Transcultural Concepts in Nursing Care Answers Test Banks

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.

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.

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: Monitoring the pulse and not taking procainamide hydrochloride if the pulse is less than a specified rate is a crucial aspect of medication adherence for clients receiving this medication. Procainamide hydrochloride is an antiarrhythmic medication that can affect conduction and increase the risk of dangerous dysrhythmias. Therefore, monitoring the pulse rate helps in early identification of potential adverse effects, such as heart block, that may necessitate withholding the medication and seeking medical attention. By adhering to this instruction, the client can actively participate in their care to ensure safe and effective treatment with procainamide hydrochloride.

Correct Answer: C

Rationale: While the interventions of spacing out nursing activities, assisting with ADLs, and consulting with a physical therapist are appropriate for a client with cardiomyopathy experiencing activity intolerance, using passive and active range-of-motion exercises may not be suitable. In this condition, the heart muscle is weakened and may not be able to tolerate the increased activity associated with range-of-motion exercises. These exercises could potentially place additional strain on the heart and exacerbate symptoms such as shortness of breath and fatigue. It would be safer to focus on activities that do not overly stress the cardiovascular system while still promoting mobility and independence.