ATI RN
Transcultural Concepts in Nursing Care 6th Edition Test Bank Questions
Question 1 of 9
While assessing for ballottement, a nurse notes that the patella rebounds against the fingers. What does this finding indicate?
Correct Answer: A
Rationale: Ballottement is a physical examination technique used to determine the presence of fluid in a joint, especially the knee joint. When assessing for ballottement, the nurse applies downward pressure on the patella and then releases it. If the patella rebounds or floats back up against the fingers, it indicates the presence of excess fluid within the joint space. This finding is commonly seen in conditions such as knee joint effusion or swelling due to inflammation, trauma, or certain medical conditions. It is an important clinical sign that can help in diagnosing the underlying cause of knee pain or swelling. In this scenario, the patella rebounding against the fingers while assessing for ballottement suggests fluid in the knee joint.
Question 2 of 9
A client receiving heparin therapy for deep venous thrombosis (DVT) complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, which is the priority action by the nurse?
Correct Answer: A
Rationale: The priority action by the nurse when a client receiving heparin therapy for deep venous thrombosis (DVT) presents with symptoms suggestive of a pulmonary embolism, such as severe chest pain and shortness of breath, is to assess the client's pulse, respirations, and blood pressure. These vital signs will provide crucial information about the client's current cardiovascular and respiratory status, which is essential for determining the severity of the condition and guiding immediate interventions. Assessing these vital signs will help the nurse quickly identify any signs of hemodynamic instability or respiratory distress, enabling prompt and appropriate treatment to be initiated. Once the assessment is done, further interventions such as oxygen therapy and notifying the healthcare provider can be implemented as needed.
Question 3 of 9
The nurse is identifying goals of care for a patient with stress incontinence. Which goal would be a priority for this patient?
Correct Answer: D
Rationale: Stress incontinence is commonly caused by the weakening of the pelvic floor muscles that support the bladder and urethra. Thus, a priority goal for a patient with stress incontinence would be to strengthen these muscles through pelvic floor muscle exercises. By performing these exercises as taught by the nurse at least twice a day, the patient can improve the support to the bladder and reduce or manage the symptoms of stress incontinence. This proactive approach addresses the root cause of the issue and can lead to significant improvement in the patient's condition over time. Understanding the chronic and benign nature of the disorder (Option A), identifying protective products (Option B), and limiting intake of certain beverages (Option C) can also be important aspects of care but may not directly address the underlying cause as effectively as pelvic floor muscle exercises.
Question 4 of 9
The nurse is documenting assessment findings on a client with angina. Which term should the nurse use to describe chest pain that occurs at night and is unrelated to activity?
Correct Answer: B
Rationale: Prinzmetal angina, also known as variant angina or vasospastic angina, is characterized by chest pain that occurs at rest, often during the night or early morning, and is unrelated to activity or emotional stress. This type of angina is caused by transient coronary artery vasospasm, which leads to a temporary reduction in blood flow to the heart. Patients with Prinzmetal angina may have normal coronary arteries or minimal atherosclerosis. It differs from stable and unstable angina, which are typically triggered by physical or emotional stress. Nonanginal pain refers to chest discomfort that is not related to cardiac causes.
Question 5 of 9
A nursing student has been assigned to present a teaching project to the class, using each of Bloom's taxonomy domains. The student has planned several activities to include when presenting the project to the class. Which activities are within the affective domain? Select all that apply.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 6 of 9
The nurse is preparing a discharge diet teaching for a patient with diverticulosis. Which foods should the nurse teach the patient to refrain from eating?
Correct Answer: C
Rationale: When preparing a discharge diet teaching for a patient with diverticulosis, the nurse should advise the patient to refrain from eating foods with small seeds, such as raspberries. These small seeds can potentially get stuck in the diverticula (small pouches formed in the colon) and lead to inflammation or infection, causing further complications for the patient with diverticulosis. It is important for patients with diverticulosis to consume a low-fiber diet to prevent aggravating the condition. Therefore, avoiding foods like raspberries with tiny seeds is advisable to help manage diverticulosis effectively.
Question 7 of 9
While assessing for ballottement, a nurse notes that the patella rebounds against the fingers. What does this finding indicate?
Correct Answer: A
Rationale: Ballottement is a physical examination technique used to determine the presence of fluid in a joint, especially the knee joint. When assessing for ballottement, the nurse applies downward pressure on the patella and then releases it. If the patella rebounds or floats back up against the fingers, it indicates the presence of excess fluid within the joint space. This finding is commonly seen in conditions such as knee joint effusion or swelling due to inflammation, trauma, or certain medical conditions. It is an important clinical sign that can help in diagnosing the underlying cause of knee pain or swelling. In this scenario, the patella rebounding against the fingers while assessing for ballottement suggests fluid in the knee joint.
Question 8 of 9
A client admitted with a cardiac dysrhythmia reports being easily fatigued and has difficulty performing normal daily activities. Which nursing diagnosis should the nurse select to address this client's issue?
Correct Answer: B
Rationale: The nursing diagnosis of Activity Intolerance is the most appropriate for a client with a cardiac dysrhythmia who reports being easily fatigued and having difficulty performing normal daily activities. Cardiac dysrhythmias can lead to decreased cardiac output, which can result in reduced oxygen delivery to the body's tissues, contributing to fatigue and weakness. Activity Intolerance is defined as the state in which an individual experiences or is at risk of experiencing insufficient physiological or psychological energy to endure or complete daily activities. This diagnosis is fitting for the client's inability to perform normal daily activities due to the cardiac dysrhythmia-induced fatigue and weakness. Addressing Activity Intolerance will involve collaborating with the client to set achievable activity goals and incorporating periods of rest to enhance tolerance to physical activity and improve overall function.
Question 9 of 9
The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client?
Correct Answer: D
Rationale: The priority nursing diagnosis for a client admitted with a gunshot wound to the femoral artery is Decreased Cardiac Output. The femoral artery is a major blood vessel that supplies oxygenated blood to the lower extremities. A gunshot wound to this artery can lead to severe blood loss, causing a decrease in cardiac output. Decreased cardiac output can result in inadequate perfusion to vital organs, potentially leading to shock and organ failure. Therefore, monitoring and addressing the client's cardiac output is the priority to ensure adequate tissue perfusion and prevent further complications. Deficient Fluid Volume may be related to the blood loss but addressing cardiac output is more critical in this situation.