Page 53 - Saunders Comprehensive Review For NCLEX-RN

administering blood and blood products. Reduction of Risk Potential addresses
content for preventing complications or health problems related to the client’s
condition or any prescribed treatments or procedures. Physiological Adaptation
addresses content for managing and providing care to clients with acute, chronic, or
life-threatening conditions. See Box 1-5 for examples of questions in this Client
Needs category.

Box 1-5

Physiological Integrity

Basic Care and Comfort
A client with Parkinson’s disease develops akinesia while ambulating, increasing
the risk for falls. Which suggestion should the nurse provide to the client to alleviate
this problem?

1. Use a wheelchair to move around.
2. Stand erect and use a cane to ambulate.
3. Keep the feet close together while ambulating and use a walker.
4. Consciously think about walking over imaginary lines on the floor.

Answer: 4
This question addresses the subcategory Basic Care and Comfort in the Client
Needs category Physiological Integrity and addresses client mobility and promoting
assistance in an activity of daily living to maintain safety. Focus on the subject,
akinesia. Clients with Parkinson’s disease can develop bradykinesia (slow
movement) or akinesia (freezing or no movement). Having these clients imagine
lines on the floor to walk over can keep them moving forward while remaining safe.

Pharmacological and Parenteral Therapies
The nurse monitors a client receiving digoxin for which early manifestation of
digoxin toxicity?

1. Anorexia
2. Facial pain
3. Photophobia
4. Yellow color perception

Answer: 1
This question addresses the subcategory Pharmacological and Parenteral Therapies
in the Client Needs category Physiological Integrity. Note the strategic word, early.
Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to
control ventricular rates in clients with atrial fibrillation. The most common early
manifestations of toxicity include gastrointestinal disturbances such as anorexia,
nausea, and vomiting. Neurological abnormalities can also occur early and include
fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares.

53