NCLEX PN Physiological Integrity: Physiological Adaptation FAQs
1. What are the early signs and nursing interventions for increased intracranial pressure (ICP)?
Increased intracranial pressure (ICP) is a potentially life-threatening condition frequently encountered in patients with traumatic brain injury, brain tumors, or intracranial hemorrhage. Early recognition is critical to prevent neurological deterioration.
Early signs and symptoms include:
- Changes in level of consciousness such as restlessness, irritability, confusion, or lethargy
- Headache that is often persistent and worsening
- Nausea and projectile vomiting
- Visual disturbances such as blurred or double vision
- Pupillary changes including unequal size or sluggish light response
- Decreased motor function or weakness on one side of the body
Nursing interventions include:
- Elevating the head of the bed to 30 degrees to promote venous drainage and reduce ICP
- Maintaining the head in a neutral, midline position to facilitate cerebral blood flow
- Avoiding activities that increase ICP such as coughing, straining, or frequent suctioning
- Monitoring vital signs closely, especially using the Glasgow Coma Scale to assess neurological status
- Administering prescribed medications, including osmotic diuretics like mannitol or corticosteroids to reduce cerebral edema
- Providing a calm and quiet environment to minimize stimulation
- Reporting any neurological deterioration immediately to the healthcare provider
These interventions and signs are essential knowledge tested frequently in NCLEX PN practice questions and LPN exam prep.
2. How should an LPN manage the care of a patient experiencing autonomic dysreflexia?
Autonomic dysreflexia is a critical emergency typically seen in patients with spinal cord injuries at or above the T6 level. It results from an exaggerated autonomic response to a noxious stimulus below the injury site.
Signs and symptoms include:
- Sudden severe hypertension (often systolic >200 mmHg)
- Bradycardia
- Severe pounding headache
- Profuse sweating and flushing above the level of injury
- Nasal congestion and blurred vision
- Cool, pale skin below the injury
Nursing actions involve:
- Immediately sitting the patient upright to lower blood pressure
- Identifying and removing the triggering stimulus such as bladder distension (check catheter patency), fecal impaction, or tight clothing
- Monitoring blood pressure every 2 to 3 minutes until stabilized
- Loosening restrictive garments to improve circulation
- Notifying the RN or healthcare provider urgently, as antihypertensive medication may be required
- Documenting the episode and educating the patient and family on prevention and recognition of future events
This scenario is a classic LPN test question and a key component in NCLEX PN practice exams.
3. What is the LPN’s role in managing fluid and electrolyte imbalances in acutely ill patients?
Fluid and electrolyte imbalances frequently complicate acute illnesses such as renal failure, heart failure, burns, or postoperative states. Licensed Practical Nurses play an important role in early identification and management.
Assessment signs to watch for include:
- Hypokalemia: muscle weakness, cardiac arrhythmias, constipation
- Hyperkalemia: muscle twitching, cardiac irregularities
- Hyponatremia: confusion, seizures
- Hypernatremia: intense thirst, dry mucous membranes
- Hypocalcemia: muscle spasms, positive Chvostek and Trousseau sign
LPN responsibilities include:
- Closely monitoring intake and output and reporting significant changes
- Weighing patients daily as weight changes reflect fluid status
- Administering electrolyte supplements as ordered and within scope
- Monitoring laboratory values and promptly reporting abnormalities
- Educating patients on diet modifications such as fluid restrictions or low sodium diets
These competencies are regularly covered in NCLEX exams.
4. How can LPNs assist in managing patients undergoing dialysis?
Dialysis is a lifesaving procedure for patients with end-stage renal disease. LPNs support this process by preparing the patient and monitoring for complications.
Before dialysis:
- Obtain baseline vital signs and weight
- Inspect vascular access for patency by checking for bruit or thrill
- Withhold medications that dialysis may remove, such as antihypertensives, as directed
- Review laboratory values like potassium, blood urea nitrogen (BUN), and creatinine
After dialysis:
- Reassess weight and vital signs
- Monitor for hypotension, dizziness, nausea, or bleeding at access sites
- Avoid blood pressure or IV punctures on the access arm to prevent complications
- Report any unusual symptoms such as muscle cramping or fatigue
For peritoneal dialysis:
- Monitor the clarity and color of outflow fluid, which should be clear and pale yellow
- Maintain sterile technique during fluid exchanges to prevent peritonitis
- Observe for abdominal pain or signs of infection
Patient education on diet, fluid restrictions, and signs to report is crucial. These nursing responsibilities are often part of NCLEX PN exams.
5. What are appropriate nursing interventions for a patient in respiratory distress or failure?
Respiratory distress can result from conditions such as COPD, pneumonia, asthma, or pulmonary embolism and requires prompt recognition and intervention.
Signs of respiratory distress include:
- Rapid breathing (tachypnea) and difficulty breathing (dyspnea)
- Use of accessory muscles to breathe
- Cyanosis (bluish skin coloration)
- Confusion or lethargy due to hypoxia
- Decreased oxygen saturation on pulse oximetry
- Abnormal breath sounds like wheezing or crackles
Nursing interventions include:
- Positioning the patient in high Fowler’s position to maximize lung expansion
- Administering oxygen therapy as ordered and continuously monitoring oxygen saturation
- Remaining with the patient to provide reassurance and reduce anxiety
- Encouraging controlled breathing techniques, such as pursed-lip breathing for COPD patients
- Notifying the RN or healthcare provider immediately if symptoms worsen
- Preparing for advanced airway management, such as intubation, if necessary
- Monitoring for complications like hypoxia, respiratory acidosis, or cardiac arrhythmias
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