ATI RN
Transcultural Concepts in Nursing Care 7th Edition Test Bank Questions
Question 1 of 5
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 2 of 5
The nurse is caring for a client who has had a myocardial infarction. The client states, "I have been smoking for 35 years, what good will quitting do?" Which response is best?
Correct Answer: A
Rationale: The best response is "Your risk of continued coronary artery disease will decrease by half when you stop." This response provides a specific and concrete benefit of quitting smoking for the client with a history of myocardial infarction. By explaining that quitting smoking can reduce the risk of continued coronary artery disease by half, the nurse is providing motivation and encouragement for the client to make a positive change in their lifestyle. This information is factual and can help the client understand the immediate benefits of quitting smoking in relation to their current health condition.
Question 3 of 5
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: In this scenario, the correct interventions for a client with DVT experiencing pain are maintaining bedrest as ordered and encouraging position changes every 2 hours. Maintaining bedrest helps prevent further complications by reducing the risk of dislodging the clot. Encouraging position changes every 2 hours promotes circulation and prevents stasis, which can worsen the DVT. Applying an egg-crate mattress on the bed is incorrect as it does not directly address the pain associated with DVT or contribute to its management. Applying warm moist heat four times a day can actually increase inflammation and blood flow to the area, potentially dislodging the clot and worsening the condition. Educationally, students need to understand the rationale behind interventions for managing DVT to prevent complications and improve patient outcomes. By explaining why specific interventions are appropriate or inappropriate, students can develop critical thinking skills and clinical reasoning to provide safe and effective nursing care.
Question 4 of 5
The nurse is caring for a child with congestive heart failure (CHF). Which clinical manifestations does the nurse anticipate when assessing this child? Select all that apply.
Correct Answer: A
Rationale: In caring for a child with congestive heart failure (CHF), the nurse must anticipate certain clinical manifestations. The correct answer is A) Excessive sweating. In CHF, the heart's inability to pump effectively leads to decreased cardiac output, causing the body to compensate by activating the sympathetic nervous system, which can result in excessive sweating. Option B) Hypertension is incorrect because CHF typically presents with hypotension due to the heart's reduced ability to pump effectively. Option C) Bradycardia is incorrect as CHF commonly causes tachycardia as the body tries to compensate for the decreased cardiac output. Option D) Difficulty breathing is a common symptom of CHF due to fluid buildup in the lungs, known as pulmonary edema, but it is not included in the anticipated clinical manifestations listed in the question stem. Understanding the expected clinical manifestations of CHF in children is crucial for nurses to provide timely and appropriate care. Recognizing these signs can help nurses intervene promptly to prevent complications and improve outcomes for pediatric patients with CHF.
Question 5 of 5
Which physiological changes associated with aging increase the risk of hypertension in older adults?
Correct Answer: A
Rationale: As individuals age, there is a natural increase in systolic blood pressure (the top number in a blood pressure reading). This rise is attributed to factors such as arterial stiffness, reduced compliance of blood vessels, and decreased elasticity of the arteries. This increase in systolic blood pressure with age is considered a significant risk factor for hypertension in older adults. Hypertension is commonly defined as having a systolic blood pressure of 140 mmHg or higher and/or a diastolic blood pressure of 90 mmHg or higher. Therefore, the age-related increase in systolic blood pressure contributes to the overall risk of developing hypertension in the elderly population.