Physiological Adaptation Rationale

1 B: "Did your provider recommend that you be tested for Chlamydia?" Epididymitis can result from Chlamydia infection, in
which case the client’s sexual partners should be tested as well. All of the questions should be asked, however, determining the
reason for the client’s referral is the most important to start with.
2 A: can predispose to dysrhythmias. The nurse should be aware of a decrease in the client’s potassium levels because low
potassium can enhance the effects of digoxin and predispose the client to dysrhythmias. The other options are seen in hyperkalemia.
Muscle weakness occurs in both hyperkalemia and hypokalemia.
3 D: weekly weight. The most accurate indicator of fluid balance in an acutely ill individual is the daily weight. A one-kilogram
or 2.2 pounds of weight gain is equal to approximately 1,000 ml of retained fluid. Other options are considered as part of data
collection, but they are not the most accurate indicators of fluid balance.
4 C: Participate with the compressions or breathing. 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 to leave the room
for equipment. The client’s advanced directives should have been filed on admission and his choices known prior to the initiation
of CPR.
5 B: pale mucosa of the eyelids and lips. In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing infant with
mild to severe tachycardia.
6 A: Stay with client and observe for airway obstruction. For the client’s safety, remain at the bedside and observe respirations and
level of consciousness. Prepare to clear the airway if obstructed. Do not place anything in the client’s mouth. For safety, do not
leave the client unattended. A cardiac arrest should only be announced if pulse or respirations are absent after the seizure
7 D: With this description of symptoms this client needs to be seen that day since painless gross hematuria is closely associated
with bladder cancer. The other complaints can be handled over the phone.
8 D: "I went to get a cold checked out last week, and I have gotten worse." Any condition that increases the body’s need for oxygen
or alters the transport of oxygen, such as infection, trauma or dehydration may result in a sickle cell crisis.
9 B: Signs of right-sided heart failure include jugular vein distention, ascites, nausea, and vomiting.
10 C: A cold, pale lower leg. This assessment suggests the presence of an embolus probably from the atrial fibrillation. Peripheral
pulses should be checked immediately.
11 C: Inspiratory crackles. In congestive heart failure, fluid backs up into the lungs (creating crackles) as a result of inefficient
cardiac pumping.
12 B: assess for dyspnea or stridor. Due to the location of the burns, the client is at risk for developing upper airway edema and
subsequent respiratory distress.
13 B:Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client is grave danger since abscesses are
often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration
called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours
of therapy for infections.
14 D: This information would alert to the complication of acute renal failure which may occur as a complication from the dye and
the procedure. Renal failure occurs most often in elderly patients who are chronically dehydrated before the dye injection.
15 C: The earliest sign of poor oxygenation is an increasing pulse rate as a part of the body’s compensatory mechanism. Abnormal
breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal.
16 B: "The client’s entire body turns a bright red color. This observation suggest anaphylaxis which results in massive vasodilation.
Other findings would be immediate wheezing and/or respiratory arrest.
17 D: "When I put the baby in a back lying position that’s how I find it hours later." Cerebral palsy is known as a condition whereby
motor dysfunction occurs secondary to damage in the motor centers of the brain. Inability to roll over by 8 months of age would
illustrate one delay in the infant''s attainment of developmental milestones.
18 C: The major pathways are called meridians, not nerve clusters.
19 B: A priority action is to turn the client to the left side to decrease pressure on the vena cava and promote adequate circulation
to the placenta and kidneys. Urine protein level and output should be checked with each voiding. Temperature should be monitored
every 4 hours or more often if indicated, but no data in the stem supports a check of temperature.
20 A: Side-lying on the left with the head elevated 10 degrees. Gravity will draw the most blood flow to the dependent portion of
the lung. For unilateral chest disease, it is best to place the healthiest part of the lung in the dependent position to enhance blood
flow to the area where gas exchange will be best. Ventilation would be minimally affected in the right dependent lung. This position
also enhances the drainage of the infected part of the lung. A head elevation of 35 degrees is counterproductive to therapeutic blood
flow and the drainage of secretions.
21 D: pupil responses. The organ most susceptible to damage in hypertensive crisis is the brain due to rupture of the cerebral blood
vessels. Neurologic status must be closely monitored.
22 A: S3 ventricular gallop. An S3 ventricular gallop is caused by blood flowing rapidly into a distended non-compliant ventricle.
