Transcultural Concepts in Nursing Care 7th Edition Test Bank

Correct Answer: C

Rationale: Monitoring serum electrolyte levels would be the most appropriate action for a client admitted with a cardiac dysrhythmia. Electrolyte imbalances, particularly potassium and magnesium, can lead to cardiac dysrhythmias. Therefore, it is crucial to monitor and maintain proper electrolyte levels to prevent or manage dysrhythmias. Restricting fluids, encouraging bedrest, or instructing in a low-fat diet are not the priority actions for managing a cardiac dysrhythmia.

Correct Answer: A

Rationale: A. Excessive sweating: Children with congestive heart failure (CHF) may experience excessive sweating as their bodies work harder to keep up with the demands of the heart, leading to increased sympathetic tone and perspiration.

Correct Answer: C

Rationale: The client who is excited to learn ambulation techniques (Option C) is exhibiting the highest motivation to learn. This client's enthusiasm for learning new skills related to ambulation indicates a strong willingness to actively engage in their rehabilitation process. Learning ambulation techniques is a crucial aspect of recovery following a total hip replacement, as it helps improve mobility and independence. The excitement to learn demonstrates that this client is eager to participate in their rehabilitation and is likely to be more proactive in achieving their recovery goals.

Correct Answer: B

Rationale: When administering albumin 5% to a client in shock, it is essential to monitor for signs of fluid overload, as albumin is a volume expander. Auscultating breath sounds for crackles is a key nursing action to assess for pulmonary edema, which can be a manifestation of fluid overload. Crackles on auscultation indicate the presence of fluid in the lungs, which may require immediate intervention to prevent respiratory compromise. Therefore, monitoring for crackles in the breath sounds is crucial to detect and address potential complications related to the administration of albumin in this client.

Correct Answer: C

Rationale: In the case of a client diagnosed with cardiomyopathy and experiencing tachycardia, a beta blocker is the anticipated medication. Beta blockers work by blocking the effects of adrenaline on the heart, reducing heart rate, blood pressure, and myocardial oxygen demand. This can help manage symptoms of tachycardia in cardiomyopathy by slowing down the heart rate and improving its overall function. Other medications like ACE inhibitors and angiotensin II receptor blockers may be used to manage specific aspects of cardiomyopathy such as hypertension or heart failure, but in the context of tachycardia, a beta blocker is the preferred choice. Cardiac glycosides, like Digoxin, are used for heart failure but not primarily for managing tachycardia in cardiomyopathy.