Questions 9

ATI RN

ATI RN Test Bank

Transcultural Concepts in Nursing Care 6th Edition Test Bank Questions

Question 1 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 2 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.

Question 3 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 4 of 5

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.

Question 5 of 5

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.

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