Pharmacology and the Nursing Process 9th Edition Test Bank

Correct Answer: D

Rationale: The correct answer is D because the patient correctly stating names of family members in the room indicates improved cognitive function and memory recall, which are positive signs of progress in resolving confusion. This demonstrates improved orientation and ability to recognize familiar individuals. Choices A and B indicate safety concerns and risk of falls, which are not related to resolving confusion. Choice C indicates pain management and mobility but does not directly reflect improvement in cognitive status.

Correct Answer: A

Rationale: The correct answer is A: Moisture replacement. Sjogren's syndrome is an autoimmune disorder that primarily affects the moisture-producing glands, leading to dryness in the eyes, mouth, and other mucous membranes. Nursing care should focus on managing these symptoms by providing moisture replacement through artificial tears, lubricating eye drops, and hydrating mouthwashes. This helps prevent complications such as corneal damage and dental issues. Nutritional supplementation (B) may be needed if there are difficulties in eating due to dry mouth, but it is not the primary focus. Electrolyte balance (C) and arrhythmia management (D) are not directly related to the symptoms of Sjogren's syndrome and are therefore not the main priorities in nursing care for this condition.

Correct Answer: D

Rationale: The correct answer is D (Downward) because it helps to maintain a clear airway for effective mouth-to-mouth respiration. By holding the victim's chin downward, you can ensure proper alignment of the airway, allowing the tongue to fall forward and prevent obstruction. Holding the chin forward (Choice A) may cause the airway to close, holding it backward (Choice B) may strain the neck, and holding it sideward (Choice C) may not provide optimal airway alignment. Holding the chin downward is the most effective and safe method for providing mouth-to-mouth respiration.

Correct Answer: B

Rationale: The correct answer is B: An improvement of the weakness. Edrophonium is a short-acting cholinesterase inhibitor that helps differentiate between myasthenic and cholinergic crises in myasthenia gravis. In cholinergic crisis, there is an overdose of cholinesterase inhibitors leading to excessive acetylcholine at the neuromuscular junction, causing muscle weakness. Administering edrophonium will temporarily improve muscle weakness in cholinergic crisis due to the increased availability of acetylcholine. The other choices are incorrect because: A: No change suggests the client is not in cholinergic crisis. C: Complaints of muscle spasms are more indicative of myasthenic crisis. D: A temporary worsening of the condition is not expected in cholinergic crisis.

Correct Answer: A

Rationale: The correct answer is A: Use parallel bars or a walker. Before a client with impaired physical mobility gets up, the nurse should provide assistive devices like parallel bars or a walker to ensure safe and supported ambulation. This helps prevent falls and promotes independence. Using incontinence pads (B) is not directly related to mobility. Applying an abdominal binder (C) is not necessary before the client gets up. Using a footboard (D) is more relevant for positioning in bed, not for assisting with ambulation.