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
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 3 of 9
Which client has the highest risk of developing peripheral vascular disease (PVD)?
Correct Answer: A
Rationale: African Americans have a higher prevalence of peripheral vascular disease (PVD) compared to other ethnic groups. Additionally, advancing age is a significant risk factor for developing PVD. Therefore, the 83-year-old African American male has the highest risk among the given options due to his age and ethnicity.
Question 4 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 5 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 6 of 9
The nurse is preparing to assess a patient’s musculoskeletal system. What should the nurse keep in mind as being the most common manifestations of musculoskeletal disorders?
Correct Answer: A
Rationale: Pain and limited mobility are the most common manifestations of musculoskeletal disorders. Patients with musculoskeletal issues often experience pain, which can be localized to the affected area or radiate to other parts of the body. Pain can range from mild discomfort to severe and debilitating. Limited mobility refers to a decreased range of motion in joints or difficulty moving due to stiffness, weakness, or structural abnormalities. These symptoms can significantly impact a patient's daily activities and quality of life. Pallor, cyanosis, decreased pulses, and exaggerated reflexes are not typically associated with musculoskeletal disorders and may indicate other health conditions.
Question 7 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 8 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.
Question 9 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.