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?

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Pharmacology and the Nursing Process 9th Edition Test Bank Questions

Question 1 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 2 of 9

Antimetabolites are a diverse group of antineoplastic agents that interfere with various metabolic actions of the cell. The mechanism of action of antimetabolites interferes with:

Correct Answer: D

Rationale: The correct answer is D because antimetabolites interfere with the synthesis of nucleic acids (RNA and/or DNA), affecting multiple stages of RNA and DNA synthesis. This disruption hinders cell division and leads to cell death. Choices A and B are incorrect because antimetabolites do not specifically target cell division during the M phase or normal cellular processes during the S phase. Choice C is also incorrect because antimetabolites primarily target nucleic acid synthesis rather than altering the chemical structure of DNA or the binding between DNA molecules.

Question 3 of 9

Which of the ff signs may be revealed by a visual examination in a client with tonsillar infection if group A streptococci is the cause?

Correct Answer: A

Rationale: The correct answer is A: White patches on the tonsils. Group A streptococci infection commonly presents with exudative tonsillitis, characterized by the presence of white patches or pus on the tonsils. This is due to the inflammatory response triggered by the bacteria. Hypertrophied tonsils (B), hemorrhage in the tonsils (C), and bleeding in the tonsils (D) are less likely to be visual signs of a streptococcal infection and are more indicative of other conditions or complications. Therefore, white patches on the tonsils are the most specific visual sign associated with group A streptococci tonsillar infection.

Question 4 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 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 would evaluate that the patient understands what triggers allergic rhinitis by which of the following patient responses?

Correct Answer: D

Rationale: The correct answer is D because airborne pollens and molds are common triggers for allergic rhinitis. Understanding these triggers helps in avoiding exposure and managing symptoms. Choices A, B, and C are incorrect as they do not specifically relate to allergic rhinitis triggers, focusing instead on other forms of medication or topical applications. By understanding airborne triggers, the patient can take appropriate preventive measures.

Question 7 of 9

Nurse Dennis provides health promotion to a group of male adults. He is correct when he states that clients with cirrhosis should include which measure to adhere to a home?

Correct Answer: C

Rationale: The correct answer is C: limit daily alcohol intake. This is crucial for clients with cirrhosis as alcohol can exacerbate liver damage. Limiting alcohol intake helps prevent further harm to the liver and promotes overall health. Supplementation with multivitamins (choice A) can be beneficial, but not as essential as avoiding alcohol. Taking sleeping pills (choice B) may worsen liver function and is not recommended. Limiting contact at all times (choice D) is irrelevant to managing cirrhosis.

Question 8 of 9

The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?

Correct Answer: B

Rationale: The correct answer is B: Counseling about respite care options. This intervention is most appropriate as it addresses the issue of role strain by providing the family member with support and options for temporary relief from caregiving responsibilities. Respite care allows the family member to take a break and recharge, reducing stress and preventing burnout. A: Assisting with activities of daily living is important but may not directly address the underlying issue of role strain. C: Teaching range-of-motion exercises is beneficial for physical well-being but does not directly address the emotional and psychological impact of role strain. D: Consulting with a social worker may be helpful for additional support but may not provide immediate relief or practical solutions for the family member's role strain.

Question 9 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.

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