ATI RN
Transcultural Concepts in Nursing Care 6th Edition Test Bank Questions
Question 1 of 9
The nurse is planning care for several clients. Which client should the nurse identify as being at greatest risk of developing heart failure?
Correct Answer: B
Rationale: Smoking is a major risk factor for developing heart failure. African Americans are at a higher risk of heart failure compared to Caucasians. Additionally, being female and smoking further increase the risk. Smoking damages the blood vessels and heart, leading to various cardiovascular problems including heart failure. Therefore, the 50-year-old African American female who smokes is at the greatest risk of developing heart failure among the given options.
Question 2 of 9
The nurse asks the client to repeat the information taught during the discharge teaching session. The client states, "I have forgotten everything you just said." Which action by the nurse would is appropriate at this time?
Correct Answer: D
Rationale: Asking the client about their preferred learning strategies is the appropriate action at this time. Everyone learns in different ways, and by identifying the client's preferred learning style, the nurse can tailor the teaching session to be more effective and memorable for the client. Understanding how the client learns best can help in providing information in a way that is easier for them to retain and recall later. It also demonstrates a client-centered approach to teaching, which can improve communication and understanding between the client and the healthcare provider.
Question 3 of 9
A client admitted with a cardiac dysrhythmia reports being easily fatigued and has difficulty performing normal daily activities. Which nursing diagnosis should the nurse select to address this client's issue?
Correct Answer: B
Rationale: The nursing diagnosis of Activity Intolerance is the most appropriate for a client with a cardiac dysrhythmia who reports being easily fatigued and having difficulty performing normal daily activities. Cardiac dysrhythmias can lead to decreased cardiac output, which can result in reduced oxygen delivery to the body's tissues, contributing to fatigue and weakness. Activity Intolerance is defined as the state in which an individual experiences or is at risk of experiencing insufficient physiological or psychological energy to endure or complete daily activities. This diagnosis is fitting for the client's inability to perform normal daily activities due to the cardiac dysrhythmia-induced fatigue and weakness. Addressing Activity Intolerance will involve collaborating with the client to set achievable activity goals and incorporating periods of rest to enhance tolerance to physical activity and improve overall function.
Question 4 of 9
A home care nurse is explaining the application of an Unna boot to a client with a stasis ulcer. Which statement about this dressing is accurate?
Correct Answer: D
Rationale: An Unna boot is a type of compression bandage that is impregnated with zinc oxide paste. This paste helps to provide a moist environment for the wound, which can promote healing and also has antimicrobial properties. The compression from the Unna boot helps to reduce swelling and improve circulation in the affected area, which is beneficial for treating stasis ulcers. By understanding that an Unna boot contains zinc oxide paste, the home care nurse can ensure proper application and effectiveness in promoting wound healing.
Question 5 of 9
The nurse is identifying goals of care for a patient with stress incontinence. Which goal would be a priority for this patient?
Correct Answer: D
Rationale: Stress incontinence is commonly caused by the weakening of the pelvic floor muscles that support the bladder and urethra. Thus, a priority goal for a patient with stress incontinence would be to strengthen these muscles through pelvic floor muscle exercises. By performing these exercises as taught by the nurse at least twice a day, the patient can improve the support to the bladder and reduce or manage the symptoms of stress incontinence. This proactive approach addresses the root cause of the issue and can lead to significant improvement in the patient's condition over time. Understanding the chronic and benign nature of the disorder (Option A), identifying protective products (Option B), and limiting intake of certain beverages (Option C) can also be important aspects of care but may not directly address the underlying cause as effectively as pelvic floor muscle exercises.
Question 6 of 9
The nurse identifies the diagnosis of Ineffective Protection as appropriate for a patient with systemic lupus erythematosus. Which intervention should the nurse include when planning this patient’s care?
Correct Answer: B
Rationale: Ineffective Protection is a nursing diagnosis that involves a compromised ability to guard against health threats. Patients with systemic lupus erythematosus are prone to skin rashes, lesions, and photosensitivity due to the autoimmune nature of the disease. Providing appropriate skincare is essential in managing the skin manifestations of lupus, such as using gentle cleansers, moisturizers, and sunscreen to protect the skin from further damage. Proper skincare can help maintain skin integrity and prevent infections, which are crucial aspects of protecting patients with systemic lupus erythematosus. While monitoring laboratory findings, practicing careful hand hygiene, and administering prescribed medications are all important aspects of care for lupus patients, providing appropriate skincare directly addresses the Ineffective Protection diagnosis by focusing on protecting the patient's skin health.
Question 7 of 9
Which risk factor for hypertension is modifiable?
Correct Answer: D
Rationale: Tobacco use is a modifiable risk factor for hypertension. Smoking cigarettes can lead to an increase in blood pressure and heart rate, as well as damage to blood vessels, which can contribute to the development of hypertension. By quitting smoking or avoiding tobacco use, individuals can reduce their risk of developing hypertension and improve their overall cardiovascular health. On the other hand, factors such as age, ethnicity, and family history are non-modifiable risk factors for hypertension, meaning individuals cannot change them through lifestyle modifications.
Question 8 of 9
The nurse is preparing a discharge diet teaching for a patient with diverticulosis. Which foods should the nurse teach the patient to refrain from eating?
Correct Answer: C
Rationale: When preparing a discharge diet teaching for a patient with diverticulosis, the nurse should advise the patient to refrain from eating foods with small seeds, such as raspberries. These small seeds can potentially get stuck in the diverticula (small pouches formed in the colon) and lead to inflammation or infection, causing further complications for the patient with diverticulosis. It is important for patients with diverticulosis to consume a low-fiber diet to prevent aggravating the condition. Therefore, avoiding foods like raspberries with tiny seeds is advisable to help manage diverticulosis effectively.
Question 9 of 9
A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse?
Correct Answer: A
Rationale: The priority action by the nurse when a client receiving heparin therapy for deep venous thrombosis (DVT) presents with symptoms suggestive of a pulmonary embolism, such as severe chest pain and shortness of breath, is to assess the client's pulse, respirations, and blood pressure. These vital signs will provide crucial information about the client's current cardiovascular and respiratory status, which is essential for determining the severity of the condition and guiding immediate interventions. Assessing these vital signs will help the nurse quickly identify any signs of hemodynamic instability or respiratory distress, enabling prompt and appropriate treatment to be initiated. Once the assessment is done, further interventions such as oxygen therapy and notifying the healthcare provider can be implemented as needed.