NCLEX Physiological Adaptation

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview NCLEX Review - Management of Ca...26 terms ish_jayme_penafiel Preview NCLEX Question Bank with Rational...77 terms Haley_Malzac Preview NCLEX 42 terms Kat The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?

• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis
• Metabolic acidosis

(3. Correct: A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. Hyperventilation occurs due to excess ketones in the body causing metabolic acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing. The hyperventilation occurs to reduce the arterial pCO₂ level.

• Incorrect: The fruity smelling breath indicates a metabolic problem. This is a result of an increase in the acetone level. The client may develop

diabetic ketoacidosis (DKA).

• Incorrect: The client is in metabolic acidosis. This is not a respiratory imbalance.
• Incorrect: The client is experiencing a metabolic situation due to the increase in the ketones in the body, the client is in metabolic acidosis.)

When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism?Select all that apply.

• Nervousness
• Weight gain
• Exophthalmos
• Loss of appetite
• Constipation
• Hot and sweating
• Nervousness
• Exophthalmos
• Hot and sweating

(1., 3., & 6. Correct: With hyperthyroidism, the client has too much energy. They report being nervous and feeling hot. Exophthalmos is an irreversible eye condition where the eyes bulge. This condition is associated with hyperthyroidism that has not been treated early enough to prevent this from occurring. Due to the hypermetabolic state, the client will often report feeling hot and will be sweating.

• Incorrect: The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption.
• Incorrect: Loss of appetite is seen in the client with hypothyroidism. The client with hyperthyroidism has an increased appetite but

experiences weight loss due to the excessive energy consumption.

• Incorrect: Constipation is a sign of hypothyroidism due to slowed GI motility. In hyperthyroidism, the nurse would expect increased GI

motility.)

What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia?Select all that apply.

• White blood cell count of 3,800 (3.8 × 10⁹/L)
• White blood cell count of 15,000 (15.0 × 10⁹/L)
• Platelet count of 90,000/µL (90 × 10⁹/L)
• Platelet count of 450,000/µL (450 × 10⁹/L)
• Red blood cell count of 3.0 million/mcL (3.0 × 10¹²/L)
• Red blood cell count of 7.3 million/mcL (7.3 × 10¹²/L)
• White blood cell count of 3,800 (3.8 × 10⁹/L)
• White blood cell count of 15,000 (15.0 × 10⁹/L)
• Platelet count of 90,000/µL (90 × 10⁹/L)
• Platelet count of 450,000/µL (450 × 10⁹/L)
• Red blood cell count of 3.0 million/mcL (3.0 × 10¹²/L)

(1., 3., 5. Correct: Pancytopenia is a condition in which there is a concurrent leukopenia (a reduction in white blood cells), thrombocytopenia (a reduction in platelets), and anemia (reduction in red blood cells). The normal white blood cell count is 5,000-10,000 (5.0-10.0 × 10⁹/L), so a level of 3,800 (3.8 × 10⁹/L) represents leukopenia. The normal platelet count is 150,000-400,000/µL (150-450 × 10⁹/L), so a level of 90,000/µL represents thrombocytopenia. The normal red blood cell count for a Female is 4.2 - 5.4 million/mcL (4.2-5.4 × 10¹²/L), and the normal red blood count for a Male is 4.7-6.1 million/mcL (4.7-6.1 × 10¹²/L). Therefore, a red blood cell count of 3.0 million/mcL (3.0 × 10¹²/L) is indicative of anemia, regardless of the sex of the client.

• Incorrect. The normal white blood cell count is 5,000-10,000 (5.0-10.0 × 10⁹/L). A WBC count of 15,000 (15.0 × 10⁹/L) is considered leukocytosis

(elevated WBC level).

• Incorrect: The normal platelet count is 150,000-400,000/µL (150-450 × 10⁹/L). Therefore, a platelet count of 450,000/µL (450 × 10⁹/L) would be

an elevated platelet level (thrombocytosis).

• Incorrect: The normal red blood cell count for a Female is 4.2-5.4 million/mcL (4.2-5.4 × 10¹²/L), and the normal red blood count for a Male is

4.7-6.1 million/mcL (4.7 - 6.1 × 10¹²/L). Therefore, a level of 7.3 million/mcL (7.3 × 10¹²/L) is elevated (polycythemia).)

The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected?

• Abrupt onset of dyspnea, fever.
• Small papule on skin resembling an insect bite.
• Pustular vesicles on skin.
• Fatigue.
• Abrupt onset of dyspnea, fever.

(1. Correct: Inhalation of anthrax spores is very serious, and clients will experience abrupt dyspnea and fever. Treatment must begin immediately.

• Incorrect: Cutaneous anthrax manifests itself as papules resembling an insect bite that progresses to depressed black ulcers.

3. Incorrect: Pustular vesicles are consistent with smallpox.

• Incorrect: Fatigue is a vague symptom that is usually not associated with inhaled anthrax.)

What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis?Select all that apply.

• Jogging
• Volleyball
• Tennis
• Bicycle riding
• Swimming
• Bicycle riding
• Swimming

(4., & 5. Correct: Rheumatoid arthritis is an autoimmune disease that affects the joints and other body symptoms. Low impact activities on joints are best such as swimming and bike riding.

• Incorrect: Jogging is a high impact activity for joints. This is not appropriate for a client with rheumatoid arthritis.
• Incorrect: Playing volleyball is a high impact activity for joints and would not be appropriate for a client with rheumatoid arthritis. The pressure

on the joints may result in additional damage to the joints.

• Incorrect: Playing tennis is a high impact activity for joints, and tennis should not be a recommended sport for a client with rheumatoid

arthritis.)