In this instance, the patient’s military experience represents an aspect of the patient’s behavior. The military culture values timeliness. The distracters represent misinterpretation of the patient’s behavior and have no bearing on the situation.

Question 7

7. A nurse in the clinic has a full appointment schedule. A Hispanic American patient arrives at 1230 for a 1000 appointment. A Native American patient does not keep an appointment at all. What understanding will improve the nurse’s planning? These patients are:
   a. members of cultural groups that have a different view of time.
   b. immature and irresponsible in health care matters.
   c. acting out feelings of anger toward the system.
   d. displaying passive-aggressive tendencies.

Answer 7

ANS: A
Hispanic Americans and Native Americans traditionally treat time in a way unlike the Western culture. They tend to be present-oriented; that is, they value the current interaction more than what is to be done in the future. If engaged in an activity, for example, they may simply continue the activity and appear later for an appointment. Understanding this, the nurse can avoid feelings of frustration and anger when the nurse’s future orientation comes into conflict with the patient’s present orientation.

Question 8

8. The sibling of an Asian American patient tells the nurse, “My sister needs help for pain. She cries from the hurt.” Which understanding by the nurse will contribute to culturally competent care for this patient? Persons of an Asian American heritage:
   a. often express emotional distress with physical symptoms.
   b. will probably respond best to a therapist who is impersonal.
   c. will require prolonged treatment to stabilize these symptoms.
   d. should be given direct information about the diagnosis and prognosis.

Answer 8

ANS: A
Asian Americans commonly express psychological distress as a physical problem. The patient may believe psychological problems are caused by a physical imbalance. Treatment will likely be short. The patient will probably respond best to a therapist who is perceived as giving. Asian Americans usually have strong family ties and value hope more than truth.

Question 9

9. Which communication techniques would be most effective for a nurse to use during an assessment interview with an adult Native American patient?
   a. Open and friendly; ask direct questions; touch the patient’s arm or hand occasionally for reassurance.
   b. Frequent nonverbal behaviors, such as gestures and smiles; make an unemotional face to express negatives.
   c. Soft voice; break eye contact occasionally; general leads and reflective techniques.
   d. Stern voice; unbroken eye contact; minimal gestures; direct questions.

Answer 9

ANS: C
Native American culture stresses living in harmony with nature. Cooperative, sharing styles rather than competitive or intrusive approaches are preferred; thus, the more passive style described would be best received. The other options would be more effective to use with patients of a Western orientation.

Question 10

10. A Native American patient sadly describes a difficult childhood. The patient abused alcohol as a teenager but stopped 10 years ago. The patient now says, “I feel stupid and good for nothing. I don’t help my people.” How should the treatment team focus planning for this patient?
    a. Psychopharmacological and somatic therapies should be central techniques.
    b. Apply a psychoanalytic approach, focused on childhood trauma.
    c. Depression and alcohol abuse should be treated concurrently.
    d. Use a holistic approach, including mind, body, and spirit.

Answer 10

ANS: D
Native Americans, because of their beliefs in the interrelatedness of parts and about being in harmony with nature, respond best to a holistic approach. No data are present to support dual diagnosis, because the patient has resolved the problem of excessive alcohol use. Psychopharmacological and somatic therapies may be part of the treatment, but the focus should be more holistic. Psychoanalysis is a long-term expensive therapy; cognitive therapy might be a better choice.

Question 11

11. A Native American patient describes a difficult childhood and dropping out of high school. The patient abused alcohol as a teenager to escape feelings of isolation but stopped 10 years ago. The patient now says, “I feel stupid. I’ve never had a good job. I don’t help my people.” Which nursing diagnosis applies?
    a. Risk for other-directed violence c. Deficient knowledge
    b. Chronic low self-esteem d. Social isolation

Answer 11

ANS: B
The patient has given several indications of chronic low self-esteem. Forming a positive self-image is often difficult for Native American individuals because these indigenous people must blend together both American and Native American worldviews. No defining characteristics are present for the other nursing diagnoses.

Question 12

12. Which viewpoint of an Asian American family will most affect decision making about care?
    a. The father is the authority figure.
    b. The mother is head of the household.
    c. Women should make their own decisions.
    d. Emotional communication styles are desirable.

