Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?

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Pharmacology and the Nursing Process 10th Edition Test Bank Questions

Question 1 of 9

Following a transsphenoidal hypophysectomy, the nurse should assess the client care fully for which of the following conditions?

Correct Answer: A

Rationale: The correct answer is A: Hypocortisolism. After a transsphenoidal hypophysectomy, the pituitary gland is removed or partially removed, leading to decreased cortisol production. Signs of hypocortisolism include weakness, fatigue, hypotension, weight loss, and electrolyte imbalances. Hyperglycemia (B) is not typically associated with this procedure. Hypoglycemia (C) is not a common concern post-hypophysectomy. Hypercalcemia (D) is not directly related to pituitary gland removal. Therefore, assessing for hypocortisolism is crucial for early detection and management post-surgery.

Question 2 of 9

Which of the ff. conditions places a patient at risk for respiratory complications following his splenectomy?

Correct Answer: C

Rationale: The correct answer is C: An incision near the diaphragm. Following a splenectomy, an incision near the diaphragm can lead to respiratory complications due to potential irritation or injury to the diaphragm. This can result in impaired breathing and increased risk of respiratory issues such as pneumonia. A: A low platelet count is not directly related to respiratory complications following a splenectomy. B: Early ambulation is generally encouraged to prevent complications such as blood clots but does not specifically impact respiratory complications. D: Early discharge may not directly lead to respiratory complications, as long as the patient is adequately monitored postoperatively.

Question 3 of 9

The nurse will monitor J.E. for the following signs and symptoms:

Correct Answer: A

Rationale: The correct answer is A because signs and symptoms listed are indicative of disseminated intravascular coagulation (DIC), which is a serious condition where blood clotting and bleeding occur simultaneously. Change in level of consciousness can indicate hypoperfusion from clotting in blood vessels. Tachypnea and tachycardia can result from tissue hypoxia. Petechiae are small red or purple spots on the skin due to bleeding under the skin. Choices B, C, and D are incorrect because they do not align with the typical signs and symptoms of DIC. Choice B suggests a possible myocardial infarction or acute coronary syndrome. Choice C indicates a possible thrombotic thrombocytopenic purpura (TTP) or acute limb ischemia. Choice D suggests a mix of symptoms that do not typically present together in DIC.

Question 4 of 9

While completing an admission database, the nurse is interviewing a patient who states “I am allergic to latex.” Which action will the nurse take first?

Correct Answer: B

Rationale: The correct answer is B: Ask the patient to describe the type of reaction. First, the nurse needs to assess the severity of the latex allergy to determine the appropriate interventions. Understanding the type of reaction can help guide treatment and prevent future exposure. Isolating the patient (choice A) is not necessary unless there is a severe reaction. Terminating the interview (choice C) prematurely is not appropriate as crucial information may be missed. Documenting the allergy (choice D) is important but not as urgent as assessing the reaction type.

Question 5 of 9

A client with cancer is scheduled for radiation therapy. The nurse knows that radiation at any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the client to expect:

Correct Answer: A

Rationale: The correct answer is A: Hair loss. Radiation therapy targets fast-growing cancer cells, which can also affect healthy cells such as those in hair follicles, leading to hair loss. This adverse effect occurs commonly with radiation therapy due to its impact on rapidly dividing cells. Hair loss is a well-known side effect that clients undergoing radiation therapy are often prepared for. The other choices, B: Fatigue, C: Stomatitis, and D: Vomiting, are also potential side effects of radiation therapy, but hair loss is specifically associated with radiation treatment due to its effect on hair follicles. Fatigue is a common side effect of cancer treatment in general, stomatitis is more commonly associated with chemotherapy, and vomiting can be a side effect of radiation but is not as directly linked as hair loss.

Question 6 of 9

Which of the following blood types would the nurse identify as the rarest?

Correct Answer: B

Rationale: The correct answer is B (AB). AB blood type is the rarest because it is a result of inheriting both A and B alleles, making it less common in the population. AB individuals can only receive blood from other AB individuals due to their unique antigens. Blood types A, B, and O are more common in the population, with O being the most common as it is the universal donor. Blood type A and B are more common than AB since they only require one allele for their respective antigens. Thus, the rarity of AB blood type is due to the inheritance of both A and B alleles, making it the least common among the choices provided.

Question 7 of 9

During the evaluation phase, what key action does the nurse perform?

Correct Answer: C

Rationale: During the evaluation phase, the nurse performs the key action of determining the effectiveness of the care plan. This involves assessing whether the client's goals are being met, if interventions are achieving the desired outcomes, and if any modifications are necessary. This step is crucial to ensure the care plan is successful and the client's needs are being addressed appropriately. Choice A is incorrect because diagnosing the client's condition is typically done in the assessment phase, not during evaluation. Choice B is incorrect as identifying nursing interventions is part of the planning phase. Choice D is incorrect as developing goals and outcomes is part of the planning phase as well. Overall, the evaluation phase focuses on assessing the effectiveness of the care plan rather than diagnosing, identifying interventions, or developing goals.

Question 8 of 9

The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?

Correct Answer: E

Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?

Question 9 of 9

What is the causative agent in HIV/AIDS?

Correct Answer: C

Rationale: The correct answer is C: Human, T-cell lymphotrophic virus, as it is the causative agent for HIV/AIDS. This virus specifically targets and infects the body's T-cells, weakening the immune system. Trichomonas vaginalis, Treponema pallidum, and Chlamydia trachomatis are all different pathogens that do not cause HIV/AIDS. Trichomonas vaginalis is a protozoan parasite that causes trichomoniasis, Treponema pallidum causes syphilis, and Chlamydia trachomatis causes chlamydia. Therefore, the correct answer is C based on the specific viral agent responsible for HIV/AIDS.

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