Transcultural Concepts in Nursing Care Test Bank

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.

Correct Answer: C

Rationale: The nurse should document that the client understood the teaching given in the class but chose to ignore it. This reflects the concept of non-compliance, where the client has the knowledge and understanding of the fall prevention measures but consciously chooses not to implement them. It is important for healthcare providers to document when patients understand the information provided but do not follow through with recommended actions, as this can help in further tailoring interventions and support to increase compliance and improve health outcomes.

Correct Answer: A

Rationale: The most appropriate response by the nurse is Option A, "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." This response is accurate because anaphylactic shock, which is caused by severe allergic reactions, can be life-threatening if not treated promptly with epinephrine (EpiPen�). While heart failure is a serious type of shock, anaphylactic shock is specifically related to severe allergic reactions and not heart failure. The nurse's response educates the mother about the seriousness of anaphylactic shock in relation to allergic responses and highlights that other types of shock can involve different organ system failures.

Correct Answer: A

Rationale: Asking the patient to clench their teeth is a common way to assess muscle strength in the face, particularly the muscles involved in the jaw. Clenching the teeth engages the muscles responsible for this action, such as the masseter muscle. Assessing the ability to clench the teeth provides insight into the strength and function of these facial muscles.