Test Bank Pharmacology and the Nursing Process

Correct Answer: A

Rationale: The correct answer is A: Measure intake and output. Monitoring intake and output is crucial in assessing electrolyte imbalances and dehydration in clients with neurologic deficits. Electrolyte imbalances can lead to neurological complications, so accurate monitoring is essential. Mini-mental status and Glasgow Coma scale are assessments of mental status, not electrolyte balance. Vital signs can provide some information, but intake and output measurement is more specific for assessing electrolyte imbalances and dehydration.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates data validation in the nursing clinical decision-making process. The nurse assesses the time of the last dressing change and observes old and new drainage, which are relevant data points for wound care. This approach ensures that the decision to remove the dressing is based on accurate and validated information, leading to appropriate patient care. Choice B is incorrect because it relies on subjective information (increased pain and family request) rather than objective data validation. Choice C is incorrect as it involves a direct request for an order without sufficient data validation. Choice D is incorrect because elevating a leg cast based solely on a patient's report of decreased mobility does not involve thorough data validation related to the specific care needed for the patient's condition.

Correct Answer: A

Rationale: Rationale: 1. Following thyroid surgery, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. 2. Symptoms of hypocalcemia include muscle twitching, hyperirritability, numbness, and tingling. 3. These symptoms align with the client's presentation, indicating a probable electrolyte imbalance. 4. Hypocalcemia is a common complication post-thyroidectomy due to parathyroid gland damage. 5. Prompt recognition and treatment of hypocalcemia are essential to prevent severe complications. Summary: B: Hyperkalemia - Not typically associated with thyroid surgery, symptoms differ. C: Hyponatremia - Unlikely post-thyroidectomy, symptoms don't match presentation. D: Hypermagnesemia - Rare post-thyroidectomy, symptoms and electrolyte disturbance don't align.

Correct Answer: A

Rationale: The correct answer is A because the nurse is using data validation by comparing the time of the last dressing change with the appearance of old and new drainage. This process ensures that the decision to remove the wound dressing is based on accurate and relevant information. By assessing both the time of the last dressing change and the characteristics of the drainage, the nurse is validating the need for the intervention. Option B is incorrect because administering pain medicine based solely on a patient's report of increased pain without further validation does not demonstrate data validation. Option C is incorrect as the nurse immediately requesting an order of potassium without further assessment of the patient's condition is not an example of data validation. Option D is incorrect as elevating a leg cast based solely on a patient's report of decreased mobility without further assessment does not involve data validation.

Correct Answer: A

Rationale: The correct answer is A: Risk for transmission of infection. This is appropriate because the girl has genital herpes, which is a sexually transmitted infection (STI) that can be transmitted to others through sexual contact. Therefore, the main concern is preventing the spread of the infection to others. Pain (B) is a symptom of herpes but not the primary concern here. Health-seeking behaviors (C) may be relevant for education and prevention, but not the immediate focus. Ineffective sexuality pattern (D) is not directly related to the risk of transmission of infection in this case.