ATI RN
Transcultural Concepts in Nursing Care Answers Test Banks Questions
Question 1 of 9
The three pathological factors that are associated with the formation of a thrombus are known as what?
Correct Answer: D
Rationale: Virchow's triad describes the three pathological factors that are associated with the formation of a thrombus. These factors include endothelial injury, abnormal blood flow, and hypercoagulability. Endothelial injury disrupts the normal function of the endothelium, leading to the exposure of collagen and tissue factor, which triggers the coagulation cascade. Abnormal blood flow can result in stasis or turbulence, which promotes the accumulation of platelets and clotting factors. Hypercoagulability refers to an increase in the tendency of the blood to clot, which can be caused by various conditions such as genetic disorders, cancer, and certain medications. These three factors work together to increase the risk of thrombus formation.
Question 2 of 9
The nurse is providing community health teaching on stroke in children and adolescents. Which risk factors for this population should the nurse identify?
Correct Answer: D
Rationale: In children and adolescents, one of the important risk factors for stroke is head trauma. Head injuries can lead to blood vessel damage, increased risk of blood clot formation, and subsequent stroke. It is crucial for healthcare providers to emphasize the importance of injury prevention and appropriate management of head trauma in this population to reduce the risk of stroke. While hypertension, dysrhythmias, and arteriosclerosis are risk factors for stroke in adults, head trauma is a key risk factor to focus on when educating the community on stroke prevention in children and adolescents.
Question 3 of 9
Which strategy to prevent hypertension is correct?
Correct Answer: C
Rationale: The correct strategy to prevent hypertension is to decrease stress. Chronic stress can lead to high blood pressure, so managing stress levels through techniques such as mindfulness, exercise, adequate sleep, and relaxation techniques can help prevent hypertension. It is not advisable to increase salt intake, reduce physical activity, or consistently take hot baths as these can exacerbate hypertension or have no significant impact on preventing it.
Question 4 of 9
After assessing a patient in the emergency department, the nurse determines that the patient has a form of arthritis that is a medical emergency. For which type of arthritis should the nurse plan care for this patient?
Correct Answer: B
Rationale: Septic arthritis is a form of arthritis that is considered a medical emergency. It is an acute, severe infection of a joint often caused by bacteria entering the joint space. Prompt recognition and treatment are essential to prevent irreversible joint damage and systemic spread of the infection. Symptoms of septic arthritis typically include severe joint pain, swelling, redness, warmth, and decreased range of motion. The nurse should plan care to facilitate rapid diagnosis, administration of antibiotics, joint drainage if necessary, and close monitoring for complications. Osteoarthritis, gouty arthritis, and reactive arthritis are not medical emergencies and generally require different treatment approaches.
Question 5 of 9
The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem?
Correct Answer: D
Rationale: When a client has an alteration in perfusion, particularly with inadequate oxygenation, positioning to increase blood return is essential in maintaining adequate tissue perfusion and oxygenation. By positioning the client in a way that maximizes venous return to the heart, the nurse can optimize cardiac output and improve oxygen delivery to the tissues. This can include elevating the legs slightly to facilitate blood return from the lower extremities, ensuring proper alignment of the body to prevent compression of major vessels, and promoting proper body mechanics to reduce the workload on the heart. Encouraging ambulation, instructing on deep breathing, and administering medications to increase heart rate may all have their place in certain scenarios, but for a client at risk for inadequate oxygenation due to perfusion issues, positioning to optimize blood return is the most crucial consideration.
Question 6 of 9
A nurse is caring for a client with cardiomyopathy who is experiencing activity intolerance. Which intervention is inappropriate for this nursing diagnosis?
Correct Answer: C
Rationale: While the interventions of spacing out nursing activities, assisting with ADLs, and consulting with a physical therapist are appropriate for a client with cardiomyopathy experiencing activity intolerance, using passive and active range-of-motion exercises may not be suitable. In this condition, the heart muscle is weakened and may not be able to tolerate the increased activity associated with range-of-motion exercises. These exercises could potentially place additional strain on the heart and exacerbate symptoms such as shortness of breath and fatigue. It would be safer to focus on activities that do not overly stress the cardiovascular system while still promoting mobility and independence.
Question 7 of 9
The nurse is caring for a patient with a small-bowel obstruction. Which action is the highest priority for this patient?
Correct Answer: A
Rationale: For a patient with a small-bowel obstruction, the highest priority action is to maintain nasogastric suction. This helps to decompress the bowel and relieve the obstruction by removing fluid and gas from the gastrointestinal tract. It can also help prevent complications such as bowel perforation and reduce the risk of aspiration if the patient vomits. Managing the obstruction is crucial to prevent further complications and promote the patient's recovery. Administering prescribed analgesics, keeping strict intake and output records, and placing the patient in a semi-Fowler's position are important interventions but may not address the immediate need to relieve the obstruction.
Question 8 of 9
The nurse is providing teaching about infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement by the client indicates that teaching was effective?
Correct Answer: B
Rationale: The correct statement indicating that teaching was effective is "It's a protein that pulls water into my blood vessels." Albumin is a type of protein found in the blood that helps to maintain blood volume and pressure by pulling water into the blood vessels from surrounding tissues. In the case of a client recovering from hypovolemic shock, infusion of albumin 5% can help to restore blood volume and improve circulation. The other statements do not accurately describe the function of albumin in the body.
Question 9 of 9
The nurse is caring for a patient in the spinal shock phase following a spinal cord injury. Which action is the most appropriate to maintain this patient’s bladder functioning?
Correct Answer: B
Rationale: In the spinal shock phase following a spinal cord injury, the patient may have impaired bladder functioning due to the disruption of nerve pathways. Stimulating voiding using Crede's method (choice A) is not appropriate as it can increase the risk of causing further harm to the patient's bladder. Catheterizing with a straight catheter every 3 to 4 hours (choice C) is also not recommended unless there is a specific indication for catheterization. Inserting an indwelling urinary catheter to accurately measure output (choice D) is invasive and may increase the risk of infection.