Transcultural Concepts in Nursing Care Answers Test Banks

Correct Answer: B

Rationale: The correct statement indicating that teaching was effective is "It's a protein that pulls water into my blood vessels." Albumin is a type of protein found in the blood that helps to maintain blood volume and pressure by pulling water into the blood vessels from surrounding tissues. In the case of a client recovering from hypovolemic shock, infusion of albumin 5% can help to restore blood volume and improve circulation. The other statements do not accurately describe the function of albumin in the body.

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: 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: D

Rationale: When a client has an alteration in perfusion, particularly with inadequate oxygenation, positioning to increase blood return is essential in maintaining adequate tissue perfusion and oxygenation. By positioning the client in a way that maximizes venous return to the heart, the nurse can optimize cardiac output and improve oxygen delivery to the tissues. This can include elevating the legs slightly to facilitate blood return from the lower extremities, ensuring proper alignment of the body to prevent compression of major vessels, and promoting proper body mechanics to reduce the workload on the heart. Encouraging ambulation, instructing on deep breathing, and administering medications to increase heart rate may all have their place in certain scenarios, but for a client at risk for inadequate oxygenation due to perfusion issues, positioning to optimize blood return is the most crucial consideration.

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.