COMPLETE REVISION QUESTIONS

NCLEX Review: Physiological Integrity

COMPLETE REVISION QUESTIONS

AND CORRECT DETAILED ANSWERS

(VERIFIED ANSWERS) ALREADY

GRADED

Cleft Palate Repair - Answer: Avoid using suction or pacing objects in mouth (ex: small spoon, thermometer, straws) for about 6 wks or until palate heals

Total Joint Hip Replacement:

Abnormal findings post surgery - Answer: affected leg outwardly rotated (indicates dislocation of prosthesis. Shortening of extremity, inablity to move it, altered alignment, abnormal rotation should all be reported to the MD

Hypertension:

Dietary management - Answer: Low-fat, Low-cholesterol diet recommended. Baking, roasting, boiling, or broiling cooking methods are preferred. Avoid fried foods.

Catheter:

Condom catheter Management and care - Answer: elastic adhesive strip should be wrapped in a spiral pattern without overlapping onto itself to ensure circulation to the penis is not impaired; tape should be snug but not too tight; 1 to 2 inches of space should be left between the end of the condom cath and the tip of the penis; clipping the hair at the base of the penis will prevent the hair to stick to the condom when it is applied or removed.

Progressive Systemic Sclerosis - Answer: Causes dysphagia and esophageal reflux; instruct client to avoid spicy foods, caffeine, & alcohol to prevent gastric secretions from being stimulated. Suggest to eat small freq meals

Parkinson's Disease: 1 / 2

normal findings - Answer: 1. Tremors: resting tremors that disappear with purposeful movements

2. bradykinesia: abnormally slow muscle movement, trouble initiating movement

3. Slurred speech: caused by weakness & incoordination of muscles

• Respiratory distress: instruct client to walk erect, watch the horizon, & use a wide-based gait

Hip Joint Rotation:

Prevention - Answer: Trochanter roll is used as a positioning device that functions as a mechanical wedge under the greater trochanter. Is placed from lateral aspect of the hip to the mid-thigh to prevent external rotation of the hip joint and femur from rolling

Chronic Renal Failure Patient:

voiding a lot throughout the day and night - Answer: High volume of urine indicates your kidneys are releasing too much fluid caused by hypertrophy of renal tissue results in increased surface available for urinary excretion.

Traction:

Buck's Traction - Answer: Keep HOB 20-22 degrees, leg extended: not internally rotated, DO NOT ELEVATE LEG. DO NOT TWIST SIDE TO SIDE. allow weights to hang freely at all times to maintain traction.Applied before hip surgery to reduce muscle spasms and help immobilize the fracture

Traction:

Buck's traction Management & Care - Answer: 1. remove foam boots x 3 times/day to inspect skin (have 2nd nurse support extremity being inspected).

• turn client to unaffected area; can turn to either side if there is no fracture
• Provide back care q 2hrs to prevent pressure sores
• ask client to dorsiflex foot on the affected leg to assess peroneal nerve function (weakness may

indicate pressure on the nerve)

• Assess c/o pain promptly to r/o nerve pressure
• elevate foot of the client's bed to provide counter traction
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