ATI RN
Transcultural Concepts in Nursing Care 7th Edition Test Bank Questions
Question 1 of 9
Which physiological changes associated with aging increase the risk of hypertension in older adults?
Correct Answer: A
Rationale: As individuals age, there is a natural increase in systolic blood pressure (the top number in a blood pressure reading). This rise is attributed to factors such as arterial stiffness, reduced compliance of blood vessels, and decreased elasticity of the arteries. This increase in systolic blood pressure with age is considered a significant risk factor for hypertension in older adults. Hypertension is commonly defined as having a systolic blood pressure of 140 mmHg or higher and/or a diastolic blood pressure of 90 mmHg or higher. Therefore, the age-related increase in systolic blood pressure contributes to the overall risk of developing hypertension in the elderly population.
Question 2 of 9
The nurse is caring for a child with congestive heart failure (CHF). Which clinical manifestations does the nurse anticipate when assessing this child? Select all that apply.
Correct Answer: A
Rationale: A. Excessive sweating: Children with congestive heart failure (CHF) may experience excessive sweating as their bodies work harder to keep up with the demands of the heart, leading to increased sympathetic tone and perspiration.
Question 3 of 9
A patient has difficulty getting to the bathroom in time to prevent urine leaks once the need to void occurs. What should the nurse teach this patient?
Correct Answer: B
Rationale: Establishing a voiding schedule that includes emptying the bladder at least every 2 hours can help prevent urine leaks in this patient. By regularly emptying the bladder, the patient can reduce the likelihood of urgency and leakage episodes. This strategy helps in managing the symptoms of urge incontinence or overactive bladder, which seem to be the underlying issues for the patient described in the scenario. The other options may also be helpful in managing urinary incontinence but creating a voiding schedule is the most direct and effective approach for the patient's specific concern.
Question 4 of 9
The nurse is planning care for a client admitted with a cardiac dysrhythmia. Which action would be the most appropriate for this client?
Correct Answer: C
Rationale: Monitoring serum electrolyte levels would be the most appropriate action for a client admitted with a cardiac dysrhythmia. Electrolyte imbalances, particularly potassium and magnesium, can lead to cardiac dysrhythmias. Therefore, it is crucial to monitor and maintain proper electrolyte levels to prevent or manage dysrhythmias. Restricting fluids, encouraging bedrest, or instructing in a low-fat diet are not the priority actions for managing a cardiac dysrhythmia.
Question 5 of 9
A client being treated for a deep venous thrombosis (DVT) is experiencing pain. Which interventions should the nurse implement? Select all that apply.
Correct Answer: B
Rationale: - **Bedrest as ordered (B):** Bedrest is essential for managing deep venous thrombosis to prevent clot dislodgment and further complications. It helps reduce excessive movement, which can increase the risk of clots breaking loose and traveling to the lungs, causing a pulmonary embolism.
Question 6 of 9
A nurse is caring for a group of clients who are recovering in a rehabilitation hospital following total hip replacements. Which client is exhibiting the highest motivation to learn?
Correct Answer: C
Rationale: The client who is excited to learn ambulation techniques (Option C) is exhibiting the highest motivation to learn. This client's enthusiasm for learning new skills related to ambulation indicates a strong willingness to actively engage in their rehabilitation process. Learning ambulation techniques is a crucial aspect of recovery following a total hip replacement, as it helps improve mobility and independence. The excitement to learn demonstrates that this client is eager to participate in their rehabilitation and is likely to be more proactive in achieving their recovery goals.
Question 7 of 9
During a 6-month well-baby check up, the mother mentions to the nurse that her infant seems to be sleeping just as much as she did as a newborn, and she seems to do everything with her left hand. The nurse recognizes that these are warning signs of stroke that occurred early in life. What other question should the nurse ask to assess for signs of stroke?
Correct Answer: A
Rationale: Jerking movements in the face, arms, or legs can be a sign of seizures, which can occur as a result of a stroke in infants. This question is important to assess whether the infant may have experienced any seizure activity, which could indicate a potential stroke. It helps the nurse gather more information to understand the infant's symptoms and assess the possibility of a stroke event.
Question 8 of 9
The nurse is auscultating heart sounds for a pregnant client in the third trimester of pregnancy. The client wants to know why her doctor told her she had an extra heart sound at the last visit. Which response by the nurse is appropriate?
Correct Answer: C
Rationale: During pregnancy, it is not uncommon for women to have an extra heart sound known as a gallop rhythm. This is often referred to as a ventricular gallop, which is the presence of an S3 heart sound. In pregnant women, the increased blood volume and changes in heart dynamics can lead to the development of this extra sound. It is considered a normal finding during the third trimester of pregnancy and is usually not a cause for concern. It is important for healthcare providers to differentiate between normal physiological changes associated with pregnancy and potential heart abnormalities, which is why a ventricular gallop in this context is typically considered a benign finding.
Question 9 of 9
During the physical assessment of a young adult, the nurse notes a lateral, S-shaped curve of the spine. What should the nurse suspect is occurring with this patient?
Correct Answer: B
Rationale: Scoliosis is a condition characterized by an abnormal lateral curvature of the spine, often forming an S-shaped or C-shaped curve when viewed from behind. It commonly occurs in young adults during growth spurts, especially teenage girls. Scoliosis can be mild or severe, and early detection is crucial to prevent further progression and potential complications. Treatment options may include physical therapy, bracing, or in more severe cases, surgery. Lordosis is an inward curvature of the lower back, Kyphosis is an excessive outward curvature of the spine commonly known as "hunchback," and Musculosis is not a recognized medical term related to spinal conditions.