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 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 3 of 9
The nurse is preparing preoperative teaching for a client scheduled for a ventricular assist device (VAD). Which should the nurse include in these instructions?
Correct Answer: D
Rationale: The nurse should include the instruction that the client can expect to be ambulating, or walking around, on the evening of surgery. Early ambulation after VAD placement is important to prevent complications such as blood clots, pneumonia, and muscle weakness. Encouraging early mobility can also improve overall recovery and decrease the risk of postoperative complications. It is important for the client to understand that they will be encouraged to begin moving around as soon as possible after the surgery.
Question 4 of 9
The nurse educator is preparing to teach a group of nursing students how to navigate the internet to research healthcare information. Which does the educator plan to include during lecture?
Correct Answer: B
Rationale: The nurse educator plans to include teaching the nursing students how to search for and evaluate health information on the internet during the lecture. This is important because in today's digital age, nurses need to be able to effectively navigate the vast amount of healthcare information available online. Teaching students how to search for reliable sources, critically evaluate the information they find, and distinguish between credible and non-credible sources will help them in their nursing practice. This knowledge is essential for evidence-based practice and providing quality care to patients. Additionally, nurses should be aware of ethical considerations related to accessing and using online healthcare information.
Question 5 of 9
During an assessment, a client with left-sided congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care?
Correct Answer: B
Rationale: In this situation, the nursing diagnosis of Ineffective Health Management is of the greatest initial importance when planning care. The client's inability to afford medications due to financial constraints directly affects their ability to manage their health effectively. Lack of funds may lead to non-adherence to the prescribed treatment plan, which can worsen the client's condition. By addressing the financial barriers to medication access, the nurse can help the client improve their health management and outcomes. This nursing diagnosis is a priority as it addresses the immediate need to ensure the client's access to necessary medications and prevent exacerbation of their congestive heart failure.
Question 6 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 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
A client is receiving procainamide hydrochloride (Pronestyl) for treatment of a dysrhythmia. Which is an appropriate client outcome related to adhering to the provided medication instruction?
Correct Answer: B
Rationale: Monitoring the pulse and not taking procainamide hydrochloride if the pulse is less than a specified rate is a crucial aspect of medication adherence for clients receiving this medication. Procainamide hydrochloride is an antiarrhythmic medication that can affect conduction and increase the risk of dangerous dysrhythmias. Therefore, monitoring the pulse rate helps in early identification of potential adverse effects, such as heart block, that may necessitate withholding the medication and seeking medical attention. By adhering to this instruction, the client can actively participate in their care to ensure safe and effective treatment with procainamide hydrochloride.
Question 9 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.