ATI RN
Pharmacology and the Nursing Process 9th Edition Test Bank Questions
Question 1 of 9
Mr. Reyes is extremely confused. The nurse provide new information slowly and in small amounts because;
Correct Answer: A
Rationale: The correct answer is A: Confusion or delirium can be a defense against further stress. This is because providing new information slowly and in small amounts can help prevent overwhelming Mr. Reyes, who is already confused. This approach allows him to process and understand the information more effectively without adding to his stress levels. Choices B, C, and D are incorrect: B: Destruction of brain cells has occurred, interrupting mental activity - This is not the most appropriate explanation as it assumes irreversible damage to the brain, which is not mentioned in the question. C: Teaching based on information progressing from the simple to the complex - While this may be a valid teaching strategy in general, it does not address Mr. Reyes' specific state of confusion and the need to reduce stress. D: A minimum of information should be given, since he is unaware of surrounding - This choice does not address the underlying reason for providing information slowly, which is to manage stress and confusion, rather than solely focusing on the
Question 2 of 9
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
Correct Answer: A
Rationale: Step 1: Assess the client's vital signs to confirm presence of fever. Step 2: Measure client's oral temperature to obtain accurate reading. Step 3: Document temperature and report findings to healthcare provider. Step 4: Initiate appropriate interventions based on temperature reading. Step 5: Reassess client's condition to evaluate effectiveness of interventions. Summary: Option A is correct as it directly addresses the cue of fever by confirming the temperature. Options B, C, and D are incorrect as they do not directly address the need to assess the client's temperature for accurate evaluation and intervention.
Question 3 of 9
The client with myasthenia gravis has become increasingly weaker. The physician prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Tensilon) is administered. Which of the following would indicate that the client is in cholinergic crisis?
Correct Answer: B
Rationale: The correct answer is B: An improvement of the weakness. Edrophonium is a short-acting cholinesterase inhibitor that helps differentiate between myasthenic and cholinergic crises in myasthenia gravis. In cholinergic crisis, there is an overdose of cholinesterase inhibitors leading to excessive acetylcholine at the neuromuscular junction, causing muscle weakness. Administering edrophonium will temporarily improve muscle weakness in cholinergic crisis due to the increased availability of acetylcholine. The other choices are incorrect because: A: No change suggests the client is not in cholinergic crisis. C: Complaints of muscle spasms are more indicative of myasthenic crisis. D: A temporary worsening of the condition is not expected in cholinergic crisis.
Question 4 of 9
Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
Correct Answer: C
Rationale: The correct answer is C because it accurately defines a transient ischemic attack (TIA) as a temporary interruption in blood flow to the brain. This response demonstrates the nurse's knowledge and ability to provide accurate information to the family member. Option A is incorrect because it deflects the question to the doctor without providing any information. Option B is incorrect because it inaccurately states that TIA causes permanent brain damage, which is not true. Option D is also incorrect because it simply restates the abbreviation without providing any explanation of what TIA actually means.
Question 5 of 9
Which of the ff nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
Correct Answer: C
Rationale: The correct answer is C: Assess apical heart before administering digitalis. This is important because digitalis can slow down the heart rate, so it is crucial to monitor the client's heart rate before giving the medication to prevent further decrease in cardiac output. Encouraging activities that engage the Valsalva maneuver (A) is contraindicated in clients with congestive heart failure as it can lead to increased intra-thoracic pressure and decreased venous return, worsening cardiac output. Encouraging the client to perform exercises (B) may also increase cardiac workload and exacerbate symptoms. Offering small frequent feedings (D) is generally beneficial for clients with congestive heart failure to prevent overeating and promote easier digestion, but it does not directly address the decreased cardiac output concern in this scenario.
Question 6 of 9
The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction?
Correct Answer: C
Rationale: The correct answer is C: Bronchospasm. Antiplatelet drugs commonly cause hypersensitivity reactions like bronchospasm due to their effects on platelet function. They can trigger an allergic response leading to bronchoconstriction. Difficulty hearing (A) is not a common hypersensitivity reaction to antiplatelet therapy. Confusion (B) is more commonly associated with central nervous system effects rather than hypersensitivity reactions. Agranulocytosis (D) is a severe drop in white blood cells and is not typically a hypersensitivity reaction to antiplatelet drugs.
Question 7 of 9
How does nosocomial pneumonia occur?
Correct Answer: A
Rationale: The correct answer is A because nosocomial pneumonia occurs in a healthcare setting, such as hospitals or long-term care facilities, where patients are at increased risk due to exposure to pathogens and weakened immune systems. Choice B is incorrect as the timeframe of onset is not limited to within 48 hours of admission. Choice C is incorrect as nosocomial pneumonia can occur in both immunocompromised and immunocompetent hosts. Choice D is incorrect as it refers to pneumonia acquired outside of a healthcare setting.
Question 8 of 9
Which of the following is a discharge criterion from the PACU for a patient following surgery?
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation above 90%. This is a discharge criterion because adequate oxygen saturation indicates the patient is breathing well and there is no immediate respiratory compromise. Oxygen saturation below 90% (choice C) would indicate hypoxemia and would not be safe for discharge. IV narcotics given less than 15 minutes ago (choice B) can still be in effect and may impair the patient's ability to function post-surgery. IV narcotics given less than 30 minutes ago (choice D) is a longer timeframe but still not ideal for discharge as the effects of the narcotics may not have fully worn off.
Question 9 of 9
Miss OB’s malignant tumor in her left breast was discovered to be spreading all over the surrounding and adjacent tissue and not entering the blood stream, it would be:
Correct Answer: A
Rationale: The correct answer is A: Malignant. A malignant tumor spreading to surrounding tissues indicates invasive growth, characteristic of malignancy. It is aggressive and can invade nearby structures. Non-malignant tumors are localized and do not invade surrounding tissues. Benign tumors are non-invasive and do not spread to other parts of the body. Choice D is incorrect because a tumor spreading to surrounding tissues is indicative of malignancy, not benignity.