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 client in the final stages of terminal cancer tells the nurse: “I wish I could be just be allowed to die. I’m tired of fighting this illness. I have lived life a good life. I only continue my chemotherapy and radiation treatment because my family wants me to.” What is the best nurse’s best response?
Correct Answer: A
Rationale: The correct answer is A: "Would you like to talk to a psychologist about your thoughts and feelings?" This response acknowledges the client's emotional distress and offers professional support. A psychologist can provide counseling and help the client explore their feelings and concerns about end-of-life decisions. Choice B is incorrect because it assumes the client's spiritual beliefs are the primary concern, neglecting the emotional and psychological aspects. Choice C involves more people in the decision-making process without addressing the client's individual needs. Choice D is dismissive and does not offer any support or explore the client's feelings further. In summary, choice A is the best response because it prioritizes the client's emotional well-being and offers appropriate support through professional counseling.
Question 3 of 9
The most significant form of meningitis is:
Correct Answer: A
Rationale: The correct answer is A: Bacterial meningitis. Bacterial meningitis is the most significant form due to its potential severity and rapid progression, requiring urgent medical intervention with antibiotics. Bacterial meningitis can lead to serious complications such as brain damage or death if left untreated. Septic meningitis (choice B) refers to meningitis caused by a systemic infection spreading to the meninges. Aseptic meningitis (choice C) is typically viral or non-bacterial in origin, usually milder than bacterial meningitis. Viral meningitis (choice D) is less severe than bacterial meningitis and often resolves on its own without specific treatment.
Question 4 of 9
The nurse assesses the motor functions during a neurologic examination of a client. Which of the ff steps will help the nurse perform the examination effectively? Choose all that apply
Correct Answer: A
Rationale: Step-by-step rationale: 1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination. 2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately. 3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits. 4. It also provides insight into the client's motor function and coordination abilities. Summary: - Choice B is incorrect because it focuses on sensory functions rather than motor functions. - Choice C assesses fine motor skills, not grip strength and coordination. - Choice D evaluates cognition and logic, which are not directly related to motor function assessment.
Question 5 of 9
A nurse is providing education to a client with newly diagnosed hypertension about the importance of adhering to prescribed medications. Which phase of the nursing process does this activity represent?
Correct Answer: C
Rationale: The correct answer is C: Implementation. In the nursing process, implementation involves carrying out the care plan, interventions, and education that were determined during the planning phase. Providing education to a client about the importance of adhering to prescribed medications falls under this phase as it involves putting the plan into action to promote positive health outcomes. Assessment (A) involves collecting data about the client's condition, Planning (B) involves developing a care plan based on the assessment findings, and Evaluation (D) involves assessing the effectiveness of the interventions implemented.
Question 6 of 9
The nurse is instructing a premenopausal woman about breast self-examination. The nurse should tell the client to do her self-examination:
Correct Answer: C
Rationale: Correct Answer: C - The nurse should tell the client to do her self-examination on the same day each month to establish a routine, making it easier to remember and detect any changes. This consistency helps in early detection of abnormalities. Incorrect Choices: A: Doing it at the end of the menstrual cycle may not be consistent due to varying cycle lengths. B: Doing it on the 1st day of the menstrual cycle may not be practical and could lead to missing potential abnormalities. D: Doing it immediately after her menstrual period may not provide a consistent schedule for self-examination.
Question 7 of 9
When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;
Correct Answer: A
Rationale: The correct answer is A: Urinary output of 30 ml in an hour. Adequate tissue perfusion is best indicated by a sufficient urinary output, as it demonstrates proper kidney perfusion and function. A low urinary output may suggest inadequate perfusion. Explanation for other choices: B: Central venous pressure reading of 2 cm H20 is not a reliable indicator of tissue perfusion to vital organs. C: Pulse rates alone are not enough to indicate tissue perfusion as they can be influenced by various factors. D: Blood pressure readings alone may not accurately reflect tissue perfusion, especially in the context of fluid replacement therapy.
Question 8 of 9
Mr. Go had a post-kidney transplant. What should the nurse immediately assess?
Correct Answer: A
Rationale: The correct answer is A because post-kidney transplant patients are at high risk for fluid and electrolyte imbalances due to the impact of the surgery on renal function. The nurse should assess for signs of fluid overload or depletion and monitor electrolyte levels closely. Choice B, hepatotoxicity, is less immediate and not directly related to kidney transplant. Choice C, infection, is important but not the immediate priority. Choice D, respiratory complications, are also significant but not the most immediate concern post-kidney transplant.
Question 9 of 9
When caring for an anxious patient with dyspnea, which of the ff. nursing actions is most helpful to include in the plan of care to relieve anxiety?
Correct Answer: C
Rationale: The correct answer is C: Staying at patient's bedside. This is the most helpful nursing action because it provides reassurance and support to the anxious patient experiencing dyspnea. By staying at the bedside, the nurse can monitor the patient closely, provide immediate assistance if needed, and offer a calming presence. Explanation of why other choices are incorrect: A: Increasing activity levels may worsen the dyspnea and anxiety of the patient. B: Pulling the privacy curtain does not directly address the patient's anxiety or dyspnea. D: Closing the patient's door may make the patient feel isolated and increase anxiety. In summary, staying at the patient's bedside is the most effective nursing action as it addresses both the physical and emotional needs of the anxious patient with dyspnea.