ATI RN
Transcultural Concepts in Nursing Care 7th Edition Test Bank Questions
Question 1 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: A. Excessive sweating: Children with congestive heart failure (CHF) may experience excessive sweating as their bodies work harder to keep up with the demands of the heart, leading to increased sympathetic tone and perspiration.
Question 2 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.
Question 3 of 5
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 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: A. Excessive sweating: Children with congestive heart failure (CHF) may experience excessive sweating as their bodies work harder to keep up with the demands of the heart, leading to increased sympathetic tone and perspiration.
Question 5 of 5
A patient has difficulty getting to the bathroom in time to prevent urine leaks once the need to void occurs. What should the nurse teach this patient?
Correct Answer: B
Rationale: Establishing a voiding schedule that includes emptying the bladder at least every 2 hours can help prevent urine leaks in this patient. By regularly emptying the bladder, the patient can reduce the likelihood of urgency and leakage episodes. This strategy helps in managing the symptoms of urge incontinence or overactive bladder, which seem to be the underlying issues for the patient described in the scenario. The other options may also be helpful in managing urinary incontinence but creating a voiding schedule is the most direct and effective approach for the patient's specific concern.
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