ATI RN
Transcultural Concepts in Nursing Care 6th Edition Test Bank Questions
Question 1 of 5
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 5
The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client?
Correct Answer: D
Rationale: The priority nursing diagnosis for a client admitted with a gunshot wound to the femoral artery is Decreased Cardiac Output. The femoral artery is a major blood vessel that supplies oxygenated blood to the lower extremities. A gunshot wound to this artery can lead to severe blood loss, causing a decrease in cardiac output. Decreased cardiac output can result in inadequate perfusion to vital organs, potentially leading to shock and organ failure. Therefore, monitoring and addressing the client's cardiac output is the priority to ensure adequate tissue perfusion and prevent further complications. Deficient Fluid Volume may be related to the blood loss but addressing cardiac output is more critical in this situation.
Question 3 of 5
The medication clopidogrel (Plavix) is most commonly given during which stage of treatment for a stroke?
Correct Answer: B
Rationale: Clopidogrel (Plavix) is an antiplatelet medication commonly prescribed during the acute care phase immediately after a stroke. This medication helps prevent blood clots from forming by inhibiting platelets in the blood. It is essential during the acute phase to prevent further blockages in the blood vessels that could lead to more strokes or complications. Once the acute phase is managed, other medications may be incorporated during the recovery, stroke prevention, and rehabilitation stages depending on the individual's condition and risk factors.
Question 4 of 5
The nurse is preparing a discharge diet teaching for a patient with diverticulosis. Which foods should the nurse teach the patient to refrain from eating?
Correct Answer: C
Rationale: When preparing a discharge diet teaching for a patient with diverticulosis, the nurse should advise the patient to refrain from eating foods with small seeds, such as raspberries. These small seeds can potentially get stuck in the diverticula (small pouches formed in the colon) and lead to inflammation or infection, causing further complications for the patient with diverticulosis. It is important for patients with diverticulosis to consume a low-fiber diet to prevent aggravating the condition. Therefore, avoiding foods like raspberries with tiny seeds is advisable to help manage diverticulosis effectively.
Question 5 of 5
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.