Physiological Adaptation NCLEX RN Practice Test Answers and Rationale
1. Answer C. Hemodilution can produce a drop in hematocrit. However, if the cause of the decrease in hematocrit were fluid retention, one would expect to find corresponding decreases in serum sodium. If the dialysis has corrected the electrolyte balance, it is unlikely that the client would retain sufficient fluid to cause this drop in hematocrit. Hemodilution does not usually produce such a drop in hemoglobin. The cause of anemia in persons with chronic renal failure is lack of erythropoietin. Erythropoietin produced by the kidneys is necessary to stimulate the bone marrow to produce red blood cells. In chronic renal failure this hormone is not produced. Hemolysis does not occur with peritoneal dialysis because red blood cells do not move outside the client’s own blood vessels, so there are no mechanical forces to harm them.
2. Answer A. A comminuted fracture usually results from a crush injury and results in fractured and crushed bones. The bone is broken in several places. A displaced bone occurs when the two ends of the fractured bone are pulled apart and separated from each other. A compound or open fracture occurs when the bone has been broken in two and one end of the bone breaks through the skin. A greenstick or incomplete fracture is when only one side of the bone is broken. A greenstick fracture happens in children whose bones are still soft.
3. Answer B. Cool, clammy skin is seen in hypoglycemia. Ketoacidosis causes dehydration that results in flushed, dry skin. Diaphoresis is seen in hypoglycemia. Silky skin is not seen in ketoacidosis.
4. Answer D. Bronchi normally expand and lengthen during inspiration and shorten during expiration. Asthma causes spasm of the smooth muscles in the bronchi and bronchioles, resulting in an even tighter airway on exhalation and prolonged exhalation. Inspirations increase in rate in an effort to relieve hypoxia. At the beginning of the attack, the cough is nonproductive and results from bronchial edema. Then the mucus becomes profuse and rattly, with a cough producing frothy, clear sputum. Gas trapping is the central feature of asthma. It is caused by allowing more air to enter alveoli than can escape from them through the narrowed airways. Gas trapping also causes an increased depth and rate of respirations. The wheeze starts during the expiratory phase because of the extreme narrowing of the bronchus on exhalation. As obstruction increases, wheezes become more high pitched and continuous.
5. Answer D. Weakness and fatigue are common in congestive heart failure. Dyspnea is common in congestive heart failure. Tachycardia is common in congestive heart failure. Oliguria is not usually seen in congestive heart failure. Diuretics are a mainstay treatment in congestive heart failure. The nurse would expect urine output. Weakness, fatigue, dyspnea, and tachycardia are clinical manifestations of congestive heart failure.
6. Answer B. Blood pressure is generally not elevated in nephrotic syndrome except in a child with severe renal insufficiency. A normal blood pressure in a two-and-a-half-year-old should be between 80 and 85 systolic and 50 and 60 diastolic. In nephrotic syndrome (nephrosis) plasma proteins are excreted in the urine due to an abnormal permeability of the glomerular basement membrane of the kidney to protein molecules, particularly albumin. The cause of nephrosis is unknown. The average age of onset is two and a half years and it is more common in boys than girls. Dark urine is not seen in nephrotic syndrome. A history of a streptococcal infection is associated with glomerulonephritis.
7. Answer C. While low serum albumin is common with liver disease, it does not weaken the existing structures of the body. Weakness of the esophageal wall is not the problem. Since the esophageal vessels lie close to the surface, under the mucous membranes, the esophageal wall does not support them at the inner surface. The liver is located to the right of the esophagus. When it enlarges, it is more likely to compromise expansion of the right lung than to affect the esophagus. The fibrosed liver obstructs flow through portal vessels, which normally receive all blood circulating from the gastrointestinal tract. The increased pressure in portal vessels shunts some of the blood into the lower pressure veins around the lower esophagus. Since these veins are not designed to handle the high-pressure portal blood flow, they develop varicosities, which often rupture and bleed. Enlargement of the liver does not displace the esophagus.
8. Answer A. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Sepsis is unlikely with a closed head injury. The assessments are classic for hypothalamus injury. Injury to the hypothalamus usually leads to decreased secretion of antidiuretic hormone (ADH), which is manifested by large amounts of very dilute urine output. The hypothalamus also controls temperature. Injury causes a very high temperature. Normal saline is isotonic and would not cause these fluid shifts.
9. Answer C. The major pulmonary problem with CF is thick tenacious secretions. CPT moves the secretions from the small airways to the large where they can be coughed out. Options a and b are used but are secondary to option c; the oral enzymes that CF patients take are for digestion, not pulmonary reasons.
10. Answer A. Until the lung incision seals, there will be air leaking from it, which will be collected and drained by the chest tube; option b would be correct if the air leak had stopped and later reappeared; the suction control chamber is separate from the water seal chamber in a typical chest drainage device.
11. Answer D. Smaller more frequent meals help decrease reflux. The patient shouldn’t eat within 3 hours of bedtime; her head should be elevated-either put bed up on 6-inch blocks or use a wedge; alcohol is contraindicated-it relaxes the GE sphincter and increases reflux.
12. Answer A. Opioids slow transit through the GI tract; older patients and those being treated chronically are at increased risk. Opioids slow not speed transit through the GI tract; patients with chronic pain often lack appetite from their pain and will eat better when it is relieved; nausea, not heartburn is often seen in the upper GI tract with opioid usage.
13. Answer C. These clients have a potential for an inability to have voluntary and involuntary muscle movement or activity. Thus, options a and b are inadequate with this problem in mind. Option d is not specific for prevention of complications associated with the lung.
14. Answer A. Until the health care provider has determined that your ejaculate doesn”t contain sperm, continue to use another form of contraception. All of these options are correct information. The most important point to reinforce is the need to take additional actions for birth control.
15. Answer A. S3 ventricular gallop An S3 ventricular gallop is caused by blood flowing rapidly into a distended non-compliant ventricle. Most common with congestive heart failure.
16. Answer C. Once CPR is started, it is to be continued using the approved technique until such time as a provider pronounces the client dead or the client becomes stable. American Heart Association studies have shown that the 2 person technique is most effective in sustaining the client. It is not appropriate to relieve the first nurse or to leave the room for equipment. The client’s advanced directives should have been filed on admission and choices known prior to starting CPR.
17. Answer D. In a client with hypertension, weakness in the extremities is a sign of cerebral involvement with the potential for cerebral infarction or stroke. Cerebral infarctions account for about 80% of the strokes in clients with hypertension. The remaining 3 choices indicate mild fluid overload and are not medical emergencies.
18. Answer: B. Due to the location of the burns, the client is at risk for developing upper airway edema and subsequent respiratory distress.
19. Answer B. In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with mild to severe tachycardia.
20. Answer B. All of the questions should be asked. However, the one about the problem is the most important to start with at this time.
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