ATI RN
Transcultural Concepts in Nursing Care Test Bank Questions
Question 1 of 9
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 2 of 9
Which pathological change related to disseminated intravascular coagulation (DIC) occurs late in the course of the disease?
Correct Answer: A
Rationale: Disseminated intravascular coagulation (DIC) is a complex, life-threatening condition characterized by widespread activation of coagulation within the blood vessels. In the early stages of DIC, there is excessive clot formation (formation of small clots) throughout the body due to the dysregulation of coagulation factors. As the disease progresses, the body's clotting factors become depleted, leading to a state of systemic anticoagulation. This anticoagulant state increases the risk of hemorrhage (bleeding) as the blood is no longer able to adequately clot. Therefore, hemorrhage is a pathological change that occurs late in the course of DIC.
Question 3 of 9
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
Question 4 of 9
What type of stroke occurs when the blood supply to a part of the brain is cut off by a thrombus, embolus, or stenosis?
Correct Answer: D
Rationale: An ischemic stroke occurs when the blood supply to a part of the brain is obstructed, typically by a thrombus (a blood clot that forms in a blood vessel and remains attached to its place of origin) or an embolus (a blood clot that travels from a different part of the body and becomes lodged in a blood vessel in the brain). Another cause of ischemic stroke can be stenosis, which is the narrowing of a blood vessel, restricting blood flow to the brain. When the brain does not receive sufficient oxygen and nutrients due to the blockage, brain cells can be damaged or die, leading to a stroke. Ischemic strokes account for the majority of strokes and are essential to manage promptly to minimize brain damage and long-term disability.
Question 5 of 9
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 6 of 9
The nurse identifies the diagnosis of Deficient Fluid Volume as appropriate for a patient with a nasogastric tube for gastric decompression. Which actions should the nurse perform to support this diagnosis? Select all that apply.
Correct Answer: A
Rationale: A. Measuring abdominal girth every 4 to 8 hours is important to monitor for signs of fluid accumulation in the abdominal cavity, indicating potential fluid volume deficit.
Question 7 of 9
The nurse is caring for a client with hypertrophic cardiomyopathy. Based on this diagnosis, which class of medications does the nurse anticipate being prescribed?
Correct Answer: D
Rationale: Beta blockers are commonly prescribed for patients with hypertrophic cardiomyopathy due to their ability to help lower heart rate, reduce myocardial oxygen demand, and improve diastolic filling time. They can also help to prevent arrhythmias in these patients. Digoxin, vasodilators, and nitrates are not typically used as first-line treatment for hypertrophic cardiomyopathy.
Question 8 of 9
The nurse monitors vital signs and laboratory values for a patient recovering from a total knee replacement. For which reason is the nurse implementing these actions?
Correct Answer: C
Rationale: The nurse is monitoring vital signs and laboratory values for the patient recovering from a total knee replacement to ensure adequate circulation to the involved extremity. After a total knee replacement surgery, there is a risk of developing complications such as deep vein thrombosis (DVT) or impaired circulation to the surgical site. Monitoring vital signs and laboratory values allows the nurse to assess for any signs of compromised circulation, which could indicate the development of complications requiring immediate intervention. By closely monitoring these parameters, the nurse can ensure that the patient's recovery is progressing smoothly and without any major complications impacting the circulation to the involved extremity.
Question 9 of 9
The nurse is providing discharge teaching to a client recovering from deep venous thrombosis (DVT). Which instructions are appropriate for the nurse to include in the teaching session? Select all that apply.
Correct Answer: A
Rationale: A. Avoid crossing the legs: Crossing the legs can impede blood flow and increase the risk of developing blood clots, so it is important for the client recovering from DVT to avoid this position.