Pharmacology and the Nursing Process 10th Edition Test Bank

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: D

Rationale: The correct answer is D: Aphasia. Aphasia is a language disorder that affects a person's ability to communicate and understand speech. In this case, Mr. Dela Isla's difficulty in comprehending what the nurse was saying indicates a problem with language processing, which aligns with the symptoms of aphasia. Insomnia (A) is a sleep disorder, not related to language comprehension. Agnosia (B) is a perception disorder where someone cannot recognize objects or people, not related to language. Apraxia (C) is a motor disorder affecting the ability to perform purposeful movements, not related to language comprehension.

Correct Answer: C

Rationale: Elevating the head of the bed is the correct answer because it helps to promote venous drainage, reduce cerebral edema, and decrease intracranial pressure (ICP). By positioning the patient with the head elevated, gravity assists in preventing further increases in ICP. Encouraging fluids may lead to fluid overload and exacerbate cerebral edema. Providing physical therapy and frequent repositioning may increase ICP by causing unnecessary movement and potential strain on the patient's head and neck.

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: Step-by-step rationale: 1. The nurse should clarify discrepancies of assessment data with the client to ensure accurate information. 2. The client's denial of breathing problems conflicts with physical signs, indicating a potential lack of awareness or reluctance to disclose symptoms. 3. By clarifying with the client, the nurse can address any misunderstandings or encourage honest communication. 4. This approach promotes client-centered care and ensures a comprehensive understanding of the client's health status. Summary: - Choice A is correct as it addresses the need to clarify discrepancies with the client for accurate assessment. - Choice B is incorrect as validation with the healthcare team may not provide insight into the client's perception. - Choice C is incorrect as it does not address the need to resolve conflicting assessment data. - Choice D is incorrect as family input may not provide accurate information if the client denies symptoms.