NCLEX-RN
NCLEX RN Client Needs Physiologic Adaptation Questions
Question 1 of 5
The nurse is caring for a client with suspected connective tissue disease. Assessment findings include chronic back pain, weight loss, joint pain and itching, and visual disturbances. The nurse anticipates a diagnosis of which disorder for this client?
Correct Answer: D
Rationale: Systemic necrotizing vasculitis (
D) causes back/joint pain, weight loss, itching, and visual issues due to vessel inflammation. Reiter (
A) involves arthritis/urethritis, Marfan (
B) affects connective tissue, and ankylosing spondylitis (
C) primarily causes spinal stiffness.
Question 2 of 5
The nurse is caring for a client with cardiogenic shock. The nurse expects which signs present with this client? Select all that apply.
Correct Answer: D
Rationale: Cardiogenic shock causes hypotension, weak pulse, and cool, clammy skin (
D) due to poor perfusion. Hypertension (
A), warm skin (
B), and increased urine output (
C) are inconsistent with shock.
Question 3 of 5
A client presents to the emergency room with severe pain in the upper right abdomen. The client is nauseated and has a temperature of 102.2°F. Which nursing action would be a priority at this time?
Correct Answer: B
Rationale: Obtaining vital signs (
B) is the priority to assess stability in a client with suspected cholecystitis or appendicitis. Pain relief (
A), fluids (
C), and surgery (
D) follow assessment.
Question 4 of 5
The nurse is preparing to remove a client's abdominal stitches as ordered by the health care provider. Which is the correct action by the nurse?
Correct Answer: B
Rationale: Hand washing and gloves (
B) are sufficient for stitch removal, a clean procedure. Soap/water (
A) is unnecessary, sterile technique (
C) is excessive, and full PPE (
D) is not required.
Question 5 of 5
A student nurse is precepting on the cardiac unit with the charge nurse. The charge nurse is educating the student about heart sounds and asks the student nurse to describe what causes the S1 sound. Which response by the student nurse reflects an understanding of cardiac sounds?
Correct Answer: A
Rationale: S1 is caused by the closure of mitral and tricuspid valves (
A) at the start of systole. Pulmonic and aortic valves (
C) cause S2, and other combinations (B,
D) are incorrect.