Pharmacology and the Nursing Process Test Bank

Correct Answer: C

Rationale: The correct answer is C: Inform the registered nurse. This is the best course of action as the LPN should escalate the situation to a higher level of care by involving the registered nurse who can further assess the patient's concerns and provide appropriate interventions. A. Reassuring the patient may not address the underlying fear and may not be sufficient to alleviate their anxiety. B. Providing statistics about surgery death rates may further escalate the patient's fears and anxiety, causing more harm than good. D. Involving the family to comfort the patient may not address the patient's specific concerns and may not be within the family's scope of understanding or expertise to effectively address the situation. Informing the registered nurse allows for a more comprehensive assessment and appropriate intervention to address the patient's fears and concerns in a holistic manner.

Correct Answer: B

Rationale: The correct answer is B: Monitor temperature every 4hrs. This is crucial in detecting signs of urinary tract infection as fever is a common symptom. Monitoring temperature regularly allows for early detection and appropriate intervention. A: Encouraging the client to breathe deeply and cough every 2hrs is a measure to prevent respiratory complications postoperatively, not related to UTI detection. C: Splinting the incision when repositioning the client is important for wound care, not for detecting UTI. D: Irrigating tubes as ordered is a specific intervention for tube care, not for monitoring UTI symptoms.

Correct Answer: C

Rationale: The correct answer is C: A decreased number of functioning acetyl-choline receptor sites. This is because in diseases like myasthenia gravis, there is an autoimmune attack on acetylcholine receptor sites, leading to decreased functionality. Choice A is incorrect because it refers to a genetic defect in acetylcholine production, which is not typically the cause of myasthenia gravis. Choice B is incorrect as it suggests a reduced amount of acetylcholine, which is not the primary issue in myasthenia gravis. Choice D is incorrect as it mentions inhibition of the enzyme Ache, which is not the main mechanism in this disease.

Correct Answer: C

Rationale: The correct answer is C: Call the physician. In this scenario, the sudden severe headache and nasal congestion along with flushed skin and goosebumps suggest autonomic dysreflexia, a medical emergency in spinal cord injury at or above T6. The nurse should immediately call the physician to address this potentially life-threatening situation. Raising the client's head (A) may worsen the condition, placing the client on a firm mattress (B) is not a priority, and administering an analgesic (D) without addressing the underlying cause could lead to further complications. The priority is to identify and address the cause of autonomic dysreflexia promptly.

Correct Answer: C

Rationale: The correct answer is C because it helps the patient explore her support system. By asking who she usually goes to when facing problems, the nurse encourages the patient to identify her sources of emotional support, which can help her cope with the new diagnosis. This response acknowledges the patient's need for support and fosters a therapeutic relationship. Explanation for incorrect choices: A: "Don't worry. You'll be okay." - This response dismisses the patient's feelings and offers false reassurance, which may not address her emotional needs. B: "The treatments you are receiving will make you feel better very soon." - While this statement provides information about treatment, it does not directly address the patient's difficulty in coping with the diagnosis. D: "Have you made end-of-life decisions?" - This response may be premature and could unnecessarily increase the patient's anxiety about her prognosis.