ATI RN
Test Bank Pharmacology and the Nursing Process Questions
Question 1 of 9
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
Correct Answer: A
Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.
Question 2 of 9
Which of the following are examples of common factors in a client that may influence assessment priorities?
Correct Answer: A
Rationale: The correct answer is A: Diet and exercise program. This is because a client's diet and exercise program directly impact their physical health and well-being, making it an important factor to consider when determining assessment priorities. Understanding their dietary habits and level of physical activity can help identify potential health risks or areas for improvement. Choices B, C, and D are incorrect because they do not directly relate to the client's physical health and well-being, which are crucial factors in determining assessment priorities. Standing in the community (B) may influence social interactions but does not necessarily impact assessment priorities. Ability to pay for services (C) relates to financial considerations rather than health assessment priorities. Developmental stage (D) may be important for understanding the client's cognitive and emotional development, but it is not as directly relevant to assessment priorities as diet and exercise.
Question 3 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 4 of 9
What part of the nursing diagnosis statement suggests the nursing interventions to be included in the plan of care?
Correct Answer: C
Rationale: The correct answer is C: Etiology of the problem. In a nursing diagnosis statement, the etiology describes the underlying cause or contributing factors to the identified problem. This is crucial as it guides the selection of appropriate nursing interventions aimed at addressing the root cause of the issue. By addressing the etiology, nurses can implement interventions that will effectively treat the problem. Choice A (Problem statement) simply identifies the issue without providing insight into its cause. Choice B (Defining characteristics) lists the signs and symptoms of the problem but doesn't directly inform the interventions needed. Choice D (Outcomes criteria) outlines the expected results of the interventions but doesn't directly suggest which interventions to implement. Thus, C is the correct choice as it directly influences the selection of appropriate nursing interventions.
Question 5 of 9
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
Correct Answer: B
Rationale: The correct answer is B, Widening pulse pressure. This indicates increasing intracranial pressure (ICP) as it signifies a significant difference between systolic and diastolic blood pressure. A widening pulse pressure is a key sign of impending herniation and requires immediate intervention. A: Gradual increase does not provide a clear indication of acute changes in ICP. C: Rapid drop followed by gradual increase may suggest other conditions and is not specific to increasing ICP. D: Rapid fluctuations may occur in various scenarios and do not specifically point to increasing ICP. In summary, a widening pulse pressure is the most critical and specific indicator of increasing ICP among the choices provided.
Question 6 of 9
Which of the ff nursing interventions is taken as a precautionary measure if shock develops when a client with a spinal cord injury is hospitalized?
Correct Answer: A
Rationale: The correct answer is A: An IV line is inserted to provide access to a vein. In shock, adequate intravenous access is crucial to administer fluids and medications rapidly. This helps stabilize the client's condition by restoring blood volume and improving circulation. Choice B is incorrect as immobilization is not a primary intervention for shock in this scenario. Choice C, traction, is not appropriate for managing shock but rather for stabilizing spinal cord injuries. Choice D, using a turning frame, is not relevant to managing shock and does not address the immediate need for fluid resuscitation.
Question 7 of 9
How can the nurse help monitor effectiveness of therapy for the patient with a pneumothorax and chest-drainage system?
Correct Answer: C
Rationale: The correct answer is C: Auscultate lung sounds. By auscultating lung sounds, the nurse can assess for changes in breath sounds which can indicate improvement or deterioration in the patient's condition. This helps monitor the effectiveness of therapy for a pneumothorax and chest-drainage system. Palpating for crepitus (A) is not directly related to monitoring therapy effectiveness. Documenting sputum color and amount (B) is important but does not specifically monitor therapy effectiveness. Monitoring suction level (D) is crucial but does not directly assess the patient's response to therapy.
Question 8 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 9 of 9
A patient tells his nurse that he has delayed having TURP because he is afraid it will affect his sexual function. Which response by the nurse is most appropriate?
Correct Answer: C
Rationale: The correct answer is C: “This type of surgery rarely affects the ability to have an erection or ejaculation.” This response is appropriate because it provides accurate information that addresses the patient's concern about sexual function without making any false claims. TURP (Transurethral Resection of the Prostate) typically does not impact a patient's ability to have an erection or ejaculate. This reassurance can help alleviate the patient's fears and provide him with accurate information to make an informed decision. Explanation for why the other choices are incorrect: A: “Don’t worry about sterility; sperm production is not affected by this surgery.” - This is incorrect as the concern is more about sexual function than sterility. B: “Would you like some information about implants used for impotence?” - This is incorrect as it jumps to a solution without addressing the patient's specific concern about TURP affecting sexual function. D: “There are many methods of sexual expression that are alternatives to sexual intercourse