Physiological Adaptation NCLEX Questions [ANSWERS & RATIONALE]

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1. A. The parathyroid glands regulate calcium in the body. Excessive activity results in calcium leaving the bones and teeth to enter the bloodstream. This makes the bones more brittle and susceptible to fracture.

2. C. Peritonitis is a grave complication with peritoneal dialysis. Hemodialysis may be necessary until infection clears. Excess fluid and protein effluent into the peritoneum also complicate care. Use of aseptic technique is essential.

3. B. Carbon dioxide is insufflated into the abdomen during a laparoscopic cholecystectomy. It may irritate the diaphragm and cause referred shoulder pain. This client’s complaint is a common response to this operation, so telling the client will be reassuring.

4. C. Moon face, thin extremities, and buffalo hump are characteristics of Cushing’s syndrome (adrenocortical hyperfunction). A positive Chvostek’s sign (3) is seen with primary aldosteronism; butterfly rash (1) is seen with lupus.

5. B. On dorsiflexion of the foot, the client will experience upper posterior pain in the calf if a clot is present. This is termed Homan’s sign. Kernig’s sign (1) indicates presence of meningeal irritation; Hegar’s sign (2) is softening of the uterus; Brudzinski’s sign (4), in which flexion of the head causes flexion of the knees and thighs, is also a sign of meningeal irritation.

6. D. The client’s complaints are consistent with meningeal irritation from bleeding into the subarachnoid space; therefore, she needs immediate transfer to an acute care setting.

7. C. Adult respiratory distress syndrome is a grave complication of pancreatitis. Pulmonary edema due to administration of large volumes of IV fluids and direct extension of inflammation resulting in pleural effusion are also seen. Pulmonary complications are associated with a poor prognosis. The other distractors are the more common presenting symptoms of pancreatitis.

8. C. The P-R interval is measured on the ECG strip from the beginning of the P wave to the beginning of the QRS complex. It is the time it takes for the impulse to travel to the ventricle.

9. A. Obesity causes a reduced insulin binding at receptor sites and this leads to pancreatic hypersecretion of insulin and eventual pancreatic cell exhaustion.

10. C. When spinal fluid is lost through a leak or the client is dehydrated, a severe headache can occur, which may last several days. Numbness (2) and no urge to void (4) would be expected with spinal anesthesia unless it continues for several hours postop. The complication of hiccoughs (1) can be associated with abdominal surgery, but is not attributable to spinal anesthesia.

11. D. Clinical manifestations of Cushing’s syndrome include water retention, moon face, hirsutism, and purple striae.

12. B. Lethargy may indicate impending encephalopathy and dictate the need for client safety measures. Fatigue is expected due to anemia, shortness of breath due to ascites, and nausea due to GI vascular congestion, but these are not as grave as lethargy.

13. B. Urinary stasis, renal infection, and dehydration predispose the client to the formation of renal calculi, which may or may not require surgery.

14. B. Peptic ulcer disease is characteristically gnawing epigastric pain that may radiate to the back. Vomiting usually reflects pyloric spasm from muscular spasm or obstruction. Cancer (1) would not evidence pain or vomiting unless the pylorus was obstructed.

15. D. The LVN must be sure that the physician has written orders. Stripping and milking chest tubes (1) is allowed only with a physician’s order because it can cause excessive negative pressure, which could damage the lung tissue. Chest tubes are milked away from the client toward the drainage receptacle. LVNs are legally allowed to do this intervention.