ATI RN
Transcultural Concepts in Nursing Care Test Bank Questions
Question 1 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 2 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 3 of 9
At a local health fair, a male participant remarks to the nurse about urine occasionally being pink and wonders if this should be a concern. How should the nurse respond?
Correct Answer: C
Rationale: Instructing the participant to track the relationship between urine color and activities would be the most appropriate response in this situation. Occasionally having pink urine can be caused by various factors, such as certain foods, medications, strenuous exercise, or even dehydration. By tracking when the urine appears pink in relation to these activities, the participant can gather valuable information to share with a healthcare provider if needed. This approach can help identify any patterns and determine the underlying cause, guiding further evaluation or management if necessary. It allows for a proactive and informative approach before seeking medical attention, as long as there are no other concerning symptoms present.
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 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.
Question 6 of 9
A nurse conducted a safety class for a group of older adult clients in the community on fall prevention. During a follow-up visit in the home of one of these clients, the nurse sees a number of fall hazards she identified during her class. What should the nurse document regarding the learning outcome for this client?
Correct Answer: C
Rationale: The nurse should document that the client understood the teaching given in the class but chose to ignore it. This reflects the concept of non-compliance, where the client has the knowledge and understanding of the fall prevention measures but consciously chooses not to implement them. It is important for healthcare providers to document when patients understand the information provided but do not follow through with recommended actions, as this can help in further tailoring interventions and support to increase compliance and improve health outcomes.
Question 7 of 9
A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen™) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate?
Correct Answer: A
Rationale: The most appropriate response by the nurse is Option A, "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." This response is accurate because anaphylactic shock, which is caused by severe allergic reactions, can be life-threatening if not treated promptly with epinephrine (EpiPen™). While heart failure is a serious type of shock, anaphylactic shock is specifically related to severe allergic reactions and not heart failure. The nurse's response educates the mother about the seriousness of anaphylactic shock in relation to allergic responses and highlights that other types of shock can involve different organ system failures.
Question 8 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 9 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.