Physiological Integrity 3

Question 1

A nurse is caring for a client with a spinal cord injury at the T4 level. The client develops a sudden severe headache (9/10), blood pressure of 190/100 mmHg, and profuse diaphoresis above the level of injury. Which condition should the nurse suspect?

Accepted Answer

Autonomic dysreflexia

Answer

Autonomic dysreflexia is a life-threatening complication of spinal cord injuries above T6, characterized by a sudden extreme hypertension, pounding headache, and diaphoresis above the injury level, triggered by a noxious stimulus below the injury.

Question 2

A nurse is caring for a client receiving peritoneal dialysis. The nurse notes that the dialysate drainage is cloudy. Which action should the nurse take first?

Accepted Answer

Stop the dialysis and notify the provider immediately

Answer

Cloudy dialysate effluent is a classic sign of peritonitis — the most serious complication of peritoneal dialysis. The nurse must stop the dialysis and notify the provider immediately so antibiotic therapy can be initiated promptly.

Question 3

A nurse is assessing a client with suspected deep vein thrombosis (DVT) in the right lower leg. Which assessment technique should the nurse avoid?

Accepted Answer

Performing Homan's sign (dorsiflexion of the foot)

Answer

Homan's sign (forceful dorsiflexion of the foot to elicit calf pain) should not be performed when DVT is suspected because it can dislodge the thrombus and cause pulmonary embolism. It has also been found to be an unreliable diagnostic test.

Question 4

A nurse is caring for a client experiencing a generalized tonic-clonic seizure. Which action has the highest priority?

Accepted Answer

Turn the client to a side-lying position and protect the head

Answer

During a seizure, the highest priority is protecting the client from injury. Turning to a side-lying position prevents aspiration of secretions and keeps the airway open; protecting the head prevents traumatic injury.

Question 5

A nurse is caring for a client with a new tracheostomy who has thick secretions that are difficult to suction. Which intervention will most effectively improve secretion clearance?

Accepted Answer

Ensure adequate systemic hydration and use tracheostomy humidification

Answer

Adequate systemic hydration and tracheostomy humidification are the most effective interventions for preventing and managing thick secretions. Bypassing the nose eliminates the natural humidification of the upper airway, making supplemental humidification essential.

NCLEX Practice Test

NCLEX Practice Test

Physiological Integrity 3