ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 9
A patient is diagnosed with Hashimoto’s thyroiditis and asks what causes it. The nurse would respond that the destruction of the thyroid in this condition is due to which of the following?
Correct Answer: C
Rationale: The correct answer is C: Autoantibodies. In Hashimoto's thyroiditis, the immune system mistakenly attacks the thyroid gland by producing autoantibodies against thyroid proteins such as thyroglobulin and thyroid peroxidase. These autoantibodies lead to inflammation and destruction of thyroid tissue. Antigen-antibody complexes (choice A) are not the main mechanism in Hashimoto's thyroiditis. Viral (choice B) and bacterial infections (choice D) do not directly cause autoimmune destruction of the thyroid in this condition. Autoantibodies targeting the thyroid gland are the key pathogenic factor in Hashimoto's thyroiditis.
Question 2 of 9
A patient tells his nurse that he has delayed having TURP because he is afraid it will affect his sexual function. Which response by the nurse is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: “This type of surgery rarely affects the ability to have an erection or ejaculation.” This response is appropriate because it provides accurate information that addresses the patient's concern about sexual function without making any false claims. TURP (Transurethral Resection of the Prostate) typically does not impact a patient's ability to have an erection or ejaculate. This reassurance can help alleviate the patient's fears and provide him with accurate information to make an informed decision. Explanation for why the other choices are incorrect: A: “Don’t worry about sterility; sperm production is not affected by this surgery.” - This is incorrect as the concern is more about sexual function than sterility. B: “Would you like some information about implants used for impotence?” - This is incorrect as it jumps to a solution without addressing the patient's specific concern about TURP affecting sexual function. D: “There are many methods of sexual expression that are alternatives to sexual intercourse
Question 3 of 9
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? The nurse determines to remove a wound dressing when the patient reveals the time
Correct Answer: A
Rationale: The correct answer is A because it demonstrates data validation in nursing clinical decision-making. In this scenario, the nurse considers the patient's self-reported information (time of last dressing change and observation of old and new drainage) as key data points to validate the need for changing the wound dressing. This aligns with the principles of evidence-based practice and ensures that the decision is based on accurate and relevant information. Choices B, C, and D are incorrect because they do not involve the systematic validation of data to inform the nursing decision-making process. Choice B relies on family input rather than objective data, Choice C jumps to a treatment decision without confirming the underlying cause, and Choice D does not involve validating the patient's reported symptom before taking action.
Question 4 of 9
The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
Correct Answer: C
Rationale: The correct answer is C: Use the smallest needle possible for injections. In a client with thrombocytopenia (low platelet count), there is an increased risk of bleeding and bruising. Using the smallest needle possible for injections reduces the risk of causing injury to blood vessels and tissues, minimizing bleeding complications. Limiting visits by family members (choice A) is not directly related to protecting the client's safety. Encouraging wheelchair use (choice B) is not necessary unless indicated for mobility reasons. Maintaining accurate fluid intake and output records (choice D) is important for overall client care but does not directly address the risk of bleeding in thrombocytopenia.
Question 5 of 9
A client receives a sealed radiation implant to treat cervical cancer. When caring for this client, the nurse should:
Correct Answer: A
Rationale: The correct answer is A because bodily fluids and excretions (urine, feces, vomitus) can become contaminated with radiation from the implant. Therefore, they should be considered highly radioactive and handled appropriately. Choice B is incorrect because the client may remain radioactive for a longer period than 10 days post-implant removal. Choice C is incorrect because soiled linens should be handled according to radiation safety protocols and removed promptly. Choice D is incorrect because bed rest is not necessary unless specifically indicated by the healthcare provider; the client should be encouraged to move around as tolerated to prevent complications.
Question 6 of 9
Which of the ff instructions should a nurse give a client with Hodgkin’s disease who is at risk of impaired skin integrity? Choose all that apply
Correct Answer: B
Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease. Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area. Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease. Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.
Question 7 of 9
Which of the following guidekines does not observe surgical asepisi in the operating room?
Correct Answer: A
Rationale: The correct answer is A because in surgical asepsis, sterile articles should not touch other sterile articles or surfaces to maintain sterility. Choice B is correct as surgical team gowns are sterile in front. Choice C is correct as any breach makes the area contaminated. Choice D is correct as sterile drapes create a sterile field.
Question 8 of 9
On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life- threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?
Correct Answer: A
Rationale: Rationale: 1. Following thyroid surgery, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. 2. Symptoms of hypocalcemia include muscle twitching, hyperirritability, numbness, and tingling. 3. These symptoms align with the client's presentation, indicating a probable electrolyte imbalance. 4. Hypocalcemia is a common complication post-thyroidectomy due to parathyroid gland damage. 5. Prompt recognition and treatment of hypocalcemia are essential to prevent severe complications. Summary: B: Hyperkalemia - Not typically associated with thyroid surgery, symptoms differ. C: Hyponatremia - Unlikely post-thyroidectomy, symptoms don't match presentation. D: Hypermagnesemia - Rare post-thyroidectomy, symptoms and electrolyte disturbance don't align.
Question 9 of 9
Which of the following are examples of common factors in a client that may influence assessment priorities?
Correct Answer: A
Rationale: The correct answer is A: Diet and exercise program. This is because a client's diet and exercise program directly impact their physical health and well-being, making it an important factor to consider when determining assessment priorities. Understanding their dietary habits and level of physical activity can help identify potential health risks or areas for improvement. Choices B, C, and D are incorrect because they do not directly relate to the client's physical health and well-being, which are crucial factors in determining assessment priorities. Standing in the community (B) may influence social interactions but does not necessarily impact assessment priorities. Ability to pay for services (C) relates to financial considerations rather than health assessment priorities. Developmental stage (D) may be important for understanding the client's cognitive and emotional development, but it is not as directly relevant to assessment priorities as diet and exercise.