NCLEX RN Review for Physiological Adaptation (ANSWERS & RATIONALE)

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1. B. This patient is suffering from frostbite, due to prolonged exposure to sub-freezing temperatures without proper protection.  Frostbite is a condition in which there is trauma to the tissues without actual freezing of tissue fluids.  Exposed areas of the body such as hands, feet, earlobes, etc. are all subject to this.  The affected part becomes hard, cold, and is not sensitive to touch, and mottled bluish-white in color. The aim of nursing care is to restore normal temperature and circulation to the part.  All other choices would be included in the management of such a patient.   Choice (2) is incorrect in that wrapping of the part could further constrict circulation.  If blankets are used, it should be supported with a foot cradle and not in direct contact with the extremity.  Prolonged applications of heat should also be avoided due to the patient’s diminished sensitivity, and could result in a burn if not carefully monitored.

2. A. If the hip if flexed to the side, on the side of the bed or in a low chair, hip displacment can occur. Displacement could result in pain, but this is not the primary reason for the instructions. The remaining two answers are not specific or adequate explanations.

3. A. Abnormal discoloration of the scrotal area following Vasectomy is not unusual, and usually responds well to warm sitz baths.  The nurse should reassure the patient of such.  However, ecchymoses, swelling, superficial wound infection of the vas-deferens or epididymitis, or sperm granulomas, are all potentially serious complications, and the M.D. should be notified of any unusual findings immediately.  Therefore, choices (2), (3) and (4) are incorrect.

4. C. The left side position facilitates easy insertion of the rectal tube due to the anatomical position of the rectum. Recumbent position will be more comfortable for the client.

5. C. The hypothalamus controls body temperature, fluid balance, particular emotions (such as pleasure and fear), sleep, and appetite. The visual area (3) is controlled by the occipital lobe. The temporal lobe contains the auditory center (4). Bradycardia (2) can be caused by a problem in the medulla oblongata.

6. B. A cast is rigid and used to maintain alignment. If it is too tight, it will press on blood vessels. The color of the toes will change first, then temperature, when blood supply is decreased. As the blood flow slows through the walls of the vessels, edema will occur.

7. C. Pressure on the head during this type of delivery will likely create a cephalohematoma.

8. A. Laceration, a more severe consequence of closed head injury, occurs as the brain tissue moves across the uneven base of the skull in a contusion. Contusion causes cerebral dysfunction which results in bruising of the brain. A concussion causes transient loss of consciousness and retrograde amnesia, and is generally reversible.

9. A. Rheumatoid Arthritis is a chronic inflammatory Connective Tissue Disease in which the synovial joints of the hands, wrist, knees, feet are usually affected.  RA also has systemic effects as well.  Choices (2), (3) and (4), are all potential assessment findings in a patient with this diagnosis.  Heberden’s Nodes, however are associated with Osteoarthritis, and appear as bony nodules on distal finger joints.

10. C. Approximately 85 percent of cases of fat embolism occur within 48 hours of injury, making this the most critical time for monitoring the client for manifestations of this complication.

11. B. At 6 months babies sit with support and by nine months they sit unassisted, therefore a child between this stage would be able to achieve sitting alone for brief period.  This is a demonstration of cephalocaudal development.  Option 1 is expected of a 12 month old, option 2 is expected of a 9 month old and option 4 is expected of a 3 month old.

12. B. Oliguria, with accompanying hypovolemic shock, is a dangerous complication of acute pancreatitis. This condition may necessitate large volumes of parenteral fluids to maintain vascular volume; a CVP catheter is often inserted for monitoring fluid needs.

13. D. Cervical dilation of 6cm, contractions lasting for 45 sec. with a frequency of 3 minutes apart is the active phase of labor.  Choices 1 and 2 are the latent phase of labor; Choice 3 is the transitional phase of labor.

14. A. Pupillary checks reflect function of the third cranial nerve, which stretches as it becomes displaced by blood, tumor, etc.

15. C. Evaluating fetal well being is of highest priority and will direct subsequent interventions.

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