ATI RN
Transcultural Concepts in Nursing Care 6th Edition Test Bank Questions
Question 1 of 9
A home care nurse is explaining the application of an Unna boot to a client with a stasis ulcer. Which statement about this dressing is accurate?
Correct Answer: D
Rationale: An Unna boot is a type of compression bandage that is impregnated with zinc oxide paste. This paste helps to provide a moist environment for the wound, which can promote healing and also has antimicrobial properties. The compression from the Unna boot helps to reduce swelling and improve circulation in the affected area, which is beneficial for treating stasis ulcers. By understanding that an Unna boot contains zinc oxide paste, the home care nurse can ensure proper application and effectiveness in promoting wound healing.
Question 2 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.
Question 3 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 4 of 9
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 9
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 6 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 7 of 9
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 8 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 9 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.