Answer 12

ANS: A
Asian American families traditionally place the father in the position of power as the head of the household. Mothers, as well as other women, are usually subservient to fathers in these cultures. Asian Americans are more likely to be reserved.

Question 13

13. Which intervention best demonstrates that a nurse correctly understands the cultural needs of a hospitalized Asian American patient diagnosed with a mental illness?
    a. Encouraging the family to attend community support groups
    b. Involving the patient’s family to assist with activities of daily living
    c. Providing educational pamphlets to explain the patient’s mental illness
    d. Restricting homemade herbal remedies the family brings to the hospital

Answer 13

ANS: B
The Asian community values the family in caring for each other. The Asian community uses traditional medicines and healers, including herbs for mental symptoms. The Asian community describes illness in somatic terms. The Asian community attaches a stigma to mental illness, so interfacing with the community would not be appealing.

Question 14

14. A nurse speaks with family members of a Chinese American parent recently diagnosed with major depression. Which comment by the nurse will the family find most comforting? “The nursing staff will:
    a. take good care of your parent.”
    b. pray with your parent several times a day.”
    c. teach your parent important self-care strategies.”
    d. educate your parent about safety information regarding medication.”

Answer 14

ANS: A
Chinese Americans hold an Eastern (balance) worldview. Persons who are ill or need health care are vulnerable and need protection. The family will find comfort in a nurse’s statement that good care will be provided. The distracters apply to persons with a Western or indigenous worldview.

Question 15

15. A patient in the emergency department shows a variety of psychiatric symptoms, including restlessness and anxiety. The patient says, “I feel sad because evil spirits have overtaken my mind.” Which worldview is most applicable to this individual?
    a. Eastern/balance c. Western/scientific
    b. Southern/holistic d. Indigenous/harmony

Answer 15

ANS: D
Persons of an indigenous worldview believe disease results from a lack of personal, interpersonal, environmental, or spiritual harmony and that evil spirits exist. The holism of body-mind-spirit is a key component of this view. If one believes an evil spirit has taken control, distress results. Western and Eastern worldviews do not embrace spirits. See relationship to audience response question.

Question 16

16. A nurse prepares to teach important medication information to a patient of Mexican heritage. How should the nurse manage the teaching environment?
    a. Stand very close to the patient while teaching.
    b. Maintain direct eye contact with the patient while teaching.
    c. Maintain a neutral emotional tone during the teaching session.
    d. Sit 4 feet or more from the patient during the teaching session.

Answer 16

ANS: A
Latin American cultures use close personal space, closer than many other minority groups.
Standing very close to the patient frequently indicates acceptance. Direct eye contact should not be prolonged with this patient. Persons of this cultural heritage have high emotionality.

Question 17

17. A Chinese American patient diagnosed with an anxiety disorder says, “My problems began when my energy became imbalanced.” The nurse asks for the patient’s ideas about how to treat the imbalance. Which comment would the nurse expect from this patient?
    a. “My family will bring special foods to help me get well.”
    b. “I hope my health care provider will prescribe some medication to help me.”
    c. “I think I would benefit from talking to other patients with a similar problem.”
    d. “I would like to have a native healer perform a ceremony to balance my energy.”

Answer 17

ANS: A
The concept of energy imbalance as a source of illness is an explanatory model familiar to Asian cultures. A source of healing is dietary change to include either “hot” or “cold” foods to correct the imbalance. “Hot” and “cold” in this case do not refer to thermal properties of the foods. Medication would not be a treatment suggested by a patient with an Eastern worldview. Someone from an indigenous culture may suggest rituals. Group discussion of mental illness would not be appealing to a Chinese American.

Question 18

18. An experienced psychiatric nurse plans to begin a new job in a community-based medication clinic. The clinic sees culturally diverse patients. Which action should the nurse take first to prepare for this position?
    a. Investigate cultural differences in patients’ responses to psychotropic medications.
    b. Contact the clinical nurse specialist for guidelines regarding cultural competence.
    c. Examine the literature on various health beliefs of members of diverse cultures.
    d. Complete an online continuing education offering about psychopharmacology.

