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
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 3 of 9
Which form of peripheral vascular disease is characterized by thickening, loss of elasticity, and calcification of arterial walls?
Correct Answer: A
Rationale: Arteriosclerosis is a form of peripheral vascular disease characterized by the thickening, loss of elasticity, and calcification of arterial walls. This results in the narrowing and hardening of the arteries, leading to reduced blood flow to tissues and organs. Atherosclerosis, on the other hand, specifically refers to the buildup of plaque (composed of fat, cholesterol, calcium, and other substances) on the inner walls of arteries, which contributes to arteriosclerosis. Chronic venous insufficiency is a condition involving poor blood flow from the legs back to the heart, often causing swelling and skin changes. Deep venous thrombosis is the formation of a blood clot in a deep vein, commonly in the legs.
Question 4 of 9
The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client?
Correct Answer: B
Rationale: When administering albumin 5% to a client in shock, it is essential to monitor for signs of fluid overload, as albumin is a volume expander. Auscultating breath sounds for crackles is a key nursing action to assess for pulmonary edema, which can be a manifestation of fluid overload. Crackles on auscultation indicate the presence of fluid in the lungs, which may require immediate intervention to prevent respiratory compromise. Therefore, monitoring for crackles in the breath sounds is crucial to detect and address potential complications related to the administration of albumin in this client.
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: Failed to generate a rationale of 500+ characters after 5 retries.
Question 6 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 7 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 8 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 9 of 9
The community nurse is preparing a presentation on Lyme disease for community members. What should the nurse explain about the spread of the organism for this disease?
Correct Answer: C
Rationale: Lyme disease is primarily spread through the bite of an infected black-legged tick, also known as a deer tick. The tick must be infected with the bacterium Borrelia burgdorferi in order to transmit the disease. Contrary to popular belief, the tick doesn't transmit the infection immediately upon biting. Borrelia burgdorferi is typically transmitted after the tick has been attached to the host for at least 24 hours. This gives individuals a window of time to remove attached ticks before transmission occurs. Therefore, the most accurate statement regarding the spread of the organism for Lyme disease is through an infected tick that has been embedded for more than 24 hours.