ATI RN
Transcultural Concepts in Nursing Care 7th Edition Test Bank Questions
Question 1 of 5
During the physical assessment of a young adult, the nurse notes a lateral, S-shaped curve of the spine. What should the nurse suspect is occurring with this patient?
Correct Answer: B
Rationale: Scoliosis is a condition characterized by an abnormal lateral curvature of the spine, often forming an S-shaped or C-shaped curve when viewed from behind. It commonly occurs in young adults during growth spurts, especially teenage girls. Scoliosis can be mild or severe, and early detection is crucial to prevent further progression and potential complications. Treatment options may include physical therapy, bracing, or in more severe cases, surgery. Lordosis is an inward curvature of the lower back, Kyphosis is an excessive outward curvature of the spine commonly known as "hunchback," and Musculosis is not a recognized medical term related to spinal conditions.
Question 2 of 5
A client being treated for a deep venous thrombosis (DVT) is experiencing pain. Which interventions should the nurse implement? Select all that apply.
Correct Answer: B
Rationale: - **Bedrest as ordered (
B):** Bedrest is essential for managing deep venous thrombosis to prevent clot dislodgment and further complications. It helps reduce excessive movement, which can increase the risk of clots breaking loose and traveling to the lungs, causing a pulmonary embolism.
Question 3 of 5
A patient has difficulty getting to the bathroom in time to prevent urine leaks once the need to void occurs. What should the nurse teach this patient?
Correct Answer: B
Rationale: Establishing a voiding schedule that includes emptying the bladder at least every 2 hours can help prevent urine leaks in this patient. By regularly emptying the bladder, the patient can reduce the likelihood of urgency and leakage episodes. This strategy helps in managing the symptoms of urge incontinence or overactive bladder, which seem to be the underlying issues for the patient described in the scenario. The other options may also be helpful in managing urinary incontinence but creating a voiding schedule is the most direct and effective approach for the patient's specific concern.
Question 4 of 5
The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate?
Correct Answer: C
Rationale: During pregnancy, it is not uncommon for women to have an extra heart sound known as a gallop rhythm. This is often referred to as a ventricular gallop, which is the presence of an S3 heart sound. In pregnant women, the increased blood volume and changes in heart dynamics can lead to the development of this extra sound. It is considered a normal finding during the third trimester of pregnancy and is usually not a cause for concern. It is important for healthcare providers to differentiate between normal physiological changes associated with pregnancy and potential heart abnormalities, which is why a ventricular gallop in this context is typically considered a benign finding.
Question 5 of 5
A nurse is caring for a group of clients who are recovering in a rehabilitation hospital following total hip replacements. Which client is exhibiting the highest motivation to learn?
Correct Answer: C
Rationale: The client who is excited to learn ambulation techniques (Option
C) is exhibiting the highest motivation to learn. This client's enthusiasm for learning new skills related to ambulation indicates a strong willingness to actively engage in their rehabilitation process. Learning ambulation techniques is a crucial aspect of recovery following a total hip replacement, as it helps improve mobility and independence. The excitement to learn demonstrates that this client is eager to participate in their rehabilitation and is likely to be more proactive in achieving their recovery goals.