Transcultural Concepts in Nursing Care Answers Test Banks

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.

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.

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.

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.

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.