Pharmacology and the Nursing Process Test Bank

Correct Answer: B

Rationale: The correct answer is B because during the evaluation phase of nursing care for a client with COPD, the nurse should review the client's progress toward meeting the goals set during the planning phase. This involves assessing whether the interventions implemented are effective in improving the client's condition and if the goals are being achieved. This step is crucial in determining the overall effectiveness of the care provided and making any necessary adjustments to the plan. A: Documenting interventions is important but not the primary focus during the evaluation phase. C: Delegating further care is not typically done during the evaluation phase as it is more about assessing the current care plan. D: Ensuring compliance with physician orders is important but does not encompass the holistic evaluation of the client's progress towards goals.

Correct Answer: C

Rationale: The correct answer is C: Confusion. Hypernatremia is an electrolyte imbalance characterized by high sodium levels in the blood. Confusion is a common symptom as high sodium levels can affect brain function. Dry skin (A) is more indicative of dehydration, tachycardia (B) is a symptom of various conditions, and pale coloring (D) is not specific to hypernatremia. Confusion is a key indicator that the nurse should assess for when monitoring for hypernatremia.

Correct Answer: B

Rationale: The correct answer is B because nurse-initiated interventions involve autonomous actions based on clinical judgment to achieve client outcomes. Nurses assess, plan, and implement care independently. Choice A involves physician orders, not nurse-initiated actions. Choice C relates to medical treatment, not nursing interventions. Choice D focuses on collaboration with other providers, not solely nurse-initiated actions. In summary, only choice B aligns with the independent and outcome-focused nature of nurse-initiated interventions.

Correct Answer: A

Rationale: Rationale: A relaxed face during conversation typically does not indicate a hearing loss, as the patient is likely able to hear and understand. B, speaking loudly, is a common sign of hearing loss. C, turning towards the speaker, suggests an effort to hear better. D, being withdrawn, could indicate difficulty in communication due to hearing loss. Therefore, A is the correct answer as it does not align with typical signs of hearing loss.

Correct Answer: B

Rationale: The correct answer is B: Lifetime dependency on hormone replacement. After hypophysectomy, the pituitary gland is removed, leading to a deficiency in essential hormones. Patients will need lifelong hormone replacement therapy to maintain normal body functions. This is crucial for regulating metabolism, growth, reproduction, and stress response. Choices A, C, and D are incorrect because abnormal distribution of body hair, increased fluid intake, and repeat surgical procedures are not typically associated with hypophysectomy. It is essential to focus on the long-term management of hormone replacement therapy to ensure the patient's overall health and well-being.