ATI RN
Transcultural Concepts in Nursing Care 6th Edition Test Bank Questions
Question 1 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 2 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 3 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 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 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 7 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 8 of 9
While assessing for ballottement, a nurse notes that the patella rebounds against the fingers. What does this finding indicate?
Correct Answer: A
Rationale: Ballottement is a physical examination technique used to determine the presence of fluid in a joint, especially the knee joint. When assessing for ballottement, the nurse applies downward pressure on the patella and then releases it. If the patella rebounds or floats back up against the fingers, it indicates the presence of excess fluid within the joint space. This finding is commonly seen in conditions such as knee joint effusion or swelling due to inflammation, trauma, or certain medical conditions. It is an important clinical sign that can help in diagnosing the underlying cause of knee pain or swelling. In this scenario, the patella rebounding against the fingers while assessing for ballottement suggests fluid in the knee joint.
Question 9 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.