NCLEX Sample Test on Physiological Adaptation [ANSWERS & RATIONALE]
1. A. Failure of the left ventricle to pump effectively causes damming of blood back into the pulmonary circuit, increasing pressure, and causing extravasation of fluid into interstitial spaces and alveoli.
2. D. The halo or “bull’s-eye” sign seen when drainage from the nose or ear of a head-injured client is collected on a sterile gauze is indicative of CSF in the drainage. The collection of a culture specimen (1) using any type of swab or suction would be contraindicated because brain tissue may be inadvertently removed at the same time or other tissue damage may result.
3. C. The state or level of consciousness is the most reliable index of cerebral status.
4. C. The client’s condition suggests pulmonary embolism (PE), which is not uncommon following orthopedic surgery on the knee. The physician will order urokinase delivered through a PICC to dissolve the clot (the primary goal in treating PE). Heparin (2) and Coumadin (4) (the oral form of warfarin) are anticoagulants and will only prevent further clots from forming. Oxygen (1) may well be ordered, but the critical intervention is the thrombolytic agent, which must be given within a few hours of the onset of the symptoms.
5. B. Elevating the head promotes reduction of cerebral edema through gravity drainage. Coughing increases intracranial pressure. The environment should be nonstimulating (dim lights and quiet) to limit the risk of seizures. Fluids are restricted to avoid increasing the cerebral edema.
6. B. Emboli are the major problem; those arising in right heart chambers will terminate in the lungs and left chamber emboli may travel anywhere in the arteries. Heart murmurs, fever and night sweats may be present, but do not indicate a complication of emboli. Congestive heart failure may be a result, but this is not as dangerous an outcome as emboli. Emboli may occur in the spleen, kidneys, brain, lungs, and in the extremities.
7. A. The increase in intraocular pressure causes atrophy of the retinal ganglion cells and the optic nerve, and leads eventually to blindness.
8. D. Pain occurs 2 to 4 hours after eating fatty foods and is located either in the epigastric region or in the upper right quadrant of the abdomen.
9. B. Although crackles often indicate fluid in the alveoli, they may also be related to hypoventilation and will clear after a deep breath or a cough. It is, therefore, premature to impose fluid (2) or activity (4) restrictions. Inspection for edema (3) would be appropriate after reauscultation.
10. C. Sometimes recurrent boils are symptoms of an underlying disease process such as glycosuria. Bathing (1) will not influence the course of the boils, and they are not communicable.
11. B. The increased pulse rate and increased cardiac output caused by thyroid compounds can cause angina, arrhythmias, or in extreme cases, heart failure. The older the client, the more compromised the cardiovascular system may become.
12. B. A second-degree burn involves the epidermis and dermis. Answer (1) is the definition of a fourth-degree burn, (2) is characteristic of a first-degree burn, and (4) is the definition of a third-degree burn.
13. B. Epidural hematomas usually form quickly within 6 hours after injury, as a result of an arterial bleed. They usually cause periods of confusion and lucidity, and may or may not cause loss of consciousness. Epidural hematomas are fatal if left untreated; in fact, subdural hematomas, not epidural hematomas, have the highest mortality of all head injuries (60 to 90 percent).
14. D. Edema is due to insufficient nitrogen for synthesis. When this occurs, it leads to a change in the body’s osmotic pressure resulting in oozing of fluids out of the vascular space. This phenomena results in the formation of edema in the abdomen and flanks.
15. C. Itching is made worse by vasodilation. Tepid water prevents excessive vasodilation. Warm environmental temperatures promote vasodilation. Alcohol not only produces vasodilation but is drying to the skin, which further compounds the problem of itching. Keeping the nails clean and short will help prevent skin irritation and infection if the client scratches, but will not prevent the itching from occurring.
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