Transcultural Concepts in Nursing Care Answers Test Banks

Correct Answer: D

Rationale: Virchow's triad describes the three pathological factors that are associated with the formation of a thrombus. These factors include endothelial injury, abnormal blood flow, and hypercoagulability. Endothelial injury disrupts the normal function of the endothelium, leading to the exposure of collagen and tissue factor, which triggers the coagulation cascade. Abnormal blood flow can result in stasis or turbulence, which promotes the accumulation of platelets and clotting factors. Hypercoagulability refers to an increase in the tendency of the blood to clot, which can be caused by various conditions such as genetic disorders, cancer, and certain medications. These three factors work together to increase the risk of thrombus formation.

Correct Answer: A

Rationale: For a patient with a small-bowel obstruction, the highest priority action is to maintain nasogastric suction. This helps to decompress the bowel and relieve the obstruction by removing fluid and gas from the gastrointestinal tract. It can also help prevent complications such as bowel perforation and reduce the risk of aspiration if the patient vomits. Managing the obstruction is crucial to prevent further complications and promote the patient's recovery. Administering prescribed analgesics, keeping strict intake and output records, and placing the patient in a semi-Fowler's position are important interventions but may not address the immediate need to relieve the obstruction.

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.

Correct Answer: B

Rationale: The nurse educator plans to include teaching the nursing students how to search for and evaluate health information on the internet during the lecture. This is important because in today's digital age, nurses need to be able to effectively navigate the vast amount of healthcare information available online. Teaching students how to search for reliable sources, critically evaluate the information they find, and distinguish between credible and non-credible sources will help them in their nursing practice. This knowledge is essential for evidence-based practice and providing quality care to patients. Additionally, nurses should be aware of ethical considerations related to accessing and using online healthcare information.

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.