Transcultural Concepts in Nursing Care Answers Test Banks

Questions 15

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Transcultural Concepts in Nursing Care Answers Test Banks Questions

Question 1 of 5

During an assessment, a client with left-sided congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care?

Correct Answer: B

Rationale: In this situation, the nursing diagnosis of Ineffective Health Management is of the greatest initial importance when planning care. The client's inability to afford medications due to financial constraints directly affects their ability to manage their health effectively. Lack of funds may lead to non-adherence to the prescribed treatment plan, which can worsen the client's condition. By addressing the financial barriers to medication access, the nurse can help the client improve their health management and outcomes. This nursing diagnosis is a priority as it addresses the immediate need to ensure the client's access to necessary medications and prevent exacerbation of their congestive heart failure.

Question 2 of 5

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 3 of 5

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 4 of 5

The nurse is providing community health teaching on stroke in children and adolescents. Which risk factors for this population should the nurse identify?

Correct Answer: D

Rationale: In children and adolescents, one of the important risk factors for stroke is head trauma. Head injuries can lead to blood vessel damage, increased risk of blood clot formation, and subsequent stroke. It is crucial for healthcare providers to emphasize the importance of injury prevention and appropriate management of head trauma in this population to reduce the risk of stroke. While hypertension, dysrhythmias, and arteriosclerosis are risk factors for stroke in adults, head trauma is a key risk factor to focus on when educating the community on stroke prevention in children and adolescents.

Question 5 of 5

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.

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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?
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During an assessment, a client with left-sided congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care?
Which client has the highest risk of developing peripheral vascular disease (PVD)?

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