Transcultural Concepts in Nursing Care Answers Test Banks

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.

Correct Answer: C

Rationale: The correct strategy to prevent hypertension is to decrease stress. Chronic stress can lead to high blood pressure, so managing stress levels through techniques such as mindfulness, exercise, adequate sleep, and relaxation techniques can help prevent hypertension. It is not advisable to increase salt intake, reduce physical activity, or consistently take hot baths as these can exacerbate hypertension or have no significant impact on preventing it.

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: 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.

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.