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NCLEX PN Physiological Integrity: Physiological Adaptation FAQs

1. What are the early signs and nursing interventions for increased intracranial pressure (ICP)?

Solution:

Increased ICP is a critical condition often associated with head injuries, brain tumors, or hemorrhage. Recognizing early signs and intervening quickly can be lifesaving.

Early signs include:

  • Change in level of consciousness (restlessness, irritability, confusion)
  • Headache
  • Nausea and vomiting (often projectile)
  • Blurred or double vision
  • Pupillary changes (e.g., unequal pupils, sluggish response)
  • Decreased motor function or strength

Nursing Interventions:

  • Elevate the head of the bed to 30 degrees to promote venous drainage.
  • Maintain a neutral head alignment.
  • Avoid activities that increase ICP: coughing, straining, or frequent suctioning.
  • Monitor vital signs and Glasgow Coma Scale regularly.
  • Administer prescribed medications such as osmotic diuretics (e.g., mannitol) or corticosteroids.
  • Ensure a calm environment with minimal stimulation.
  • Report deterioration to the healthcare provider immediately.

2. How should an LPN manage the care of a patient experiencing autonomic dysreflexia?

Solution:

Autonomic dysreflexia is a medical emergency seen in patients with spinal cord injuries above T6. It results from a noxious stimulus below the level of injury and can lead to hypertensive crisis or stroke.

Signs and Symptoms:

  • Severe hypertension (systolic often >200 mmHg)
  • Bradycardia
  • Pounding headache
  • Sweating and flushing above the injury
  • Cool, pale skin below the injury
  • Nasal congestion and vision changes

Nursing Actions:

  • Sit the patient upright immediately to reduce blood pressure.
  • Identify and remove the stimulus (e.g., check for bladder distension, fecal impaction, tight clothing).
  • Monitor blood pressure closely every 2–3 minutes.
  • Loosen restrictive clothing.
  • Notify the RN or provider—they may order antihypertensive medications.
  • Document the episode thoroughly, including the trigger and response to treatment.
  • Provide education to the patient and family to recognize signs and prevent future episodes.

3. What is the LPN’s role in managing fluid and electrolyte imbalances in acutely ill patients?

Solution:

Fluid and electrolyte imbalances are common in many medical conditions, including renal failure, heart failure, burns, and post-surgery. LPNs play a vital role in early identification and management.

Key responsibilities:

  • Assessment: Monitor for signs of imbalance:
    • Hypokalemia: muscle weakness, arrhythmias, constipation
    • Hyperkalemia: cardiac irregularities, muscle twitching
    • Hyponatremia: confusion, seizures
    • Hypernatremia: thirst, dry mucous membranes
    • Hypocalcemia: tetany, positive Chvostek/Trousseau signs
  • Monitor intake and output carefully; alert the RN if there are major changes.
  • Check daily weights, a reliable indicator of fluid status.
  • Administer prescribed electrolyte replacements (oral or IV, if within LPN scope) and observe for reactions.
  • Monitor labs as ordered and report abnormal values promptly.
  • Educate patients on fluid restrictions, low sodium or potassium diets as applicable.

4. How can LPNs assist in managing patients undergoing dialysis?

Solution:

Dialysis is a lifesaving treatment for patients with end-stage renal disease. LPNs support the process by monitoring the patient and preparing for the procedure.

Hemodialysis care:

  • Before dialysis:
    • Obtain weight and vital signs.
    • Check the vascular access site for patency (bruit/thrill).
    • Hold medications that may be removed by dialysis (e.g., antihypertensives).
    • Monitor labs for potassium, BUN, creatinine.
  • After dialysis:
    • Reassess weight and vital signs.
    • Monitor for hypotension, dizziness, nausea, or bleeding from access site.
    • Avoid blood pressure or IV sticks in the access arm.
    • Report unusual symptoms such as cramping, fatigue, or access complications.

Peritoneal dialysis care:

  • Monitor the color and clarity of outflow fluid (should be clear and pale yellow).
  • Ensure sterile technique during exchanges to prevent peritonitis.
  • Watch for abdominal distension, pain, or signs of infection.

LPNs must also provide patient education, especially on dietary restrictions, signs of fluid overload, and when to seek help.

5. What are appropriate nursing interventions for a patient in respiratory distress or failure?

Solution:

Respiratory distress is a potentially life-threatening condition that requires rapid recognition and intervention. It can be caused by COPD, pneumonia, asthma, pulmonary embolism, or trauma.

Signs of respiratory distress/failure:

  • Tachypnea, dyspnea
  • Use of accessory muscles
  • Cyanosis
  • Confusion or lethargy
  • Decreased oxygen saturation
  • Abnormal breath sounds (e.g., wheezing, crackles, diminished)

Nursing interventions:

  • Position the patient in high Fowler’s to maximize lung expansion.
  • Administer oxygen as ordered and monitor SpO₂ continuously.
  • Stay with the patient and provide reassurance to reduce anxiety.
  • Encourage controlled breathing (e.g., pursed-lip breathing for COPD).
  • Notify the RN or provider immediately if symptoms worsen.
  • Prepare for advanced airway management if necessary (e.g., intubation).
  • Monitor for complications like hypoxia, respiratory acidosis, or cardiac issues.
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