Physiological Adaptation NCLEX RN Questions

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The nurse monitoring a postoperative client should recognize which behaviors as indicators that the client is in pain? Select all that apply.

  • A. Gasping
  • B. Lip biting
  • C. Muscle tension
  • D. Pacing activities
  • E. Staring out the window
  • F. Asking for the television to be turned off
Correct Answer: A,B,C,D

Rationale: The nurse should assess verbalization, vocal response, facial and body movements, and social interaction as indicators of pain. Behavioral indicators of pain include gasping, lip biting (facial expressions), muscle tension, pacing activities, moaning, crying, grunting (vocalizations), grimacing, clenching teeth, wrinkling the forehead, tightly closing or widely opening the eyes or mouth, restlessness, immobilization, increased hand and finger movements, rhythmic or rubbing motions, protective movements of body parts (body movement), avoidance of conversation, focusing only on activities for pain relief, avoiding social contacts and interactions, and reduced attention span. Options 5 and 6 are not to be assumed as pain-related behaviors because there can be a variety of reasons for such actions.

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A client is scheduled for hydrotherapy for a burn dressing change. Which action should the nurse take to ensure that the client is comfortable during the procedure?

  • A. Ensure that the client is appropriately dressed.
  • B. Administer an opioid analgesic 30 to 60 minutes before therapy.
  • C. Schedule the therapy at a time when the client generally takes a nap.
  • D. Assign an unlicensed assistive personnel (UAP) to stay with the client during the procedure.
Correct Answer: B

Rationale: The client should receive pain medication approximately 30 to 60 minutes before a burn dressing change. This will help the client tolerate an otherwise painful procedure. None of the remaining options addresses the issue of pain effectively.

What action should the nurse take to assess the pharyngeal reflex on a child?

  • A. Ask the client to swallow.
  • B. Pull down on the lower eyelid.
  • C. Shine a light toward the bridge of the nose.
  • D. Stimulate the back of the throat with a tongue depressor.
Correct Answer: D

Rationale: The pharyngeal (gag) reflex is tested by touching the back of the throat with an object, such as a tongue depressor. A positive response to this reflex is considered normal. Asking the client to swallow assesses the swallowing reflex. To assess the palpebral conjunctiva, the nurse would pull down and evert the lower eyelid. The corneal light reflex is tested by shining a penlight toward the bridge of the nose at a distance of 12 to 15 inches (light reflection should be symmetrical in both corneas).

A client is receiving cisplatin. On assessment of the client, which findings indicate that the client is experiencing an adverse effect of the medication?

  • A. Tinnitus
  • B. Increased appetite
  • C. Excessive urination
  • D. Yellow halos in front of the eyes
Correct Answer: A

Rationale: Cisplatin is an antineoplastic medication. An adverse effect related to the administration of cisplatin is ototoxicity with hearing loss. The nurse should assess for this adverse reaction when administering this medication. Options 2, 3, and 4 are not adverse effects of this medication.

The nurse reviews the client's vital signs in the client's chart. Based on these data findings, what is the client's pulse pressure? Fill in the blank.

Correct Answer: 74 mm Hg

Rationale: The difference between the systolic and diastolic blood pressure is the pulse pressure. Therefore, if the client has a blood pressure of 146/72 mm Hg, then the pulse pressure is 74.

An adult client arrives in the emergency department with burns to both entire legs and the perineal area. Using the rule of nines, the nurse should determine that approximately what percentage of the client's body surface has been burned? Fill in the blank.

Correct Answer: 37%

Rationale: The most rapid method used to calculate the size of a burn injury in adult clients whose weights are in normal proportion to their heights is the rule of nines. This method divides the body into areas that are multiples of 9%, except for the perineum. Each entire leg is 18%, each arm is 9%, and the head is 9%. The trunk is 36%, and the perineal area is 1%. Both legs and perineal area equal 37%.

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