NCLEX Review for Physiological Integrity (ANSWERS & RATIONALE)

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1. B. The object should be left in place until the client is in the operating room where hemorrhage can be controlled and the cause of bleeding repaired. This is the safest option.

2. B. Tetracycline should be taken with a full glass of water to prevent esophageal erosion and gastrointestinal irritation, the most common complaint of clients taking medication. Manifestations include nausea, vomiting, diarrhea, epigastric distress, and abdominal discomfort.

3. D. Following tonsillectomy, the gag reflex may be suppressed from local anesthetics of edema. To prevent aspiration, the gag reflex must be present before allowing the client to have fluids.

4. D. Flank pain and hematuria are classic manifestations of a hemolytic transfusion reaction. As the kidneys work to excrete hemolyzed red blood cells, the client may progress to acute renal failure. Other manifestations include headache, feelings of doom, tachycardia, and hypotension leading to shock. Unless treated immediately, a hemolytic transfusion reaction will rapidly progress to coma and death.

5. A. You have remembered an important point about postoperative concerns for clients after gastric surgery: the high risk for atelectasis and pneumonia secondary to reluctance to cough and deep breathe because of the high surgical incision. Other postoperative concerns for clients after gastric reduction are peritonitis, stomal obstruction, ulcers, and thromboembolism.

6. B. Open wounds place the client at an increased risk for wound infection.

7. C. One breath every five seconds equals a rate of 12 breaths per minute (60 : 5 = 12). This rate is appropriate for an adult.

8. D. FFP is plasma rich in clotting factors. It is given to treat acute clotting disorders, and the desired affect would be a decrease in the prothrombin time.

9. D. The goal of CPT is the mobilization of secretions in the airways. Bronchodilators may be given prior to CPT, and the client should be encouraged to breathe deeply and cough after CPT.

10. A. An elevated eosinophils count can be seen on asthma, especially when the condition is associated with a hypersensitivity reaction. Eosinophils can also be elevated in several autoimmune diseases.

11. B. To avoid burning and sloughing, the client must protect the graft from direct sunlight. The other three interventions are helpful to the client and his recovery but are less important.

12. C. Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

13. C. Decreased heart and respiratory rates and increased systolic blood pressure reflect Cushing’s triad, which may develop when ICP increases. Shock typically causes tachycardia, tachypnea, and hypotension. In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate. If the client doesn’t maintain adequate hydration, hypotension may occur. Status epilepticus causes unceasing seizures, not changes in vital signs.

14. C. According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

15. B. Spironolactone can cause menstrual irregularities and decreased libido. Men may also experience gynecomastia and impotence. Breast tenderness, increased facial hair, and hair loss aren’t associated with spironolactone.

16. A. A history of peripheral neuropathy, renal or hepatic impairment, hyperuricemia, or pancreatitis warrants cautious use of didanosine because these disorders increase the risk of adverse effects. Diabetes mellitus, hypertension, and asthma aren’t significant history findings for a client who is to receive didanosine.

17. A. During an acute crisis, the examiner checks the corneal reflex response to rapidly assess brain stem function. Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in all arms and legs. If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs. Emergency assessment doesn’t include fundus examination unless the client has sustained direct eye trauma. The client shouldn’t be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible. Bowel and bladder functions aren’t vital, so the nurse should delay their assessment.

18. D. The nurse should infuse gentamicin sulfate (Garamycin) I.V. over at least 30 minutes. Infusing the drug more rapidly may increase the client’s risk of adverse reactions.

19. D. If the client uses an alternative method of communication, he’ll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. In a client with an endotracheal tube or tracheostomy tube, the family members are also likely to encounter difficulty interpreting the client’s wishes. Making them responsible for interpreting the client’s gestures may frustrate the family. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

20. A. An irrigation bag should be elevated 18″ to 24″ (40 to 60 cm) above the stoma. Typically, adults use 500 to 1,000 ml of water at a temperature no higher than 105° F (41° C) to irrigate a colostomy. If cramping occurs during irrigation, irrigation should be stopped and the client should take deep breaths until the cramping stops. Irrigation can then be resumed. Hand washing reduces the spread of microorganisms.

21. A. The client should take glipizide twice a day, 30 minutes before a meal, because food decreases its absorption. The drug doesn’t cause hyponatremia and therefore doesn’t necessitate monthly serum sodium measurement. The client must continue to monitor the blood glucose level during glipizide therapy.

22. C. Ischemic myocardial tissue changes cause elevation of the ST segment, a peaked or inverted T wave, and a pathological Q wave. A prolonged PR interval occurs with first-degree heart block, the least dangerous atrioventricular heart block; this disorder may arise in healthy people but sometimes results from drug toxicity, electrolyte or metabolic disturbances, rheumatic fever, or chronic degenerative disease of the conduction system. An absent Q wave is normal; an MI may cause a significant Q wave. A widened QRS complex indicates a conduction delay in the His-Purkinje system.

23. B. After hip pinning, the client must keep the affected leg abducted at all times; placing a pillow between the legs reminds the client not to cross the legs and to keep the leg abducted. Passive or active ROM exercises shouldn’t be performed on the affected leg during the postoperative period because this could damage the operative site and cause hip dislocation. Most clients should be turned to the unaffected side, not from side to side. After hip pinning, the client must avoid acute flexion of the affected hip to prevent possible hip dislocation; therefore, semi-Fowler’s position should be avoided.

24. B. A client with appendicitis is at risk for infection related to inflammation, perforation, and surgery because obstruction of the appendix causes mucus fluid to build up, increasing pressure in the appendix and compressing venous outflow drainage. The pressure continues to rise with venous obstruction; arterial blood flow then decreases, leading to ischemia from lack of perfusion. Inflammation and bacterial growth follow, and swelling continues to raise pressure within the appendix, resulting in gangrene and rupture. Geriatric, not middle-aged, clients are especially susceptible to appendix rupture.

25. B. Ovarian cancer usually requires aggressive treatment — initially, surgery. The client will require a total abdominal hysterectomy and bilateral salpingo-oophorectomy with tumor resection, omentectomy, appendectomy, and lymphadenectomy. Radiation therapy is palliative for a client in this advanced stage of the disease. Chemotherapy also is largely palliative during this stage; however, prolonged remissions have been achieved in some clients.

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