ATI RN
Pharmacology and the Nursing Process 10th Edition Test Bank Questions
Question 1 of 5
A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces?
Correct Answer: B
Rationale: The correct answer is B because turning the patient every 2 hours helps prevent pressure ulcers caused by shearing forces. This intervention redistributes pressure, improving blood flow to the skin, thus reducing the risk of skin breakdown. Administering pain medication (A) does not directly address the skin integrity issue. Monitoring vital signs (C) is important but does not address skin integrity. Keeping bed rails up (D) may actually increase the risk of shearing forces.
Question 2 of 5
A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome?
Correct Answer: A
Rationale: The correct answer is A because stating feeling better after talking with family and friends demonstrates the use of healthy coping skills. This behavior indicates the patient is seeking and utilizing social support, which is crucial for managing stress and emotions effectively in diabetes management. Choices B, C, and D are incorrect because consuming high-carbohydrate foods when stressed can lead to poor blood sugar control, disliking support group meetings indicates avoidance of beneficial support resources, and spending most of the day in bed can contribute to physical and emotional deterioration, rather than effective coping.
Question 3 of 5
A nurse is collecting information from a client with dementia. The client’s daughter accompanies the client. Which of the following statements by the nurse would recognize the client’s value as an individual?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the client's value as an individual by directly addressing them and asking about their own self-care practices, which respects their autonomy and personhood. Choice A focuses on the client's father rather than the client themselves. Choice B addresses the daughter, not the client, and implies a lack of prioritization of the client's needs. Choice D is dismissive and does not recognize the client's capacity to communicate, undermining their dignity.
Question 4 of 5
The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible wheezing, and nasal flaring. During the interview, the client denies problems with breathing. What action should the nurse take next?
Correct Answer: A
Rationale: Step-by-step rationale: 1. The nurse should clarify discrepancies of assessment data with the client to ensure accurate information. 2. The client's denial of breathing problems conflicts with physical signs, indicating a potential lack of awareness or reluctance to disclose symptoms. 3. By clarifying with the client, the nurse can address any misunderstandings or encourage honest communication. 4. This approach promotes client-centered care and ensures a comprehensive understanding of the client's health status. Summary: - Choice A is correct as it addresses the need to clarify discrepancies with the client for accurate assessment. - Choice B is incorrect as validation with the healthcare team may not provide insight into the client's perception. - Choice C is incorrect as it does not address the need to resolve conflicting assessment data. - Choice D is incorrect as family input may not provide accurate information if the client denies symptoms.
Question 5 of 5
A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: 'Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language.' Which part of this diagnosis is considered the problem statement?
Correct Answer: A
Rationale: The correct answer is A: Disturbed thought processes. This is the problem statement because it identifies the specific nursing diagnosis that reflects the client's cognitive impairment. "Disturbed thought processes" directly addresses the issue the nurse is observing in the client. The other choices are not the problem statement. "Related to" is the etiology or cause of the problem, "Alzheimer’s disease" is the medical condition, and "Incoherent language" is the defining characteristic or evidence of the problem. Therefore, A is the correct answer as it clearly states the client's primary issue.