NCLEX - Physiological Adaptation Day1 (Part 2)

A client experiencing an outbreak of genital herpes makes the following statement. Which indicates a need for further teaching?

• I will be sure we use condoms during intercourse as long as I have lesions.
• I will not touch the lesions to prevent spreading the virus to other parts of my body.
• I will use a hair dryer on a cool setting to dry the lesions after showering.
• I will use warm running water and mild soap without perfumes to wash the area.
• –

Answer explanation

Genital herpes spreads via skin contact; condoms aren't sufficient during active lesions. Avoid sex completely until healed.

A client with pinworm infection is being assessed. Which findings would the nurse expect?

• Vomiting
• Constipation
• Restlessness
• Perianal itching
• Disturbed sleep

Answer explanation

Pinworms cause intense nighttime perianal itching, leading to disturbed sleep and restlessness, especially in children.

The home health nurse is caring for an 85-year-old client. Which report requires immediate follow-up?

• A painful red area on the buttocks
• New onset dependent edema of the feet
• Progressive loss of central vision
• No memory of activities performed yesterday
• –

Answer explanation

Dependent edema can signal heart failure—needs prompt evaluation and possible intervention to prevent complications.

A client being evaluated for suspected ectopic pregnancy reports sudden severe abdominal pain and dizziness. Which findings suggest rupture?

• Blood pressure 82/64 mm Hg
• Crackles on auscultation
• Distended jugular veins
• Pulse 120/min
• Shoulder pain

Answer explanation

Hypotension, tachycardia, and referred shoulder pain point to internal bleeding from ruptured ectopic pregnancy.

The nurse in the emergency department is caring for a client with hypothyroidism and decreased consciousness. What action should be taken first?

• Administer IV levothyroxine
• Place a warming blanket
• Prepare for endotracheal intubation
• Obtain TSH, T3, T4 blood panel
• –

Answer explanation

Myxedema coma can cause hypoventilation—secure airway and prep for intubation is the top priority.

A laboring client experiences rupture of membranes followed by abrupt fetal heart rate change. What should the nurse do first?

• Administer IV fluid bolus
• Assess for umbilical cord prolapse
• Notify the health care provider
• Prepare for emergency cesarean birth
• –

Answer explanation

Cord prolapse causes fetal bradycardia; visual or manual assessment should happen immediately.

During an obstetrical emergency simulation for uterine inversion, which nurse statement requires correction?

• I will administer IV oxytocin before the uterus is corrected.
• I will establish a second IV line with an 18-gauge catheter.
• I will initiate blood pressure monitoring every 3–5 minutes.
• I will notify anesthesia and operating room staff immediately.
• –

Answer explanation

Uterotonics must be delayed until the uterus is replaced—oxytocin before repositioning is contraindicated.

A hypothermic client arrives at the emergency department. What additional intervention is a priority?

• Attach cardiac monitor
• Cover the client's head
• Draw blood for electrolytes and glucose
• Place an additional large-bore IV catheter
• –

Answer explanation

Hypothermia predisposes to fatal dysrhythmias; cardiac monitoring must be established ASAP.

The nurse cares for a client who had a seizure 10 minutes ago and is now confused with a headache. Which seizure phase is the client experiencing?

• Ictal phase
• Aural phase
• Postictal phase
• Prodromal phase
• –

Answer explanation

Postictal phase follows the active seizure—marked by confusion, fatigue, and recovery symptoms.