Test Bank Pharmacology and the Nursing Process

Correct Answer: B

Rationale: The correct answer is B, Widening pulse pressure. This indicates increasing intracranial pressure (ICP) as it signifies a significant difference between systolic and diastolic blood pressure. A widening pulse pressure is a key sign of impending herniation and requires immediate intervention. A: Gradual increase does not provide a clear indication of acute changes in ICP. C: Rapid drop followed by gradual increase may suggest other conditions and is not specific to increasing ICP. D: Rapid fluctuations may occur in various scenarios and do not specifically point to increasing ICP. In summary, a widening pulse pressure is the most critical and specific indicator of increasing ICP among the choices provided.

Correct Answer: A

Rationale: The correct answer is A: "Would you like to talk to a psychologist about your thoughts and feelings?" This response acknowledges the client's emotional distress and offers professional support. A psychologist can provide counseling and help the client explore their feelings and concerns about end-of-life decisions. Choice B is incorrect because it assumes the client's spiritual beliefs are the primary concern, neglecting the emotional and psychological aspects. Choice C involves more people in the decision-making process without addressing the client's individual needs. Choice D is dismissive and does not offer any support or explore the client's feelings further. In summary, choice A is the best response because it prioritizes the client's emotional well-being and offers appropriate support through professional counseling.

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: The correct answer is A because post-kidney transplant patients are at high risk for fluid and electrolyte imbalances due to the impact of the surgery on renal function. The nurse should assess for signs of fluid overload or depletion and monitor electrolyte levels closely. Choice B, hepatotoxicity, is less immediate and not directly related to kidney transplant. Choice C, infection, is important but not the immediate priority. Choice D, respiratory complications, are also significant but not the most immediate concern post-kidney transplant.

Correct Answer: C

Rationale: The correct answer is C: Eye opening, verbal response, motor response. The Glasgow Coma Scale assesses a patient's level of consciousness using these three factors. Eye opening measures arousal, verbal response assesses communication abilities, and motor response evaluates motor function. In the case of J.E., since he is alert and oriented, his eye opening is intact. His ability to communicate verbally and move his limbs appropriately would be crucial in determining his neurological status. Choices A and B are incorrect as they do not include the necessary assessment factor of eye opening. Choice D is incorrect as it mentions "response to pain" instead of verbal response, which is a key component of the Glasgow Coma Scale.