NCLEX Questions for Physiological Integrity (ANSWERS & RATIONALE)

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1. A. Cold minimizes swelling and erythema to the affected area. However, cold compresses should not be applied continuously for more than 30 minutes.

2. A. This question asks you to identify a physician’s order that would be inappropriate for this client. Rectal temperatures should never be done on any client who is immuno-compromised. This order would require clarification.

3. A. The peak flow meter is used by clients with asthma to monitor airway
Resistance to air flow. By knowing their own personal norm or best effort, client can then recognize deviations form this norm and increase their use of prophylactic medications. If the deviation from normal is severe, clients will recognize the need to notify their physician or seek emergency treatment.

4. A. Establishing an airway is always the initial priority. The airway has to be maintained for adequate ventilation.

5. B. The process of teething is a normal physiological development and does not cause an elevation in body temperature. If an infant has a fever, there is an infectious process occurring in the body. Remember, babies have passive immunity form their mothers until around six months of age. Then they lose this immunity and are therefore more susceptible to infection.

6. D. A two-year-old should have a 300 word vocabulary. A four to six word vocabulary may indicate health problems, such as hearing loss.

7. A. A lack of consistency indicates inappropriate injuries for the given history. When the history does not match the injury, other causes such as abuse should be suspected.

8. B. A five year old needs to have an apical pulse rate of at lease a 70 before digoxin can be administered. This medication slows the heart rate, and the normal heart rate if a five year old is between 70 and 100 beats per minute.

9. B. Vaccines offer artificially acquired active immunity. A small amount of a microorganism is injected into the host to cause the host to form antibodies for a particular disease.

10. C. A chest x-ray will confirm that the PICC line is properly situated in the superior vena cava.

11. A. When family members are unable to stay at the hospital, the toddler will probably feel frightened and alone and may feel abandoned. If the parents leave something that belongs to them, the toddler will feel more secure.

12. C. Preterm infants do not require extra essential amino acids. Due to the immaturity of preterm infants, they have difficulty metabolizing protein. Therefore, increased protein intake can cause increased essential amino acids.

13. A. The drug most frequently prescribed is epinephrine. Epinephrine provides rapid bronchodilation that will increase the diameter of the airways and increase the flow of air through the bronchi.

14. B. At eighteen months of age, fine motor skills should be developed well enough to allow the toddler to begin to hold crayon and scribble. If an eighteen-month-old is not scribble, further developmental assessment is needed.

15. A. Rationale; Due to the viscosity of the blood cells as they change shape during a crisis, the child needs to increase fluid intake to help prevent dehydration.

16. A. Diets low in iron and calcium and high in fat have been shown to increase lead absorption in children exposed to a high-lead environment. Iron deficiency is especially problematic in these children. The diet should be also be high in iron because many children with lead poisoning are anemic because lead is extremely toxic to the biopsynthesis of hemoglobin.

17. C. DTaP, IPV, Hib, and hepatitis B are administered at ages 2 and 4 months. Rotavirus vaccine is no longer recommended because of the associated risk of intussusception. The MMR vaccine is typically administered at age 15 months. The varicella vaccine is commonly administered between ages 12 and 18 months.

18. A. Birth weight typically doubles by age 6 months and triples by age 12 months. Therefore, an infant who weighed 7 lb (3.2 kg) at birth should weigh 14 lb (6.4 kg) at age 6 months.

19. C. In an emergency, intraosseous drug administration is typically used when a child is critically ill and under age 3.

20. C. Although all of the options are appropriate questions to ask when assessing a young child’s ear problems, questions about the child’s behavior are most useful because a young child usually can’t describe symptoms accurately.

21. D. A child with thrombocytopenia or neutropenia shouldn’t receive rectal medication because of the increased risk of infection and bleeding that may result from tissue trauma. No contraindications exist for administering rectal medication to a child with sepsis, leukocytosis, or anemia.

22. A. The best recommendation is to allow the child to feed herself because the child’s stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. It’s important to offer new foods and choices, not just serve her favorite foods. Using a small table and chair would also enhance the primary recommendation.

23. B. When a nurse attempts to influence a family’s decision with her own opinions and values, the situation becomes one of overinvolvement on the nurse’s part and a nontherapeutic relationship. When a nurse keeps communication channels open, works with family members to decrease their dependence on health care providers, and instructs family members so they can accomplish tasks independently, she has developed an appropriate therapeutic relationship.

24. D. Rheumatic fever is a systemic inflammatory disease that follows a Group A streptococcal infection. Therefore, early detection and treatment of streptococcal infections helps prevent the development of rheumatic fever. Hepatitis B vaccine provides immunity against the hepatitis B virus — not streptococci. Because rheumatic fever isn’t contagious, isolation measures aren’t necessary. Prophylactic antibiotics are used for invasive procedures only in clients with a history of carditis to prevent bacterial endocarditis.

25. B. When vasopressin is given S.C., it begins to act within 1 hour. Its duration of action is 2 to 8 hours.

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