ATI RN
Transcultural Concepts in Nursing Care Test Bank Questions
Question 1 of 5
A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen™) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate?
Correct Answer: A
Rationale: The most appropriate response by the nurse is Option A, "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." This response is accurate because anaphylactic shock, which is caused by severe allergic reactions, can be life-threatening if not treated promptly with epinephrine (EpiPen™). While heart failure is a serious type of shock, anaphylactic shock is specifically related to severe allergic reactions and not heart failure. The nurse's response educates the mother about the seriousness of anaphylactic shock in relation to allergic responses and highlights that other types of shock can involve different organ system failures.
Question 2 of 5
The nurse is assessing muscle strength. What should the nurse ask the patient to do to assess facial muscle strength?
Correct Answer: A
Rationale: Asking the patient to clench their teeth is a common way to assess muscle strength in the face, particularly the muscles involved in the jaw. Clenching the teeth engages the muscles responsible for this action, such as the masseter muscle. Assessing the ability to clench the teeth provides insight into the strength and function of these facial muscles.
Question 3 of 5
A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen™) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate?
Correct Answer: A
Rationale: The most appropriate response by the nurse is Option A, "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." This response is accurate because anaphylactic shock, which is caused by severe allergic reactions, can be life-threatening if not treated promptly with epinephrine (EpiPen™). While heart failure is a serious type of shock, anaphylactic shock is specifically related to severe allergic reactions and not heart failure. The nurse's response educates the mother about the seriousness of anaphylactic shock in relation to allergic responses and highlights that other types of shock can involve different organ system failures.
Question 4 of 5
The nurse is assessing an adult client with a cardiac dysrhythmia. Which finding would the nurse identify as possibly contributing to this client's dysrhythmia?
Correct Answer: A
Rationale: Consuming caffeinated coffee can potentially contribute to cardiac dysrhythmias in susceptible individuals. Caffeine is a stimulant that can increase heart rate and blood pressure, leading to arrhythmias in some people. Regular intake of caffeinated beverages can disrupt the normal electrical activity of the heart, especially in those with underlying cardiac conditions. Therefore, the nurse would identify drinking caffeinated coffee as a possible contributing factor to the client's dysrhythmia.
Question 5 of 5
The nurse is caring for a pregnant woman with congenital heart disease. The woman asks if she will be able to have a vaginal delivery. Which answer by the nurse is correct?
Correct Answer: C
Rationale: A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. Aortic stenosis is a type of congenital heart disease that restricts blood flow from the heart to the rest of the body due to a narrowing of the aortic valve. In women with aortic stenosis, the increased blood volume and heart rate during labor and delivery can put extra strain on the heart. However, in most cases, vaginal delivery is preferred over a Cesarean section to avoid the risks associated with major abdominal surgery, such as bleeding, infection, and thrombophlebitis. A vaginal birth allows for a more gradual and controlled increase in cardiac output compared to the more sudden changes that can occur during a Cesarean section. Additionally, the stress of labor may mimic the stress test for some patients, providing valuable information about their heart function. However, each case is unique and must be evaluated by the healthcare team
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