Pharmacology and the Nursing Process 9th Edition Test Bank

Pharmacology and the Nursing Process 9th Edition Test Bank Related

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Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;

  • A. Confusion or delirium can be a defense against further stress
  • B. Destruction of brain cells has occurred, interrupting mental activity
  • C. Teaching based on information progressing from the simple to the complex
  • D. A minimum of information should be given, since he is unaware of surrounding
Correct Answer: A

Rationale: The correct answer is A: Confusion or delirium can be a defense against further stress. This is because providing new information slowly and in small amounts can help prevent overwhelming Mr. Reyes, who is already confused. This approach allows him to process and understand the information more effectively without adding to his stress levels.

Choices B, C, and D are incorrect:
B: Destruction of brain cells has occurred, interrupting mental activity - This is not the most appropriate explanation as it assumes irreversible damage to the brain, which is not mentioned in the question.
C: Teaching based on information progressing from the simple to the complex - While this may be a valid teaching strategy in general, it does not address Mr. Reyes' specific state of confusion and the need to reduce stress.
D: A minimum of information should be given, since he is unaware of surrounding - This choice does not address the underlying reason for providing information slowly, which is to manage stress and confusion, rather than solely focusing on the

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The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?

  • A. No change in the condition
  • B. An improvement of the weakness
  • C. Complaints of muscle spasms
  • D. A temporary worsening of the condition
Correct Answer: B

Rationale: The correct answer is B: An improvement of the weakness. Edrophonium is a short-acting cholinesterase inhibitor that helps differentiate between myasthenic and cholinergic crises in myasthenia gravis. In cholinergic crisis, there is an overdose of cholinesterase inhibitors leading to excessive acetylcholine at the neuromuscular junction, causing muscle weakness. Administering edrophonium will temporarily improve muscle weakness in cholinergic crisis due to the increased availability of acetylcholine. The other choices are incorrect because: A: No change suggests the client is not in cholinergic crisis. C: Complaints of muscle spasms are more indicative of myasthenic crisis. D: A temporary worsening of the condition is not expected in cholinergic crisis.

Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:

  • A. Assess the involved extremity for color and temperature
  • B. Check for capillary refill
  • C. Evaluate pulse rate
  • D. Do all of the above
Correct Answer: D

Rationale: The correct answer is D because assessing for localized ischemia involves evaluating multiple factors. A: Assessing color and temperature helps determine perfusion. B: Checking capillary refill assesses circulation. C: Evaluating pulse rate indicates cardiac output. Doing all of the above provides a comprehensive assessment of arterial flow and potential ischemia. Other choices are incorrect as they do not cover all aspects necessary for a thorough assessment.

Which of the ff. nursing interventions would have the highest priority in the plan of care for the postoperative eye patient?

  • A. Do not leave the patient unattended at any time.
  • B. Teach the patient not to bend over.
  • C. Report sudden onset of acute pain.
  • D. Apply sandbags to either side of the head.
Correct Answer: C

Rationale: The correct answer is C: Report sudden onset of acute pain. This is the highest priority because sudden onset of acute pain postoperatively can indicate a serious complication such as hemorrhage or infection. Prompt reporting allows for timely intervention to prevent further complications.

A: Do not leave the patient unattended at any time - While important for safety, it is not the highest priority compared to addressing sudden onset of acute pain.
B: Teach the patient not to bend over - Important for preventing complications postoperatively, but not as urgent as addressing sudden onset of acute pain.
D: Apply sandbags to either side of the head - This intervention is not typically indicated for postoperative eye patients and would not address the potential serious complication of sudden onset of acute pain.

For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?

  • A. Compression of blood vessels due to blood loss
  • B. Increase in the circulating blood volume
  • C. Inadequate renal perfusion
  • D. Hypovolemia and shock
Correct Answer: D

Rationale: The correct answer is D: Hypovolemia and shock.
Rationale:
1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms.
2. These signs indicate inadequate perfusion due to reduced blood volume.
3. Hypovolemia can progress to shock if not addressed promptly.
Summary:
A: Compression of blood vessels is not directly related to low blood volume.
B: Increasing circulating blood volume would not occur in a client with low blood volume.
C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.

Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?

  • A. "I think you should ask the doctor. Would you like me to cail him for you?"
  • B. " The blood supply to the brain has decreased causing permanent brain damage."
  • C. "It Is a temporary interruption in the blood flow to the brain."
  • D. "TIA means a transient ischemic attack."
Correct Answer: C

Rationale: The correct answer is C because it accurately defines a transient ischemic attack (TIA) as a temporary interruption in blood flow to the brain. This response demonstrates the nurse's knowledge and ability to provide accurate information to the family member.

Option A is incorrect because it deflects the question to the doctor without providing any information. Option B is incorrect because it inaccurately states that TIA causes permanent brain damage, which is not true. Option D is also incorrect because it simply restates the abbreviation without providing any explanation of what TIA actually means.

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