ATI RN
Transcultural Concepts in Nursing Care 6th Edition Test Bank Questions
Question 1 of 9
A client admitted with a cardiac dysrhythmia reports being easily fatigued and has difficulty performing normal daily activities. Which nursing diagnosis should the nurse select to address this client's issue?
Correct Answer: B
Rationale: The nursing diagnosis of Activity Intolerance is the most appropriate for a client with a cardiac dysrhythmia who reports being easily fatigued and having difficulty performing normal daily activities. Cardiac dysrhythmias can lead to decreased cardiac output, which can result in reduced oxygen delivery to the body's tissues, contributing to fatigue and weakness. Activity Intolerance is defined as the state in which an individual experiences or is at risk of experiencing insufficient physiological or psychological energy to endure or complete daily activities. This diagnosis is fitting for the client's inability to perform normal daily activities due to the cardiac dysrhythmia-induced fatigue and weakness. Addressing Activity Intolerance will involve collaborating with the client to set achievable activity goals and incorporating periods of rest to enhance tolerance to physical activity and improve overall function.
Question 2 of 9
The nurse asks the client to repeat the information taught during the discharge teaching session. The client states, "I have forgotten everything you just said." Which action by the nurse would is appropriate at this time?
Correct Answer: D
Rationale: Asking the client about their preferred learning strategies is the appropriate action at this time. Everyone learns in different ways, and by identifying the client's preferred learning style, the nurse can tailor the teaching session to be more effective and memorable for the client. Understanding how the client learns best can help in providing information in a way that is easier for them to retain and recall later. It also demonstrates a client-centered approach to teaching, which can improve communication and understanding between the client and the healthcare provider.
Question 3 of 9
A client diagnosed with cardiomyopathy asks the nurse to explain the different types of the disease. Which is inappropriate for the nurse to include in the teaching session?
Correct Answer: D
Rationale: Arrhythmogenic right ventricular dysplasia (ARVD) is not a type of cardiomyopathy; it is a separate condition that affects the heart muscle. The other options, dilated cardiomyopathy, restrictive cardiomyopathy, and hypertrophic cardiomyopathy, are all types of cardiomyopathy that involve the heart muscle becoming weak, stiff, or abnormally thick. It is important for the nurse to clarify this distinction in order to provide accurate information to the client.
Question 4 of 9
The nurse is planning care for several clients. Which client should the nurse identify as being at greatest risk of developing heart failure?
Correct Answer: B
Rationale: Smoking is a major risk factor for developing heart failure. African Americans are at a higher risk of heart failure compared to Caucasians. Additionally, being female and smoking further increase the risk. Smoking damages the blood vessels and heart, leading to various cardiovascular problems including heart failure. Therefore, the 50-year-old African American female who smokes is at the greatest risk of developing heart failure among the given options.
Question 5 of 9
The nurse identifies the diagnosis of Ineffective Protection as appropriate for a patient with systemic lupus erythematosus. Which intervention should the nurse include when planning this patient’s care?
Correct Answer: B
Rationale: Ineffective Protection is a nursing diagnosis that involves a compromised ability to guard against health threats. Patients with systemic lupus erythematosus are prone to skin rashes, lesions, and photosensitivity due to the autoimmune nature of the disease. Providing appropriate skincare is essential in managing the skin manifestations of lupus, such as using gentle cleansers, moisturizers, and sunscreen to protect the skin from further damage. Proper skincare can help maintain skin integrity and prevent infections, which are crucial aspects of protecting patients with systemic lupus erythematosus. While monitoring laboratory findings, practicing careful hand hygiene, and administering prescribed medications are all important aspects of care for lupus patients, providing appropriate skincare directly addresses the Ineffective Protection diagnosis by focusing on protecting the patient's skin health.
Question 6 of 9
The nurse is documenting assessment findings on a client with angina. Which term should the nurse use to describe chest pain that occurs at night and is unrelated to activity?
Correct Answer: B
Rationale: Prinzmetal angina, also known as variant angina or vasospastic angina, is characterized by chest pain that occurs at rest, often during the night or early morning, and is unrelated to activity or emotional stress. This type of angina is caused by transient coronary artery vasospasm, which leads to a temporary reduction in blood flow to the heart. Patients with Prinzmetal angina may have normal coronary arteries or minimal atherosclerosis. It differs from stable and unstable angina, which are typically triggered by physical or emotional stress. Nonanginal pain refers to chest discomfort that is not related to cardiac causes.
Question 7 of 9
The nurse is identifying goals of care for a patient with stress incontinence. Which goal would be a priority for this patient?
Correct Answer: D
Rationale: Stress incontinence is commonly caused by the weakening of the pelvic floor muscles that support the bladder and urethra. Thus, a priority goal for a patient with stress incontinence would be to strengthen these muscles through pelvic floor muscle exercises. By performing these exercises as taught by the nurse at least twice a day, the patient can improve the support to the bladder and reduce or manage the symptoms of stress incontinence. This proactive approach addresses the root cause of the issue and can lead to significant improvement in the patient's condition over time. Understanding the chronic and benign nature of the disorder (Option A), identifying protective products (Option B), and limiting intake of certain beverages (Option C) can also be important aspects of care but may not directly address the underlying cause as effectively as pelvic floor muscle exercises.
Question 8 of 9
A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse?
Correct Answer: A
Rationale: The priority action by the nurse when a client receiving heparin therapy for deep venous thrombosis (DVT) presents with symptoms suggestive of a pulmonary embolism, such as severe chest pain and shortness of breath, is to assess the client's pulse, respirations, and blood pressure. These vital signs will provide crucial information about the client's current cardiovascular and respiratory status, which is essential for determining the severity of the condition and guiding immediate interventions. Assessing these vital signs will help the nurse quickly identify any signs of hemodynamic instability or respiratory distress, enabling prompt and appropriate treatment to be initiated. Once the assessment is done, further interventions such as oxygen therapy and notifying the healthcare provider can be implemented as needed.
Question 9 of 9
Which risk factor for hypertension is modifiable?
Correct Answer: D
Rationale: Tobacco use is a modifiable risk factor for hypertension. Smoking cigarettes can lead to an increase in blood pressure and heart rate, as well as damage to blood vessels, which can contribute to the development of hypertension. By quitting smoking or avoiding tobacco use, individuals can reduce their risk of developing hypertension and improve their overall cardiovascular health. On the other hand, factors such as age, ethnicity, and family history are non-modifiable risk factors for hypertension, meaning individuals cannot change them through lifestyle modifications.