ATI RN
Transcultural Concepts in Nursing Care 6th Edition Test Bank Questions
Question 1 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 2 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 3 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 4 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 5 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 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
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 8 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.
Question 9 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.