Transcultural Concepts in Nursing Care 6th Edition Test Bank

Correct Answer: D

Rationale: Asking the client about their preferred learning strategies is the appropriate action at this time. Everyone learns in different ways, and by identifying the client's preferred learning style, the nurse can tailor the teaching session to be more effective and memorable for the client. Understanding how the client learns best can help in providing information in a way that is easier for them to retain and recall later. It also demonstrates a client-centered approach to teaching, which can improve communication and understanding between the client and the healthcare provider.

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.

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.

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.

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.