NCLEX-PN health promotion practice questions, set 12
NCLEX-PN · health promotion
NCLEX-PN health promotion practice questionsset 12
You teach screening, development, and prevention in the words a patient can use. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the NCLEX-PN exam guide or more NCLEX-PN practice questions.
Five health promotion questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
A client in labor complains of back discomfort. Which position will best aid in relieving the discomfort? What position should the nurse encourage the mother to assume?
A. Prone
B. Standing
C. Supine
D. Hands and knees
Show answer and rationale
Correct answer: D — Hands and knees
During back labor, when the back of the fetal head puts pressure on the woman's sacral promontory, the hands-and-knees position is encouraged. This position helps the fetus move away from the sacral promontory, reducing back pain and enhancing the internal-rotation mechanism of labor. A prone position would be difficult for the woman to assume and not helpful in relieving back discomfort. The supine position is risky due to supine hypotension, while standing may increase pressure, worsening backache.
Question 2
A nurse preparing to assist with data collection of the abdomen asks the client to void and then assists the client into a supine position. Which primary finding does the nurse expect to note on percussing all four quadrants of the abdominal cavity?
A. Dullness
B. Tympany
C. Borborygmus
D. Hyperresonance
Show answer and rationale
Correct answer: B — Tympany
The nurse expects to primarily note tympany when percussing the abdomen. Tympany should predominate because air in the intestines rises to the surface when the client is in a supine position. Dullness is usually heard over a distended bladder, adipose tissue, fluid, or a mass. Borborygmus, which refers to hyperperistalsis, is typically heard on auscultation, not percussion. Hyperresonance is present with gaseous distention, not the typical finding when percussing all four quadrants of the abdomen.
Question 3
A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?
A. Headache
B. Neck trauma
C. Sinus infection
D. Muscle spasms
Show answer and rationale
Correct answer: B — Neck trauma
A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.
Question 4
Around what age do children typically start to develop 'stranger anxiety'?
A. 9 months
B. 6 months
C. 3 months
D. 12 months
Show answer and rationale
Correct answer: B — 6 months
The correct answer is '6 months.' At around this age, children typically start to develop 'stranger anxiety' as they become more aware of unfamiliar faces and may start showing signs of distress or anxiety around strangers. At 3 months, infants are still very young and unlikely to display stranger anxiety. While by 9 or 12 months, children have usually already developed some level of stranger anxiety, it typically starts around 6 months, making it the most appropriate answer in this context.
Question 5
The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?
A. eating breakfast
B. drinking fluids
C. getting out of bed to use the bathroom
D. brushing teeth
Show answer and rationale
Correct answer: C — getting out of bed to use the bathroom
The correct answer is 'getting out of bed to use the bathroom.' Risperdal can cause orthostatic hypotension, leading to a drop in blood pressure when changing positions from lying down to standing up. This effect increases the risk of falls, emphasizing the need to assist the client with this task to prevent potential harm. Choices A, B, and D are less likely to be directly impacted by the medication, unlike the significant risk of orthostatic hypotension associated with changing positions.
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Question 6
The client has an order for an IV piggyback of Ceftriaxone 750mg in 50mL D5W to run over 30 minutes. What is the appropriate drip rate?
A. 100 mL/hr
B. 150 mL/hr
C. 200 mL/hr
D. 50 mL/hr
Correct answer:
To calculate the drip rate, you need to convert the time from minutes to hours. The formula is (Volume to be infused / Time for infusion in minutes) x (60 minutes / 1 hour). Substituting the values, (50 mL / 30 min) x (60 min / 1 hr) = 100 mL/hr. Therefore, the appropriate drip rate is 100 mL/hr. Choices B, C, and D are incorrect as they do not match the calculated drip rate. Option A, 100 mL/hr, is the correct drip rate for administering Ceftriaxone 750mg in 50mL D5W over 30 minutes.
During a routine office visit, which of the following developmental milestones should the nurse screen for in a 6-month-old child?
