Transcultural Concepts in Nursing Care Test Bank

Correct Answer: A

Rationale: A. Measuring abdominal girth every 4 to 8 hours is important to monitor for signs of fluid accumulation in the abdominal cavity, indicating potential fluid volume deficit.

Correct Answer: A

Rationale: Disseminated intravascular coagulation (DIC) is a complex, life-threatening condition characterized by widespread activation of coagulation within the blood vessels. In the early stages of DIC, there is excessive clot formation (formation of small clots) throughout the body due to the dysregulation of coagulation factors. As the disease progresses, the body's clotting factors become depleted, leading to a state of systemic anticoagulation. This anticoagulant state increases the risk of hemorrhage (bleeding) as the blood is no longer able to adequately clot. Therefore, hemorrhage is a pathological change that occurs late in the course of DIC.

Correct Answer: C

Rationale: A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. Aortic stenosis is a type of congenital heart disease that restricts blood flow from the heart to the rest of the body due to a narrowing of the aortic valve. In women with aortic stenosis, the increased blood volume and heart rate during labor and delivery can put extra strain on the heart. However, in most cases, vaginal delivery is preferred over a Cesarean section to avoid the risks associated with major abdominal surgery, such as bleeding, infection, and thrombophlebitis. A vaginal birth allows for a more gradual and controlled increase in cardiac output compared to the more sudden changes that can occur during a Cesarean section. Additionally, the stress of labor may mimic the stress test for some patients, providing valuable information about their heart function. However, each case is unique and must be evaluated by the healthcare team

Correct Answer: C

Rationale: The nurse is monitoring vital signs and laboratory values for the patient recovering from a total knee replacement to ensure adequate circulation to the involved extremity. After a total knee replacement surgery, there is a risk of developing complications such as deep vein thrombosis (DVT) or impaired circulation to the surgical site. Monitoring vital signs and laboratory values allows the nurse to assess for any signs of compromised circulation, which could indicate the development of complications requiring immediate intervention. By closely monitoring these parameters, the nurse can ensure that the patient's recovery is progressing smoothly and without any major complications impacting the circulation to the involved extremity.

Correct Answer: D

Rationale: An ischemic stroke occurs when the blood supply to a part of the brain is obstructed, typically by a thrombus (a blood clot that forms in a blood vessel and remains attached to its place of origin) or an embolus (a blood clot that travels from a different part of the body and becomes lodged in a blood vessel in the brain). Another cause of ischemic stroke can be stenosis, which is the narrowing of a blood vessel, restricting blood flow to the brain. When the brain does not receive sufficient oxygen and nutrients due to the blockage, brain cells can be damaged or die, leading to a stroke. Ischemic strokes account for the majority of strokes and are essential to manage promptly to minimize brain damage and long-term disability.