Select All That Apply Practice Test #4: Physiological Adaptation

Correct answers (A, C, E):
A. Heart rate climbing above the client's baseline.
C. New restlessness and anxiety.
E. Urine output falling below the expected amount.

Rationale: When blood volume drops, the body tries to protect blood flow to the brain and heart. The heart rate rises first (A), the brain gets less oxygen so the client becomes restless or anxious (C), and the kidneys receive less blood so urine output falls (E). The skin also turns cool, pale and clammy, and breathing becomes fast and shallow. Blood pressure can stay near normal early on because of this compensation, so a normal reading does not rule out shock; a falling blood pressure is a later sign. Option B is wrong because warm, flushed skin is not expected in hypovolemic shock; it is seen in the early phase of distributive shock such as sepsis. Option D is wrong because breathing becomes rapid, not slow and deep. Expected urine output depends on the client and the facility's parameters, so the nurse compares it with the ordered target and the client's own trend.

Correct answers (A, C, D):
A. Stop the antibiotic infusion.
C. Call for help (rapid response) and stay with the client.
D. Give intramuscular epinephrine as prescribed or per the facility's anaphylaxis protocol.

Rationale: Hives with throat tightness and wheezing after a new drug point to anaphylaxis, which can close the airway and drop the blood pressure within minutes. The nurse stops the drug at once (A), calls for help and stays with the client (C), and gives intramuscular epinephrine, usually into the mid-outer thigh, which is the first-line treatment (D). The dose comes from the order or protocol and the client's weight. Oxygen, IV fluids, and positioning follow: lying flat with the legs raised, or sitting up if breathing is hard. Option B is wrong because antihistamines treat itching and hives but do not open the airway or raise blood pressure; they are add-on drugs and must never delay epinephrine. Option E is wrong because flushing the old tubing pushes more of the drug into the client; the tubing is disconnected and IV access is kept with new tubing and normal saline.

Correct answers (C, D, E):
C. Sudden shortness of breath with a falling oxygen saturation.
D. New confusion and restlessness.
E. Small red-purple spots (petechiae) on the chest and in the armpits.

Rationale: Fractures of long bones such as the femur, and of the pelvis, can release fat droplets into the bloodstream. Fat embolism syndrome most often shows up within the first few days after the injury, with a classic set of findings: breathing problems with low oxygen (C), changes in mental status such as confusion or restlessness (D), and a petechial rash on the chest, armpits, neck or inside the eyelids (E). This is an emergency: the nurse gives oxygen as prescribed or per protocol, raises the head of the bed if allowed, and calls the provider or rapid response. Early stabilization of the fracture helps prevent it. Options A and B are wrong because bruising and swelling at the fracture and steady pain are expected after this injury. The nurse still checks the limb for signs of compartment syndrome.

Correct answers (B, D, E):
B. Singed nasal hair and eyebrows.
D. A hoarse voice that the family says is new.
E. Soot around the mouth and in the sputum.

Rationale: Heat and smoke can injure the airway even when the skin burns look small. Signs of inhalation injury include burns or singed hair on the face and nose (B), a new hoarse voice or stridor (D), and soot in the mouth, nose or sputum (E). Being trapped in a closed space with smoke also raises the risk. Airway swelling can get worse over the next hours, so the nurse watches closely, gives oxygen as prescribed, and alerts the provider early because a breathing tube may be needed before swelling makes it hard to place. Option A is wrong because leg burns alone do not point to an airway injury. Option C is wrong because a standard pulse oximeter cannot tell carbon monoxide from oxygen on hemoglobin, so the reading can look normal while the client is poisoned; a blood test for carboxyhemoglobin is needed.

Correct answers (A, D, E):
A. Severe upper abdominal (epigastric) pain that spreads to the back.
D. Bluish discoloration around the belly button (Cullen sign).
E. Bluish discoloration of the flanks (Grey Turner sign).

Rationale: Acute pancreatitis typically causes sudden, severe epigastric or upper abdominal pain that often spreads to the back (A). Bluish bruising around the umbilicus (D) or on the flanks (E) is less common but points to bleeding into the tissues around the pancreas and severe disease, so the nurse reports it promptly. Other findings include nausea and vomiting, fever, abdominal tenderness and guarding, and a rise in serum lipase or amylase. Option B is wrong because lying flat on the back usually makes the pain worse; many clients find some relief sitting up and leaning forward or lying curled on the side. Option C is wrong because the pain, inflammation and fluid loss usually cause a fast heart rate, not a slow one, and the client may develop hypotension.

