Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet

Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet Related

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A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?

  • A. Proceed to the next patient’s room to make rounds.
  • B. Determine the patient does not want any pain medicine.
  • C. Ask the patient about the facial grimacing with movement.
  • D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C

Rationale: The correct answer is C: Ask the patient about the facial grimacing with movement. This is the initial action because the discrepancy between the patient's verbal pain level and non-verbal cues needs clarification. By directly asking the patient about the facial grimacing, the nurse can gather more information to assess the actual pain level accurately. This step ensures a comprehensive understanding of the patient's pain experience and guides further interventions.

Incorrect choices:
A: Proceed to the next patient’s room to make rounds - This choice neglects the need to address the discrepancy in the patient's pain assessment.
B: Determine the patient does not want any pain medicine - Assuming the patient's preference without further assessment can lead to inadequate pain management.
D: Administer the pain medication ordered for moderate to severe pain - Without clarifying the reason behind the facial grimacing, administering pain medication may not be appropriate and could result in unnecessary medication use.

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The nurse is aware that in communicating with an elderly client, the nurse will

  • A. Lean and shout at the ear of the client
  • B. Use a low-pitched voice
  • C. Open mouth wide while talking to the client
  • D. Use a medium-pitched voice
Correct Answer: B

Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals may have age-related hearing loss, making it difficult for them to hear higher frequencies. Using a low-pitched voice can help ensure that the client can hear and understand the nurse clearly.

A: Leaning and shouting at the ear of the client may come across as aggressive and disrespectful.
C: Opening the mouth wide while talking is not necessary and may be seen as patronizing.
D: Using a medium-pitched voice may still be too difficult for the elderly client to hear clearly due to age-related hearing loss.

If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:

  • A. Flexion of both upper and lower extremities
  • B. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
  • C. Flexion of elbows, extension of the knees, and plantar flexion of the feet
  • D. Extension of upper extremities, flexion of lower extremities
Correct Answer: A

Rationale: The correct answer is A because decorticate posturing is characterized by flexion of both upper and lower extremities. This occurs due to damage to the cerebral hemispheres, resulting in abnormal muscle contractions. Choice B describes decerebrate posturing, which is associated with extension of elbows and knees. Choice C is incorrect as it describes abnormal posturing seen in other conditions. Choice D is also incorrect as it describes a different type of abnormal posturing.

An adult suffered 2nd and third degree burns over 20% of hid body 2 days ago. What is the best way to assess the client’s fluid balance?

  • A. Maintain strict records of intake and output
  • B. Monitor skin turgor
  • C. Weigh the client daily
  • D. Check for edema
Correct Answer: A

Rationale: The correct answer is A: Maintain strict records of intake and output. This is the best way to assess fluid balance in a burn patient because it provides quantitative data on fluid intake and output, helping to monitor for fluid imbalance. Monitoring skin turgor (B) is unreliable in burn patients due to skin damage. Weighing the client daily (C) may not accurately reflect fluid balance changes. Checking for edema (D) is not specific to assessing fluid balance in burn patients. Maintaining intake and output records allows for precise monitoring and early detection of fluid shifts, making it the most appropriate choice.

The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

  • A. Limit visits by family members
  • B. Encourage the client to use a wheelchair
  • C. Use the smallest needle possible for injections
  • D. Maintain accurate fluid intake and output records
Correct Answer: C

Rationale: The correct answer is C: Use the smallest needle possible for injections. This is important for a client with thrombocytopenia because they have a low platelet count, leading to an increased risk of bleeding. Using a small needle minimizes the risk of causing bleeding or bruising during injections. Limiting family visits (choice A) is not directly related to protecting the client from bleeding. Encouraging wheelchair use (choice B) is not specifically relevant to protecting the client with thrombocytopenia. Maintaining accurate fluid intake and output records (choice D) is important but not directly related to preventing bleeding in a client with thrombocytopenia.

For a client diagnosed with idiopathic thrombocytopenic purpura (ITP), which nursing intervention is appropriate?

  • A. Teaching coughing and deep-breathing techniques to help prevent infection
  • B. Administering platelets, as ordered to maintain an adequate platelet count
  • C. Giving aspirin, as prescribed to control body temperature
  • D. Administering stool softeners, as ordered, to prevent straining during infection
Correct Answer: B

Rationale: The correct answer is B: Administering platelets, as ordered to maintain an adequate platelet count. In ITP, the client has low platelet count leading to risk of bleeding. Administering platelets helps raise platelet levels and prevent bleeding complications. Teaching coughing and deep-breathing techniques (A) is important for preventing respiratory infections but not directly related to ITP. Giving aspirin (C) is contraindicated as it can further decrease platelet count. Administering stool softeners (D) is important for preventing straining but not specific to managing ITP.

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