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?

Questions 15

ATI RN

ATI RN Test Bank

Transcultural Concepts in Nursing Care 7th Edition Test Bank Questions

Question 1 of 9

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 9

The nurse is caring for a client diagnosed with cardiomyopathy. The client experiences tachycardia. Which medication does the nurse anticipate being prescribed?

Correct Answer: C

Rationale: In the case of a client diagnosed with cardiomyopathy and experiencing tachycardia, a beta blocker is the anticipated medication. Beta blockers work by blocking the effects of adrenaline on the heart, reducing heart rate, blood pressure, and myocardial oxygen demand. This can help manage symptoms of tachycardia in cardiomyopathy by slowing down the heart rate and improving its overall function. Other medications like ACE inhibitors and angiotensin II receptor blockers may be used to manage specific aspects of cardiomyopathy such as hypertension or heart failure, but in the context of tachycardia, a beta blocker is the preferred choice. Cardiac glycosides, like Digoxin, are used for heart failure but not primarily for managing tachycardia in cardiomyopathy.

Question 3 of 9

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 4 of 9

A nurse is caring for a group of clients who are recovering in a rehabilitation hospital following total hip replacements. Which client is exhibiting the highest motivation to learn?

Correct Answer: C

Rationale: The client who is excited to learn ambulation techniques (Option C) is exhibiting the highest motivation to learn. This client's enthusiasm for learning new skills related to ambulation indicates a strong willingness to actively engage in their rehabilitation process. Learning ambulation techniques is a crucial aspect of recovery following a total hip replacement, as it helps improve mobility and independence. The excitement to learn demonstrates that this client is eager to participate in their rehabilitation and is likely to be more proactive in achieving their recovery goals.

Question 5 of 9

Which form of peripheral vascular disease is characterized by thickening, loss of elasticity, and calcification of arterial walls?

Correct Answer: A

Rationale: Arteriosclerosis is a form of peripheral vascular disease characterized by the thickening, loss of elasticity, and calcification of arterial walls. This results in the narrowing and hardening of the arteries, leading to reduced blood flow to tissues and organs. Atherosclerosis, on the other hand, specifically refers to the buildup of plaque (composed of fat, cholesterol, calcium, and other substances) on the inner walls of arteries, which contributes to arteriosclerosis. Chronic venous insufficiency is a condition involving poor blood flow from the legs back to the heart, often causing swelling and skin changes. Deep venous thrombosis is the formation of a blood clot in a deep vein, commonly in the legs.

Question 6 of 9

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.

Question 7 of 9

The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client?

Correct Answer: B

Rationale: When administering albumin 5% to a client in shock, it is essential to monitor for signs of fluid overload, as albumin is a volume expander. Auscultating breath sounds for crackles is a key nursing action to assess for pulmonary edema, which can be a manifestation of fluid overload. Crackles on auscultation indicate the presence of fluid in the lungs, which may require immediate intervention to prevent respiratory compromise. Therefore, monitoring for crackles in the breath sounds is crucial to detect and address potential complications related to the administration of albumin in this client.

Question 8 of 9

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: - **Bedrest as ordered (B):** Bedrest is essential for managing deep venous thrombosis to prevent clot dislodgment and further complications. It helps reduce excessive movement, which can increase the risk of clots breaking loose and traveling to the lungs, causing a pulmonary embolism.

Question 9 of 9

The community nurse is preparing a presentation on Lyme disease for community members. What should the nurse explain about the spread of the organism for this disease?

Correct Answer: C

Rationale: Lyme disease is primarily spread through the bite of an infected black-legged tick, also known as a deer tick. The tick must be infected with the bacterium Borrelia burgdorferi in order to transmit the disease. Contrary to popular belief, the tick doesn't transmit the infection immediately upon biting. Borrelia burgdorferi is typically transmitted after the tick has been attached to the host for at least 24 hours. This gives individuals a window of time to remove attached ticks before transmission occurs. Therefore, the most accurate statement regarding the spread of the organism for Lyme disease is through an infected tick that has been embedded for more than 24 hours.

Access More Questions!

ATI RN Basic


$89/ 30 days

ATI RN Premium


$150/ 90 days