Test Bank Pharmacology and the Nursing Process

Correct Answer: A

Rationale: The correct answer is A: Diet and exercise program. This is because a client's diet and exercise program directly impact their physical health and well-being, making it an important factor to consider when determining assessment priorities. Understanding their dietary habits and level of physical activity can help identify potential health risks or areas for improvement. Choices B, C, and D are incorrect because they do not directly relate to the client's physical health and well-being, which are crucial factors in determining assessment priorities. Standing in the community (B) may influence social interactions but does not necessarily impact assessment priorities. Ability to pay for services (C) relates to financial considerations rather than health assessment priorities. Developmental stage (D) may be important for understanding the client's cognitive and emotional development, but it is not as directly relevant to assessment priorities as diet and exercise.

Correct Answer: B

Rationale: The correct answer is B: The potential complication. In a collaborative problem, the focus of a diagnostic statement should be on identifying any potential complications that may arise due to the client's condition or treatment. This allows nurses and other healthcare professionals to anticipate and address these complications proactively. A: The client problem - While important, the client problem is usually addressed in the nursing diagnosis rather than the diagnostic statement for a collaborative problem. C: The nursing diagnosis - The nursing diagnosis focuses on the actual or potential health problems that the client is experiencing, which is different from the focus of a diagnostic statement for a collaborative problem. D: The medical diagnosis - The medical diagnosis is the identification of a disease or condition by a healthcare provider, which is not the focus when identifying potential complications in a collaborative problem.

Correct Answer: C

Rationale: The correct answer is C: platelets 18,000. A critically low platelet count can lead to life-threatening bleeding in the ICU. Normal platelet count ranges from 150,000 to 450,000. A count of 18,000 indicates severe thrombocytopenia. Immediate reporting is crucial for prompt intervention. Rationale for why other choices are incorrect: A: Hematocrit of 48% is within normal range (male: 42-52%, female: 37-47%). B: paCO2 of 38 mm Hg is within normal range (35-45 mm Hg). D: WBC count of 8000 is within normal range (4000-11000/uL). In critical care settings, it is vital to prioritize and address life-threatening conditions promptly, hence the urgent need to report the critically low platelet count.

Correct Answer: A

Rationale: Step-by-step rationale: 1. Allowing the client to grasp the nurse's hand firmly assesses grip strength and motor coordination. 2. This step helps evaluate the client's ability to follow instructions and perform a coordinated motor task accurately. 3. Assessing grip strength is essential in determining any muscle weakness or neurological deficits. 4. It also provides insight into the client's motor function and coordination abilities. Summary: - Choice B is incorrect because it focuses on sensory functions rather than motor functions. - Choice C assesses fine motor skills, not grip strength and coordination. - Choice D evaluates cognition and logic, which are not directly related to motor function assessment.

Correct Answer: C

Rationale: The correct answer is C: Menstrual irregularities. After a unilateral adrenalectomy, the remaining adrenal gland may be affected by spironolactone, leading to hormonal imbalances and menstrual irregularities. This drug is a potassium-sparing diuretic that can interfere with the production of aldosterone, affecting hormonal regulation. Breast tenderness (A) is not a common side effect of spironolactone. Increased facial hair (B) is associated with hirsutism, not typically seen with spironolactone. Hair loss (D) is more commonly associated with other medications like chemotherapy, not spironolactone.