NCLEX PHYSIOLOGICAL ADAPTATION NEWEST ACTUAL EXAM QUESTION WITH 100 CORRECT ANSWERS

NCLEX PHYSIOLOGICAL ADAPTATION NEWEST ACTUAL

2025/2026 EXAM QUESTION WITH 100% CORRECT ANSWERS

VERIFIED /ANSWERS/

A nurse is caring for a client admitted with chronic fatigue and weakness. During the physical assessment, the nurse notes jaundiced sclera, abdominal distension, swelling in the legs and ankles, and bruises in various stages of healing throughout the body. What nursing interventions should the nurse initiate?Select all that apply.

• Measure abdomen

• Monitor intake and output

• Obtain daily weight

• Place on fall precautions

• Provide three meals per day

• Dangle legs - ----Answers---1. Measure abdomen

• Monitor intake and output
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• Obtain daily weight

• Place on fall precautions

(1., 2., 3., & 4. Correct: The symptoms presented are indicative

of liver disease. Measuring abdominal girth will monitor for accumulating ascitic fluid. Clients with liver disease have fluid volume problems, so daily weight and I&O are indicated. This client is at risk for injury related to chronic fatigue and weakness, so fall prevention is indicated. The client may need help eating if fatigue is severe.

5. Incorrect: Poor tolerance to larger meals may be due to

abdominal distension and ascites. Clients should eat smaller, more frequent meals (6/day). The recommended diet is high calorie and low sodium with protein regulated based on liver function. Between meal snacks should be provided.

6. Incorrect: Elevating legs enhances venous return and

reduces edema in extremities. Dangling the leg would cause the fluid in the lower extremities to accumulate more.)

How would the nurse determine the correct size oropharyngeal airway for a client?

• Select the same size as the little finger of the victim.

• Measure from the tip of the lips to the epiglottis. 2 / 4

• Determine the length from the earlobe to the xiphoid

process.

• Measure from the earlobe to the corner of the mouth. - ----

Answers---4. Measure from the earlobe to the corner of the mouth.

(4. Correct: An airway of proper size will extend from the

corner of the client's mouth to the tip of the earlobe on the same side of the client's face.

1. Incorrect: The size of the client's little finger does not

determine the size of the oral airway that should be used. This would result in an inappropriate size oropharyngeal airway to be selected.

2. Incorrect: The epiglottis is an internal body part thus making

it impossible to correctly measure it. In addition, the measurement would not determine the appropriate size oropharyngeal airway to use.

3. Incorrect: Measuring from the client's earlobe to the client's

xiphoid process would make the oral airway too long.)

A client diagnosed with major depression has been taking a selective serotonin reuptake inhibitor for the past 6 weeks.When visiting the mental health center, the nurse discusses 3 / 4

the medication and response with the client. The nurse's assessment reveals that the client is confused about the date and about the prescribed dosage of the medication. Which question would be most important for the nurse to ask to further assess the situation?

• Are you having trouble sleeping at night?

• Do you have periods of muscle jerking?

• Are you having any sexual dysfunction?

• Is your mood improving? - ----Answers---2. Do you have

periods of muscle jerking?

(2. Correct: Myoclonus, high body temperature, shaking, chills,

and mental confusion are some of the symptoms of serotonin syndrome. This client may be having symptoms of this adverse reaction which, if severe, can be fatal.

1. Incorrect: Sleep disturbances are common with depression.

Selective serotonin reuptake inhibitors (SSRIs) may cause insomnia; however, there is a more pertinent question needed for assessment of this client. You should be concerned with the more serious or life-threatening issue.

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