Answer 18

ANS: A
An experienced nurse working on a mental health inpatient unit would be familiar with the action and side effects of most commonly prescribed psychotropic medications. However, because the clinic serves a culturally diverse population, reviewing cultural differences in patients’ responses to these medications is helpful and vital to patient safety. The distracters identify actions the nurse would take later.

Question 19

19. A psychoeducational session will discuss medication management for a culturally diverse group of patients. Group participants are predominantly members of minority cultures. Of the four staff nurses below, which nurse should lead this group?
    a. Very young registered nurse c. Newly licensed registered nurse
    b. Older, mature registered nurse d. A registered nurse who is very thin

Answer 19

ANS: B
Persons of minority cultures value age and wisdom. Persons with a Western worldview tend to value youth. An older, mature registered nurse would be the most credible leader of this group. The nurse’s size has no bearing on credibility.

Question 20

20. A nurse wants to engage an interpreter for a severely anxious 21-year-old male who immigrated to the United States two years ago. Of the four interpreters below who are available and fluent in the patient’s language, which one should the nurse call?
    a. 65-year-old female professional interpreter
    b. 24-year-old male professional interpreter
    c. A member of the patient’s family
    d. The patient’s best friend

Answer 20

ANS: B
A professional interpreter will be most effective because he/she will be able to interpret both language and culture. When an interpreter is engaged, the interpreter should be matched to the patient as closely as possible in gender, age, social status, and religion. Interpreters should not be relatives or friends of the patient. The stigma of mental illness may prevent the openness needed during the encounter.

Question 21

21. A patient who has been hospitalized for 3 days with a serious mental illness says, “I’ve got to get out of here and back to my job. I get 60 to 80 messages a day, and I’m getting behind on my email correspondence.” What is this patient’s perspective about health and illness?
    a. Fateful, magical c. Western, biomedical
    b. Eastern, holistic d. Harmonious, religious

Answer 21

ANS: C
The Western biomedical perspective holds the belief that sick people should be as independent and self-reliant as possible. Self-care is encouraged; one gets better by “getting up and getting going.” An ability to function at a high level is valued. See relationship to audience response question.

Question 22

22. A white patient of German descent rocks back and forth, grimaces, and rubs both temples. What is the nurse’s best action?
    a. Assess the patient for extrapyramidal symptoms.
    b. Sit beside the patient and rock in sync.
    c. Offer to pray with the patient.
    d. Assess the patient for pain.

Answer 22

ANS: D
This patient of German descent would hold a Western worldview and be stoic about pain. This patient will keep pain as silent as possible and be reluctant to disclose pain unless the nurse actively assesses for it. The patient’s nonverbal communication suggests pain rather than EPS. The patient would probably not respond positively to prayer or the nurse’s rocking behavior.

Question 23

23. A Vietnamese patient’s family reports that the patient has wind illness. Which menu selection will be most helpful for this patient?
    a. Iced tea c. Warm broth
    b. Ice cream d. Gelatin dessert

Answer 23

ANS: C
Wind illness is a culture-bound syndrome found in the Chinese and Vietnamese population. It is characterized by a fear of cold, wind, or drafts. It is treated by keeping very warm and avoiding foods, drinks, and herbs that are cold. Warm broth would be most in sync with the patient’s culture and provide the most comfort. The distracters are cold foods.

Question 24

24. A Mexican American patient puts a picture of the Virgin Mary on the bedside table. What is the nurse’s best action?
    a. Move the picture so it is beside a window.
    b. Send the picture to the business office safe.
    c. Leave the picture where the patient placed it.
    d. Send the picture home with the patient’s family.

Answer 24

ANS: C
Cultural heritage is expressed through language, works of art, music, dance, customs, traditions, diet, and expressions of spirituality. This patient’s prominent placement of the picture is an example of expression of cultural heritage and spirituality. The nurse should not move it unless the patient’s safety is jeopardized.

Question 25

25. A nurse begins work in an agency that provides care to members of a minority ethnic population. The nurse will be better able to demonstrate cultural competence after:
    a. identifying culture-bound issues.
    b. implementing scientifically proven interventions.
    c. correcting inferior health practices of the population.
    d. exploring commonly held beliefs and values of the population.