A. standing while holding something
B. rolling over
C. sitting up
D. creeping
Correct answer:
The correct developmental milestone for a 6-month-old child that should be screened during a routine office visit is rolling over. At this age, infants typically start rolling over from their stomach to their back and vice versa. Sitting up usually occurs between 7 and 8 months, creeping between 9 and 10 months, and standing while holding something between 8 and 10 months. Therefore, choices A, C, and D are developmentally appropriate but not typically expected at 6 months of age.
Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?
A. Liver
B. Spleen
C. Pancreas
D. Appendix
Correct answer:
The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.
A healthcare professional reviewing a client's health care record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the healthcare professional determine that the client has?
A. Scoliosis
B. Osteoarthritis
C. Rotator cuff lesions
D. Carpal tunnel syndrome
Correct answer:
The correct answer is Osteoarthritis. Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes. In this disorder, when these nodes occur on the proximal interphalangeal joints, they are called Bouchard nodes. Heberden nodes are not associated with scoliosis, rotator cuff lesions, or carpal tunnel syndrome. Therefore, choices A, C, and D are incorrect.
A nurse is preparing to auscultate a client's breath sounds. To assess vesicular breath sounds, the nurse places the stethoscope over which area?
A. Major bronchi
B. The xiphoid process
C. The trachea and larynx
D. The peripheral lung fields
Correct answer:
To assess vesicular breath sounds, the nurse should place the stethoscope over the peripheral lung fields. Vesicular breath sounds are heard in these areas where air flows through the smaller bronchioles and alveoli. Bronchovesicular breath sounds, not vesicular, are heard over the major bronchi. Bronchial (tracheal) breath sounds are heard over the trachea and larynx, not vesicular sounds. Breath sounds are not heard over the xiphoid process, making it an incorrect choice.
The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?
A. She prefers crawling over walking and makes no attempt to walk.
B. She seems distressed by new adults.
C. She does not respond to her own name.
D. She only babbles "mama"? and "dada."?
Correct answer:
The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.
A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?
A. By checking the client's urine for blood
B. By checking the client's stool for blood
C. By checking the client's urine for a decrease in output
D. By checking the client's bowel movements for diarrhea
Correct answer:
Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.
During a home visit, the LPN finds a client taking Amiodarone. Which statement by the client indicates an understanding of potential drug side effects?
A. "It is normal if I have numbing or tingling in my feet."?
B. "I need to make sure I wear sunblock when going outdoors."?
C. "I need to take supplemental vitamin B12."?
D. "I should avoid eating leafy vegetables."?
Correct answer:
The correct answer is B. Amiodarone can cause increased photosensitivity, making it essential for the client to wear sunblock when exposed to sunlight. Choice A is incorrect because numbing or tingling in the feet is not a common side effect of Amiodarone. Choice C is unrelated as the drug does not typically require supplemental vitamin B12. Choice D is also incorrect as there is no need to avoid leafy vegetables specifically due to Amiodarone.
The LPN is taking care of a client who is on Phenelzine (Nardil) for depression. Which meal would the nurse encourage the client to avoid?
A. steak and potatoes
B. prosciutto and cheese plate
C. orange juice and toast
D. carbonated water, shrimp and rice
Correct answer:
The correct answer is 'prosciutto and cheese plate.' Phenelzine (Nardil) is an MAOI (Monoamine Oxidase Inhibitor), and clients on these drugs should avoid foods high in tyramine due to the risk of dangerous elevations in blood pressure. Prosciutto and aged cheeses are examples of foods rich in tyramine, so they should be avoided. Choices A, C, and D do not contain high levels of tyramine and are considered safe to consume while on Phenelzine.
While assisting with data collection on a client, a nurse hears a bruit over the abdominal aorta. What action should the nurse prioritize based on this finding?
A. Document the finding
B. Palpate the area for a mass
C. Notify the healthcare provider
D. Percuss the abdomen to check for tympany
Correct answer:
Detection of a bruit over the aorta during abdominal assessment may indicate the presence of an aneurysm. The nurse's priority action should be to notify the healthcare provider to further evaluate the situation. Palpating the area or percussing the abdomen could potentially increase the risk of an aneurysm rupture. While documenting the finding is important, the priority is to ensure timely intervention by involving the healthcare provider.
NCLEX-PN health promotion practice questions, set 12 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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