This is most common with congestive heart failure.
23 A: Status of the eyes and the tongue. Clinical findings of dehydration include sunken eyes, dry tongue, lethargy, irritability, dry
skin, decreased play activity, and increased pulse. The normal pulse rate in this age child is 70-110.
24 D: A preschooler with intermittent episodes of alertness. A preschooler is most likely of these clients to have difficulty with the
use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the
use of a PCA pump.
25 B: fever of 103 degrees Fahrenheit (39.5 degrees Celsius). Persistent, prolonged fever may be an indication that the antibiotics
are not effective and may need to be changed.
26 D: weakness in left arm. 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.
27 A: Assess the apical pulse, counting for a full 60 seconds. It is the nurse’s responsibility to take the client’s pulse before
administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds.
Digoxin is held for a pulse below 60 beats per minute. A radial pulse, potentially less accurate, or blood pressure are not part of the
initial assessment before administering an initial dose of digoxin.
28 B: It is critical to report promptly to your health care provider any findings of peptic ulcers. Such findings include night-time
awakening with burning, cramp-like abdominal pain, vomiting and even hematemesis, and change in appetite. Abdominal pain,
rigidity and tenderness can signal perforation of the ulcer and should be reported to the provider immediately. Zollinger-Ellison
syndrome can occur in both children and adults.
29 D: Hair loss. The major concern for adolescence is body image, so hair loss would be the most disturbing.
30 C: Kawasaki disease occurs most often in boys, children younger than age 5 and children of Asian descent, particularly
Japanese. Other findings in the initial phase are extremely red eyes (conjunctivitis), a rash on the main part of the body (trunk) and
in the genital area, red, dry, cracked lips; a red, swollen tongue resembling a strawberry; swollen, red skin on the palms of the hands
and the soles of the feet; swollen lymph nodes in the neck. Fever reduction signals the second phase, when the findings slowly go
away. In the third phase findings, except for abnormal lab values, are gone unless complications associated with the heart develop.
The disease lasts from 2 to 12 weeks without treatment. With treatment, the child usually improves within 24 hours. The cause of
Kawasaki disease is not known.
31 D: pale, have thin arms and legs, and uninterested in surroundings. Diagnosis of NOFTT is made on anthropomorphic findings
documenting growth retardation which would lead the nurse to expect muscle-wasting and paleness. In cases of NOFTT, the cause
may be a variety of psychosocial factors and these children may be below normal in intellectual development, language and social
interactions.
32 A: acute compartment syndrome. Increasing pain that is not relieved by narcotic analgesics is an indication of compartment
syndrome after a bone fracture and requires immediate action by the nurse. Thromboembolic complications include deep vein
thrombosis and pulmonary embolism which are not characterized by increasing pain at the site of injury. Both pulmonary embolism
and fat embolism present with respiratory findings. Osteomyelitis is a bone infection which could occur some time after the initial
injury, usually at least 48 to 72 hours.
33 A: Anemia caused by reduced endogenous erythropoietin production, primarily end-stage renal disease is treated
withsubcutaneous injections of Procrit or Epogen to stimulate the bone marrow to produce red blood cells.
34 B: Leukocytosis and fever are common starting on day 2 because of the inflammatory process associated with an acute MI.
Nursing interventions should focus on promoting comfort.
35 A: An increase in FHT may indicate maternal infection. The other assessment findings are normal.
36 A: All of these options are correct information. The most important point to reinforce is the continuing need to take additional
action for birth control.
37 D: Fibroids that cause no findings may require only "watchful waiting" with no treatment. Only when the client’s findings
become disturbing to them would surgical interventions be considered.
38 C: Options A, B, and D are expected complaints after this procedure. Option C needs to be reported immediately since minimal
urinary drainage puts the client at risk for bladder rupture. The flow rate of the continuous irrigation would need to be slowed until
the provider is notified. If an order to irrigate the system is written, sterile technique would be used.
39 C: Chest physiotherapy twice a day. These clients have potential inability to have voluntary and involuntary muscle movement
or activity. Thus, options A and B may not be feasible for the immobilized client. Option D is not specific for prevention of
complications associated with the lung.
40 B: Pupils fixed and dilated. Pupils that are fixed and dilated indicate overwhelming injury and intrinsic damage to the upper
brain stem. It is a poor prognostic sign.