Correct answers (B, C, E):
B. Give IV fluids and encourage oral fluids as prescribed.
C. Give the prescribed opioid on a schedule or by PCA rather than waiting until the pain is severe.
E. Report new chest pain, fever, cough or falling oxygen saturation right away.

Rationale: In a pain crisis, sickled red cells block small blood vessels and cut off oxygen to tissues. Fluids, given as prescribed, help reduce blood thickness and sickling (B), though the amount must be watched for fluid overload. Pain is often severe and is treated quickly and steadily, usually with scheduled opioids or a PCA pump, then reassessed often (C). New chest pain, fever, cough, or low oxygen can mean acute chest syndrome, a leading cause of death in sickle cell disease, so it is reported at once (E). Oxygen is given when the saturation is low. Option A is wrong because cold makes blood vessels narrow and can worsen sickling; warmth is used instead. Option D is wrong because withholding pain medicine is unsafe and based on stigma; addiction is not more common in sickle cell disease, and untreated pain causes real harm.

Correct answers (A, B, E):
A. Restrict fluids to the amount prescribed.
B. Weigh the client daily on the same scale at the same time.
E. Watch for headache, confusion, muscle cramps or seizures.

Rationale: In SIADH, too much antidiuretic hormone makes the kidneys hold on to water. The blood becomes diluted, so the sodium level falls, and the urine becomes small in amount and concentrated. Treatment starts with fluid restriction set by the provider (A). Daily weights on the same scale at the same time show whether water is building up (B). Low sodium affects the brain, causing headache, confusion, muscle cramps and, if severe, seizures, so the nurse checks neurological status and uses seizure precautions as needed (E). Option C is wrong because extra water would lower the sodium further. Option D is wrong because SIADH causes small amounts of concentrated urine; large amounts of dilute urine fit diabetes insipidus. If sodium is corrected, the provider sets the rate, because raising it too fast can cause serious brain injury (osmotic demyelination).

Correct answers (B, C, D):
B. Secretions are building up in the airway.
C. The client is biting down on the endotracheal tube.
D. The ventilator tubing is kinked or has water pooled in it.

Rationale: A high-pressure alarm means the ventilator meets more resistance than expected as it pushes air in. Common causes are secretions that need suctioning (B), the client biting the tube (C), and kinked tubing or water collecting in the circuit (D). Coughing, bronchospasm, the client fighting the ventilator, and a pneumothorax can also cause it. The nurse checks the client first, then works from the client to the machine. If the problem cannot be fixed quickly and the client is in distress, the nurse disconnects the ventilator and gives breaths with a manual resuscitation bag per facility policy while help from respiratory therapy is called. Options A and E are wrong because a disconnection or a cuff leak lets air escape, which sets off the low-pressure alarm, not the high-pressure alarm.

Correct answers (A, C, D, E):
A. Low blood pressure.
C. Low serum sodium.
D. High serum potassium.
E. Low blood glucose.

Rationale: In Addison disease the adrenal glands do not make enough cortisol or aldosterone. Illness, vomiting or missed steroid doses can trigger an adrenal crisis, which is life threatening. Without aldosterone the kidneys lose sodium and water and keep potassium, so the nurse expects low sodium (C), high potassium (D), dehydration and low blood pressure that can progress to shock (A). Without cortisol the blood glucose can fall (E). Other findings include severe weakness, abdominal pain, nausea, vomiting and confusion. Treatment is fast: IV hydrocortisone and IV fluids as prescribed, with glucose and electrolytes checked often and the heart rhythm watched because of the high potassium. Option B is wrong because high blood pressure with fluid retention fits too much cortisol (Cushing syndrome), not a lack of it.

Correct answers (B, C, D):
B. Have the client lie on the abdomen (prone) for periods each day if prescribed.
C. Treat phantom limb pain as real pain and give the prescribed pain medicine.
D. Wrap the residual limb with an elastic bandage in a figure-eight pattern, or apply a shrinker, as prescribed.

Rationale: The main goals after an amputation are healing, pain control, and preparing the limb for a prosthesis. Lying prone for periods, if prescribed and tolerated, stretches the hip and helps prevent flexion contractures (B). Phantom limb pain is real nerve pain and is treated with prescribed medicine and other measures, never dismissed (C). A figure-eight elastic wrap or a shrinker sock, applied as prescribed, controls swelling and shapes the residual limb so a prosthesis can fit (D). The nurse also checks the dressing for bleeding and the site for infection. Options A and E are wrong because keeping the residual limb raised on a pillow, or the knee bent for long periods, can cause a flexion contracture of the hip or knee that makes it hard or impossible to wear a prosthesis. Any raising of the limb in the first day follows the surgeon's orders.