Answer 25

ANS: D
Cultural competence is dependent on understanding the beliefs and values of members of a different culture. A nurse who works with an individual or group of a culture different from his or her own must be open to learning about the culture. The other options have little to do with cultural competence or represent only a portion of the answer.

Question 26

26. A nurse cares for a first-generation American whose family emigrated from Germany. Which worldview about the source of knowledge would this patient likely have?
    a. Knowledge is acquired through use of affective or feeling senses.
    b. Science is the foundation of knowledge and proves something exists.
    c. Knowledge develops by striving for transcendence of the mind and body.
    d. Knowledge evolves from an individual’s relationship with a supreme being.

Answer 26

ANS: B
The European-American perspective of acquiring knowledge evolves from science. The distracters describe the beliefs of other cultural groups. See relationship to audience response question.

Question 27

27. The nurse administers medications to a culturally diverse group of patients on a psychiatric unit. What expectation should the nurse have about pharmacokinetics?
    a. Patients of different cultural groups may metabolize medications at different rates.
    b. Metabolism of psychotropic medication is consistent among various cultural groups.
    c. Differences in hepatic enzymes will influence the rate of elimination of psychotropic medications.
    d. It is important to provide patients with oral and written literature about their psychotropic medications.

Answer 27

ANS: A
Cytochrome enzyme systems, which vary among different cultural groups, influence the rate of metabolism of psychoactive drugs. Renal function influences elimination of psychotropic medication; hepatic function influences metabolism rates. Information about medication is important but does not apply to pharmacokinetics.

Question 28

28. A nurse prepares to assess a newly hospitalized patient who moved to the United States 6 months ago from Somalia. The nurse should first determine:
    a. if the patient’s immunizations are current.
    b. the patient’s religious preferences.
    c. the patient’s specific ethnic group.
    d. whether an interpreter is needed.

Answer 28

ANS: D
The assessment depends on communication. The nurse should first determine whether an interpreter is needed. The other information can be subsequently assessed.

Question 29

1. Which questions should the nurse ask to determine an individual’s worldview? Select all that apply.
   a. What is more important: the needs of an individual or the needs of a community?
   b. How would you describe an ideal relationship between individuals?
   c. How long have you lived at your present residence?
   d. Of what importance are possessions in your life?
   e. Do you speak any foreign languages?

Answer 29

ANS: A, B, D
The answers provide information about cultural values related to the importance of individuality, material possessions, relational connectedness, community needs versus individual needs, and interconnectedness between humans and nature. These will assist the nurse to determine a patient’s worldview. Other follow-up questions are needed to validate findings.

Question 30

2. Why is the study of culture so important for psychiatric nurses in the United States? Select all that apply.
   a. Psychiatric nurses often practice in other countries.
   b. Psychiatric nurses must advocate for the traditions of the Western culture.
   c. Cultural competence helps protect patients from prejudice and discrimination.
   d. Patients should receive information about their illness and treatment in terms they understand.
   e. Psychiatric nurses often interface with patients and their significant others over a long period of time.

Answer 30

ANS: C, D, E
One purpose of cultural competence is for the psychiatric nurse to relate and explain information about the patient’s illness and treatment in an understandable way, incorporating the patient’s own beliefs and values. A fundamental aspect of nursing practice is advocacy. Cultural competence promotes recognition of prejudices in care, such as stigma and misdiagnosis. Psychiatric nurses often interface with patients and families over years and in community settings.

Question 31

3. The nurse should be particularly alert to somatization of psychological distress among patients whose cultural beliefs include: (select all that apply)
   a. mental illness reflects badly on the family.
   b. mental illness shows moral weakness.
   c. intergenerational conflict is common.
   d. the mind, body, and spirit are merged.
   e. food choices influence one’s health.

Answer 31

ANS: A, B, D
Physical symptoms are seen as more acceptable in cultural groups in which interdependence and harmony of the group are emphasized. Mental illness is often perceived as reflecting a failure of the entire family. In groups in which mental illness is seen as a moral weakness and both the individual and family are stigmatized, somatization of mental distress is better accepted. In groups in which mind, body, and spirit are holistically perceived, somatization of psychological distress is common. Somatization and food are not commonly related. Intergenerational conflict has not been noted as a risk factor for somatization.