Pharmacology and the Nursing Process 10th Edition Test Bank

Correct Answer: C

Rationale: Rationale: - A: Diuretics are not necessary before the test and may affect test results. - B: Dehydration is not recommended before the test as it can impact cardiac function. - C: Medication to relieve cough is necessary to reduce any potential interference with the scan. - D: Administering analgesics is not required for the test and may not be relevant to the client's condition.

Correct Answer: D

Rationale: The correct answer is D, a behavior change. Urinary retention in older adults with a neurologic deficit can manifest as a behavior change, such as increased agitation, confusion, or restlessness due to discomfort from the inability to empty the bladder. Amnesia (A) is memory loss and not directly related to urinary retention. Hypertension (B) and hypotension (C) are related to blood pressure regulation and are not specific signs of urinary retention. In contrast, a behavior change (D) is a common and characteristic sign indicating urinary retention in this population.

Correct Answer: D

Rationale: The correct action for the nurse to take is to notify the physician stat (choice D). Firstly, the patient presents with painful bladder spasms and blood-tinged urine, indicating a potential complication post-TURP. This warrants immediate medical attention to assess for possible bladder injury or hemorrhage. Giving Demerol (choice A) or B&O suppository (choice B) may provide symptomatic relief but does not address the underlying issue. Warming the irrigation solution (choice C) is not a priority in this situation and does not address the potential serious complications. Notifying the physician immediately allows for prompt evaluation and appropriate intervention to address the patient's condition effectively.

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.

Correct Answer: A

Rationale: The correct answer is A because shampooing the hair thoroughly helps remove oil and dirt, which can interfere with the CT scan results. By having clean hair, the scan can produce clearer images. Choice B is incorrect because some preparation is needed for a CT scan, especially regarding cleanliness. Choice C is incorrect as giving a cleansing enema and fluids until 8 AM is not necessary for a CT scan of the head. Choice D is incorrect as shaving the scalp and attaching electrodes are not part of routine preparation for a CT scan.