Pharmacology and the Nursing Process 10th Edition Test Bank Quizlet

Correct Answer: B

Rationale: The correct answer is B: Safety of the immediate environment. This is crucial for the client's well-being and can impact their health. The nurse should assess for hazards like loose rugs, clutter, or slippery floors. This ensures a safe living environment for the client. The other choices (A, C, D) are not directly related to the client's immediate safety or well-being. The number of rooms in the house (A) is not as important as ensuring the safety of the environment. The frequency of home visits (C) can be planned later based on the initial assessment. The friendliness of the client and family (D) is important for building rapport but does not address the immediate safety concerns of the client.

Correct Answer: D

Rationale: The correct answer is D: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.

Correct Answer: D

Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion can occur from trauma or surgery, while infections from other organs like the lungs or heart can travel through the bloodstream to the brain. Infections from nearby sites such as the sinuses or ears can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C alone do not encompass all the possible causes of a brain abscess, making D the correct comprehensive answer.

Correct Answer: B

Rationale: The correct answer is B: Have a mammogram annually. Mammograms are recommended by the American Cancer Society for breast cancer screening in women as they are effective in detecting early signs of breast cancer. Mammograms have been shown to reduce mortality rates from breast cancer. Annual mammograms are crucial for early detection and treatment. A: Performing breast self-examination annually is not recommended as a standalone screening method as it has not been shown to significantly reduce mortality rates. C: Having a normal receptor assay annually is not a standard screening test for breast cancer recommended by the American Cancer Society. D: Having a physician conduct a clinical examination every 2 years is not as effective as annual mammograms for detecting early signs of breast cancer.

Correct Answer: D

Rationale: The correct answer is D, "Ineffective thermoregulation related to dehydration." The client's high serum glucose level of 618mg/dl indicates severe hyperglycemia, leading to dehydration. The client's hot, dry skin and elevated temperature can be signs of dehydration, impacting the body's ability to regulate temperature. Dehydration can also affect other vital signs, contributing to the elevated heart rate and low blood pressure. Addressing ineffective thermoregulation is crucial as it can lead to further complications. Choices A, B, and C are not the highest priority because addressing dehydration and ineffective thermoregulation takes precedence due to the immediate risk of complications such as heatstroke or hypothermia. Deficient volume, decreased cardiac output, and imbalanced nutrition are important but not as urgent in this scenario.