Pharmacology and the Nursing Process Test Bank Free

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Correct Answer: B

Rationale: The correct answer is B: helicobacter pylori infection. This bacterium is a major cause of peptic ulcers by weakening the protective mucous layer of the stomach and duodenum. Research has shown a strong association between H. pylori infection and peptic ulcer development. Genetic defects in the gastric mucosa (choice A) are not a proven cause of peptic ulcers. While a high-fat diet (choice C) can exacerbate symptoms, it is not the primary cause. Work-related stress (choice D) may exacerbate symptoms but is not a direct cause of peptic ulcers. Therefore, choice B is the most supported and logical answer based on current research findings.

Correct Answer: A

Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.

Correct Answer: D

Rationale: The correct answer is D: Human papilloma virus (HPV) infection at age 32. HPV infection is a well-known risk factor for cervical cancer as certain strains of HPV can lead to cellular changes in the cervix that may progress to cancer. Here's the rationale: 1. HPV is a known risk factor: HPV is a sexually transmitted infection that is strongly linked to the development of cervical cancer. 2. Age of infection: The client's history of acquiring HPV at age 32 is significant as long-standing HPV infection increases the risk of cervical cancer. 3. Other choices are not directly linked: Choices A, B, and C are not directly associated with an increased risk of cervical cancer. Age of sexual activity onset, spontaneous abortion, and eclampsia are not established risk factors for cervical cancer.

Correct Answer: C

Rationale: The correct answer is C: Hematuria. Bacillus Calmette-Guerin (BCG) is a type of immunotherapy used to treat bladder cancer by stimulating the immune system to attack cancer cells. One common side effect of BCG instillations is hematuria, which is the presence of blood in the urine. This occurs because BCG irritates the bladder lining, leading to inflammation and bleeding. It is important for the nurse to educate the client about this potential side effect so they are aware and can report any excessive bleeding to their healthcare provider promptly. Other choices are incorrect: A: Renal calculi - BCG therapy is not known to cause renal calculi. B: Delayed ejaculation - BCG therapy is not associated with delayed ejaculation. D: Impotence - BCG therapy is not linked to impotence.