NCLEX Prep for Physiological Integrity (ANSWERS & RATIONALE)

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1. C. Babinski’s reflex should disappear by age 12 months; its presence after this age indicates neurologic dysfunction. The gag reflex, tonic neck reflex, and corneal reflex are normal findings for a toddler.

2. B. Asking such an open-ended question as “Can you describe the pain?” encourages the client to describe any and all aspects of the pain in the client’s own words

3. B. When initiating a 24-hour urine specimen, have the client void, then start the timing. The collection should start on an empty bladder. The exact time the test starts isn’t important but it’s commonly started in the morning.

4. A. Kawasaki disease, which affects young children, is characterized by acute systemic vasculitis. Myocarditis, a major complication of this disease, commonly causes left-sided heart failure. Therefore, the nurse must monitor the client’s weight, fluid intake and output, and vital signs closely for evidence of heart failure.

5. D. During a bronchoscopy, a vasovagal response may be caused by stimulating the pharynx, and it, in turn, may cause stimulation of the vagus nerve. The client may, therefore, experience a sudden drop in heart rate leading to syncope. Stimulation of the vagus nerve doesn’t lead to pupillary dilation or bronchodilation. Stimulation of the vagus nerve increases gastric secretions

6. C. Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP. Keeping the head in midline and avoiding extreme neck flexion prevents obstruction of venous outflow from the brain. Both sensory stimulation and noxious stimuli can increase ICP.

7. B. The leg should be elevated to promote venous return and prevent edema. The cast shouldn’t be covered while drying because this will cause heat buildup and prevent air circulation. No foreign object should be inserted inside the cast because of the risk of cutting the skin and causing an infection. A foul smell from a cast is never normal and may indicate an infection.

8. D. A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in the prevention of rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

9. A. The high abdominal incision used in a cholecystectomy interferes with respirations postoperatively, increasing the risk of atelectasis. Therefore, incentive spirometry is used to promote lung expansion, increase alveolar inflation, and strengthen respiratory muscles. Incentive spirometry has no effect on intubation, nutrition, or analgesia.

10. D. Because this client has fluid overload, the nurse first should slow the infusion to prevent additional fluid overload, and then notify the physician and obtain further orders. Notifying the physician without slowing the infusion would put the client at risk for pulmonary complications or respiratory failure. Discontinuing the infusion is inappropriate because vascular access still may be needed to administer I.V. fluids (at a decreased rate) or additional I.V. medications. Administering a diuretic without changing the I.V. infusion rate wouldn’t prevent fluid overload from recurring.

11. B. Factors that may precipitate a sickle cell crisis during pregnancy include dehydration, infection, stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and tachycardia aren’t known to precipitate a sickle cell crisis.

12. B. A serum sodium level of 118 mEq/L indicates severe hyponatremia, which places the client at risk for seizures. Therefore, instituting seizure precautions takes highest priority. Fluid and sodium replacement should be done rapidly. Diuretic therapy isn’t indicated because it may cause additional sodium loss. In a child with hyperkalemia, administering sodium bicarbonate would be appropriate because it promotes movement of potassium into the intracellular spaces.

13. C. Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn’t taken. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism.

14. D. To prevent hip dislocation after a total hip replacement, the client must avoid bending the hips beyond 90 degrees. Assistive devices, such as a raised toilet seat, should be used to prevent severe hip flexion. Using an abduction pillow or placing several pillows between the legs reduces the risk of hip dislocation by preventing adduction and internal rotation of the legs.

15. C. Chelation therapy removes lead by combining it with another substance to form a soluble compound that the kidneys can excrete. As lead is mobilized from bone and other tissues, the serum lead level rises rapidly, increasing the client’s risk of seizures. Chelation therapy doesn’t cause anaphylaxis, fever, chills, or heart failure.

16. B. During pregnancy, blurred vision may be a danger sign of preeclampsia or eclampsia, complications that require immediate attention because they can cause severe maternal and fetal consequences. Although hemorrhoids may occur during pregnancy, they don’t require immediate attention. Dyspnea on exertion and increased vaginal mucus are common discomforts caused by the physiologic changes of pregnancy.

17. C. For epidural analgesia, a catheter is placed outside the dura mater in the epidural space. Catheter displacement, which may cause spinal injury, is signaled by loss of motion and sensation in the legs. Therefore, the nurse should assess closely for sensation and ask about numbness of the legs. The nurse should change the catheter site dressing every day or every other day. Capillary refill time has no bearing on epidural analgesia. A client with an epidural catheter may ambulate and need not be confined to bed.

18. B. Interventions should address the etiology of the client’s problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client’s condition but doesn’t address poor coughing. Improving airway clearance is too vague. Suctioning isn’t indicated unless other measures fail to clear the airway.

19. A. Because exercise decreases the blood glucose level, the nurse should instruct the child to eat a snack before engaging in physical activity to prevent a hypoglycemic episode.

20. B. Coarctation of the aorta causes signs of peripheral hypoperfusion, such as a weak femoral pulse and a bounding radial pulse. These signs are rare in patent ductus arteriosus, ventricular septal defect (VSD), and truncus arteriosus.

21. D. In the client with hyperthyroidism, excessive thyroid hormone production leads to hypermetabolism and increased nutrient metabolism. These conditions may result in a negative nitrogen balance, increased protein synthesis and breakdown, decreased glucose tolerance, and fat mobilization and depletion. This puts the client at risk for marked nutrient and calorie deficiency, making Imbalanced nutrition: Less than body requirements the most important nursing diagnosis.

22. B. In Parkinson’s crisis, dopamine-related symptoms are severely exacerbated, virtually immobilizing the client. A client confined to bed during such a crisis is at risk for aspiration and pneumonia. Also, excessive drooling increases the risk of airway obstruction. Because of these concerns, the nursing diagnosis of Ineffective airway clearance takes highest priority. Although the other options also are appropriate, they aren’t immediately life-threatening.

23. D. Frequent swallowing — an attempt to clear the throat of trickling blood — suggests postoperative hemorrhage. Emesis may be brown or blood-tinged after a tonsillectomy; only bright red emesis signals hemorrhage. The child may refuse fluids because of painful swallowing, not bleeding. Hemorrhage is associated with an increased, not decreased, heart rate.

24. D. The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body’s first line of defense has been broken when the blisters opened; removing the skin exposes a larger area to the risk of infection.

25. A. The nurse should withhold all oral intake to suppress pancreatic secretions, which may worsen pancreatitis. Typically, this client requires a nasogastric tube to decompress the stomach and GI tract. Although pancreatitis may cause considerable pain, it’s treated with I.M. meperidine (Demerol), not morphine, which may worsen pain by inducing spasms of the pancreatic and biliary ducts. Pancreatitis places the client at risk for fluid volume deficit from fluid loss caused by increased capillary permeability. Therefore, this client needs fluid resuscitation, not fluid restriction. A client with pancreatitis is most comfortable lying on the side with knees flexed.

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