NCLEX-RN Physiological Adaptation Exam

A client with history of primary adrenal insufficiency presents to the emergency department complaining of muscle weakness, dizziness, nausea, and vomiting. The nurse suspects that the client is experiencing Addisonian crisis.

> Which clinical manifestation(s) is strongly supportive of this crisis?

A nurse is caring for a client with cirrhosis. During the morning assessment, the nurse notices that the client has developed asterixis and seems confused. The nurse strongly suspects the onset of hepatic encephalopathy and anticipates an order to change the client’s diet.

> Which dietary modification is necessary in the client with hepatic encephalopathy?

A client has just been given news of a cancer diagnosis and is very upset. The nurse is providing emotional support and notes that the client’s respiratory rate is increased at 24 breaths per minute, pulse is 116 beats per minute, blood pressure is 140/96 (increased from baseline), and pupils are dilated.

> Which physiological response is being stimulated?

A client newly diagnosed with endometriosis asks the nurse for clarification about the disorder.

> Which statements accurately describe endometriosis? Select all that apply.

The nurse is teaching a client with hypophosphatemia about dietary management.

> Which food item should the client avoid?

A 2-year-old child is brought to the emergency department 6 hours after ingesting an unknown quantity of aspirin. The child is hyperventilating, lethargic, and has a significantly altered mental status.

> Which arterial blood gas result most strongly supports late-stage salicylate toxicity?

While assessing a client with acute pancreatitis, the nurse observes bluish discoloration and ecchymosis around the umbilical area.

> How should the nurse document this finding?

The nurse is assessing a client following surgical removal of an adrenal gland.

> Which finding would the nurse monitor for most closely?

A client is admitted after sustaining a hip fracture from a fall.

> Which assessment finding would the nurse most likely note in the affected extremity?

A client receiving peritoneal dialysis asks why glucose is included in the dialysate solution.

> Which explanation should the nurse provide about the purpose of glucose in the solution?

The nurse is reviewing client assignments on a medical-surgical unit.

> Which clients are most likely to require total parenteral nutrition (TPN)? Select all that apply.

A pregnant client at 28 weeks’ gestation is diagnosed with symphysis pubis dysfunction.

> The nurse explains that increased joint laxity during pregnancy is caused by which hormones? Select all that apply.

A client with a closed head injury is being monitored for secondary brain injury over the next 48 hours.

> Which findings are manifestations of secondary brain injury? Select all that apply.

A laboring client with placental separation begins to show signs of abnormal bleeding. Laboratory studies are pending, and the nurse is closely monitoring for a possible coagulopathy.

> Which assessment findings would most strongly support the development of disseminated intravascular coagulation (DIC)? Select all that apply.

A client with untreated hyperthyroidism is admitted after developing sudden worsening symptoms following an infection.

> Which findings would alert the nurse to a life-threatening complication? Select all that apply.

A client reports low back pain that radiates down the posterior aspect of one leg and occasionally feels worse after certain daily activities.

> Which factor would the nurse expect to aggravate this type of pain?

A nurse is assessing a client with suspected stimulant toxicity after using amphetamines.

> Which assessment finding would the nurse most expect?

A client in the first trimester is being followed for iron deficiency anemia and asks how they will know if the condition is improving.

> Which finding suggests the anemia has not yet resolved?

The emergency department is notified that a client is arriving with severe anaphylaxis and worsening respiratory symptoms. The nurse prepares the room.

> Which intervention should be performed first on arrival?

A child is admitted with persistent vomiting for two days and minimal oral intake.

> Which problem is the child at greatest risk for developing?