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

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. This is the first action the nurse should take because it helps determine the severity of the allergy and how to best proceed with care. By understanding the specific type of reaction the patient experiences, the nurse can implement appropriate precautions and interventions to prevent any adverse reactions during the patient's stay. Choice A is incorrect because placing the patient in isolation is not necessary for a latex allergy. Choice C is incorrect as terminating the interview is premature and does not address the patient's allergy. Choice D is also incorrect as documenting the allergy is important but not the first action to take when assessing a patient's allergic reaction.

Question 3 of 9

Mr. Santos a 59-year old businessman was diagnosed with angina pectoris. The nurse understands that the cause of angina pectoris is:

Correct Answer: B

Rationale: The correct answer is B: inadequate supply of oxygen to the myocardium. Angina pectoris is chest pain or discomfort caused by reduced blood flow to the heart muscle. This lack of oxygenated blood supply to the myocardium leads to ischemia, resulting in the characteristic chest pain. Choice A is incorrect as it refers to a decrease in alveolar surface area for gas exchange, which is related to conditions like emphysema, not angina. Choice C is incorrect as it pertains to pulmonary circulation, not coronary circulation. Choice D is incorrect as an increase in alveolar surface area would not be a cause of angina pectoris.

Question 4 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 5 of 9

A patient was diagnosed with hiatal hernia. She frequently has regurgitation and a sour taste on his mouth especially after eating large meals. Which action by the client shows understanding of her treatment regimen?

Correct Answer: D

Rationale: The correct answer is D: avoid caffeine, alcohol, and chocolate. This helps to reduce acid reflux symptoms associated with hiatal hernia. Caffeine, alcohol, and chocolate can relax the lower esophageal sphincter, leading to increased reflux. Elevating legs (choice A) does not address the underlying issue. Drinking more fluids (choice B) can exacerbate symptoms by increasing stomach volume. Increasing roughage (choice C) may worsen symptoms due to increased gastric distension. By avoiding triggers like caffeine, alcohol, and chocolate, the client can effectively manage her symptoms.

Question 6 of 9

The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the A stand for?

Correct Answer: C

Rationale: The correct answer is C: Asymmetry. The ABCD method is a mnemonic used for assessing skin lesions for possible skin cancer. The A in ABCD stands for Asymmetry, indicating that the lesion is not symmetrical in shape or color. Skin cancers often exhibit asymmetrical features. Actinic (Choice A) refers to sun damage, Arcus (Choice B) is a term related to the eye, and Assessment (Choice D) is a general term that does not specifically relate to skin lesion evaluation. By focusing on asymmetry, healthcare providers can identify potential skin cancer lesions early for further evaluation and treatment.

Question 7 of 9

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.

Question 8 of 9

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

Correct Answer: D

Rationale: The correct answer is D: “I will receive parenteral vitamin B12 therapy for the rest of my life.” This statement is correct because pernicious anemia is a lifelong condition requiring ongoing vitamin B12 supplementation. Patients with pernicious anemia lack intrinsic factor, which is needed to absorb vitamin B12 from food. Therefore, they need lifelong B12 therapy to prevent complications such as anemia and neurological damage. Choices A, B, and C are incorrect because they suggest a limited duration of therapy. Pernicious anemia is a chronic condition that necessitates continuous treatment. Choice A implies therapy until signs and symptoms disappear, which may not address the underlying cause of the deficiency. Choice B mentions therapy until vitamin B12 levels normalize, which may not prevent recurrence. Choice C suggests monthly therapy for a fixed period, which may not be sufficient for lifelong management.

Question 9 of 9

In which of the ff circumstances should a nurse avoid using midline and mid clavicular sites for IV therapy? Choose all that apply.

Correct Answer: B

Rationale: The correct answer is B: To administer antineoplastic chemotherapy. This is because antineoplastic chemotherapy agents are highly irritating and toxic to the surrounding tissues. Using midline and mid clavicular sites for IV therapy in this case can increase the risk of extravasation, leading to tissue damage and potential complications. Incorrect choices: A: To administer solutions with a pH greater than 5 and less than 9 - pH of the solution does not directly affect the choice of site for IV therapy. C: To administer slow, low-volume infusions - Midline and mid clavicular sites can be appropriate for slow, low-volume infusions. D: To administer high-pressure bolus injections - While midline and mid clavicular sites may not be ideal for high-pressure bolus injections, the question specifically mentions IV therapy, not bolus injections.

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