ATI RN
Transcultural Concepts in Nursing Care 7th Edition Test Bank Questions
Question 1 of 9
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 9
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 3 of 9
The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client?
Correct Answer: B
Rationale: When administering albumin 5% to a client in shock, it is essential to monitor for signs of fluid overload, as albumin is a volume expander. Auscultating breath sounds for crackles is a key nursing action to assess for pulmonary edema, which can be a manifestation of fluid overload. Crackles on auscultation indicate the presence of fluid in the lungs, which may require immediate intervention to prevent respiratory compromise. Therefore, monitoring for crackles in the breath sounds is crucial to detect and address potential complications related to the administration of albumin in this client.
Question 4 of 9
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 5 of 9
Which form of peripheral vascular disease is characterized by thickening, loss of elasticity, and calcification of arterial walls?
Correct Answer: A
Rationale: Arteriosclerosis is a form of peripheral vascular disease characterized by the thickening, loss of elasticity, and calcification of arterial walls. This results in the narrowing and hardening of the arteries, leading to reduced blood flow to tissues and organs. Atherosclerosis, on the other hand, specifically refers to the buildup of plaque (composed of fat, cholesterol, calcium, and other substances) on the inner walls of arteries, which contributes to arteriosclerosis. Chronic venous insufficiency is a condition involving poor blood flow from the legs back to the heart, often causing swelling and skin changes. Deep venous thrombosis is the formation of a blood clot in a deep vein, commonly in the legs.
Question 6 of 9
The community nurse is preparing a presentation on Lyme disease for community members. What should the nurse explain about the spread of the organism for this disease?
Correct Answer: C
Rationale: Lyme disease is primarily spread through the bite of an infected black-legged tick, also known as a deer tick. The tick must be infected with the bacterium Borrelia burgdorferi in order to transmit the disease. Contrary to popular belief, the tick doesn't transmit the infection immediately upon biting. Borrelia burgdorferi is typically transmitted after the tick has been attached to the host for at least 24 hours. This gives individuals a window of time to remove attached ticks before transmission occurs. Therefore, the most accurate statement regarding the spread of the organism for Lyme disease is through an infected tick that has been embedded for more than 24 hours.
Question 7 of 9
The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action would be the most appropriate for this client?
Correct Answer: C
Rationale: Monitoring serum electrolyte levels would be the most appropriate action for a client admitted with a cardiac dysrhythmia. Electrolyte imbalances, particularly potassium and magnesium, can lead to cardiac dysrhythmias. Therefore, it is crucial to monitor and maintain proper electrolyte levels to prevent or manage dysrhythmias. Restricting fluids, encouraging bedrest, or instructing in a low-fat diet are not the priority actions for managing a cardiac dysrhythmia.
Question 8 of 9
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 9 of 9
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.