ATI RN
Pharmacology and the Nursing Process Test Bank Questions
Question 1 of 5
A client with spinal cord injury at the level of T3 complains of a sudden severe headache and nasal congestion. The nurse observes that the client has a flushed skin with goose bumps. Which of the ff actions should the nurse first take?
Correct Answer: C
Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.
Question 2 of 5
An adult is brought in by ambulance after a motor vehicle accident. He is unconscious, on a backboard with his neck immobilized. He is bleeding profusely from a large gash on his right thigh. What is the first action the nurse should take?
Correct Answer: C
Rationale: The correct answer is C: Check his airway. Ensuring a patent airway is the priority in trauma care to maintain oxygenation and ventilation. With the patient unconscious and bleeding profusely, airway obstruction or compromise is a critical concern. By checking the airway first, the nurse can quickly assess and address any immediate threats to the patient's breathing. Stopping the bleeding (choice A) can be addressed once the airway is secured. Taking vital signs (choice B) and finding out what happened from eyewitnesses (choice D) can be important but are secondary to ensuring the patient's airway is clear and unobstructed.
Question 3 of 5
The nurse assesses for the characteristic movement of Parkinson’s disease which is a (n):
Correct Answer: C
Rationale: The correct answer is C because pronation-supination of the hand and forearm is a characteristic movement in Parkinson's disease called "pill-rolling tremor." This movement interferes with normal hand activities due to involuntary shaking. A is incorrect because exaggerated muscle flaccidity does not lead to frequent falls in Parkinson's disease. B is incorrect as hyperextension of the back and neck is not a characteristic movement of Parkinson's disease. D is incorrect as it combines all options, which is not accurate.
Question 4 of 5
Mrs. Zeno asks the nurse why the disease has occurred. The nurse bases the reply on the knowledge that there is:
Correct Answer: C
Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.
Question 5 of 5
If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
Correct Answer: B
Rationale: The correct answer is B because the right side weakness indicates a lesion in the left hemisphere of the brain. The brain's motor functions are contralaterally controlled, meaning the left hemisphere controls the right side of the body. Therefore, a right-sided weakness suggests a lesion in the left hemisphere. The other choices are incorrect because expressive aphasia is associated with left hemisphere lesions, judgment of distance and proprioception are more related to parietal lobe lesions, and orientation to time and space is not directly linked to right-sided weakness.