NCLEX-PN health promotion practice questions, set 6
NCLEX-PN · health promotion
NCLEX-PN health promotion practice questionsset 6
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
What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
A. immobility
B. altered growth and development
C. hemarthrosis
D. altered family processes
Show answer and rationale
Correct answer: D — altered family processes
Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.
Question 2
The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?
A. I'm worried that my child is not using two-word phrases yet.
B. My child has recently taken a few steps but does not seem stable when standing.
C. My child seems to have developed separation anxiety when I leave.
D. I'm letting my child use a spoon to eat.
Show answer and rationale
Correct answer: B — My child has recently taken a few steps but does not seem stable when standing.
The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up. Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.
Question 3
Which of the following strategies should the nurse include when planning care for children of migrant workers?
A. Delay immunizations due to acute illness.
B. Provide parents with copies of medical records.
C. Offer preventive services during acute illness visits.
D. Emphasize the importance of having one primary care provider.
Show answer and rationale
Correct answer: B — Provide parents with copies of medical records.
When planning care for children of migrant workers, providing parents with copies of medical records is essential. This helps ensure continuity of care, especially as migrant families may move frequently. Immunizations should not be delayed due to acute illness; preventive care, including immunizations, should be provided even during acute illness visits to ensure the child stays up to date. While it is important to offer preventive services during routine visits, it is not ideal to provide them only during acute illness visits. Emphasizing the importance of having one primary care provider is valuable in healthcare, but it may not be feasible for migrant families due to their mobility.
Question 4
The LPN is taking care of a client with a documented allergy to Penicillin. After rounds, the LPN notices that the client has an order for Cefazolin. Which of the following actions would be the least appropriate?
A. The LPN clarifies the severity of the Penicillin allergy.
B. The LPN discusses the order with the care team prior to administering Cefazolin.
C. The LPN administers all ordered medications except for the Cefazolin.
D. The LPN monitors the client after a test dose of Cefazolin is administered.
Show answer and rationale
Correct answer: C — The LPN administers all ordered medications except for the Cefazolin.
The least appropriate action is for the LPN to administer all ordered medications except for the Cefazolin. The LPN should always consider the client's documented allergy to Penicillin seriously. It is crucial to discuss the order with the care team before administering Cefazolin to ensure patient safety. Administering a medication that could potentially cause harm due to a documented allergy is unsafe practice. While monitoring the client after a test dose of Cefazolin is important, it should not precede clarification with the care team regarding the allergy and the appropriateness of the medication. Therefore, withholding the Cefazolin is the most appropriate action in this scenario.
Question 5
A healthcare professional reviewing the health care record of a client notes documentation of grade 4 muscle strength. The healthcare professional understands that this indicates:
A. Full ROM with gravity
B. Full ROM against gravity with full resistance
C. Full ROM with gravity eliminated (passive motion)
D. Full ROM against gravity with some resistance
Show answer and rationale
Correct answer: D — Full ROM against gravity with some resistance
Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction. Therefore, the correct answer is 'Full ROM against gravity with some resistance.' Choices A, B, and C are incorrect as they do not match the description of muscle strength associated with a grade of 4.
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Question 6
The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?
A. McGill Pain Scale
B. FLACC Pain Scale
C. CRIES Pain Scale
D. Wong-Baker Pain Scale
Correct answer:
The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.
A mother brings her 1-year-old child to the clinic. The child has no record of previous immunizations, and the mother confirms the child has not been immunized. Teaching by the nurse should include which of the following?
A. Immunizations may be started at any age.
B. The recommended immunization schedule should be followed.
C. If a primary series of immunizations is interrupted, it can be continued.
D. Delaying the start of vaccines does not increase the risk of reaction.
Correct answer:
The correct answer is 'Immunizations may be started at any age.' While there is a recommended immunization schedule, immunizations can be initiated at any age. It is essential to emphasize the flexibility in starting immunizations. The statement 'The recommended immunization schedule should be followed' is too rigid; while recommended, there is flexibility in initiation. Choice C is correct as an interrupted series can be continued without restarting. The statement 'Delaying the start of vaccines does not increase the risk of reaction' is correct. Delaying does not increase the risk of reaction; in fact, it is important to start immunizations to protect the child and the community.
A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 8-10 cm. The nurse correctly documents the finding as:
A. increased ferning capacity.
B. lack of ferning.
C. spinnbarkheit.
D. inhospitable.
Correct answer:
The nurse should document the finding as 'spinnbarkheit.' Spinnbarkheit is the term used to describe the clear, thin, and elastic cervical mucus that can be stretched 8-10 cm, indicating ovulation. It helps couples determine the most fertile period for conception. Ferning capacity or crystallization increases as ovulation approaches, but it requires microscopic examination to be confirmed. Lack of ferning cannot be determined without such examination. 'Inhospitable' cervical mucus refers to patterns that prohibit sperm motility, caused by various factors like hormone levels or infection. These conditions cannot be assessed based solely on the description provided in the question.
During a genital examination of a male client, a nurse notices wrinkled skin on the penis and scrotum. What should the nurse do based on this finding?
A. Documents the normal finding
B. Checks for penile discharge, as this indicates infection
C. Palpates for a mass in the scrotum, as wrinkling suggests the presence of one
D. Obtains additional subjective data from the client, focusing on the scrotal abnormality
Correct answer:
The penile skin typically appears wrinkled and hairless, without lesions, during a normal examination. Also, the scrotal skin naturally has a wrinkled appearance known as rugae. It is common for the left half of the scrotum to be positioned lower than the right, indicating normal asymmetry. Given these normal variations, the nurse should document the finding of wrinkled skin on the penis and scrotum. Checking for penile discharge or palpating for a mass in the scrotum is not indicated based on the presence of wrinkled skin, as this is a normal finding. Obtaining additional subjective data focusing on a scrotal abnormality is unnecessary since the wrinkled appearance is typical.
How should a nurse listen to the breath sounds of a client?
A. Ask the client to lie prone.
B. Ask the client to breathe in and out through the nose.
C. Hold the bell of the stethoscope lightly against the chest.
D. Listen for at least one full respiration in each location on the chest.
Correct answer:
To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.
The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?
A. "I will need to avoid eating excessive leafy greens."?
B. "It's best to take this medication with food."?
C. "I can't wait to get back to my nightly glass of wine."?
D. "I should try to take this medication at the same time every day."?
Correct answer:
The correct answer is, "I can't wait to get back to my nightly glass of wine,"? as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, "I will need to avoid eating excessive leafy greens,"? is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, "It's best to take this medication with food,"? is a general instruction and not specific to phenobarbital. Choice D, "I should try to take this medication at the same time every day,"? is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.
The client provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information?
A. ''I should eat five or six small meals a day rather than three full meals.''
B. ''I need to be sure not to drink liquids with my meals.''
C. ''I should keep dry crackers at my bedside and eat them before I get out of bed in the morning.''
D. ''I need to avoid eating fried or greasy foods.''
Correct answer:
To alleviate nausea and vomiting, the client should avoid drinking liquids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage. The incorrect choices are: A) Eating five or six small meals a day instead of three full meals is a correct recommendation. C) Keeping dry crackers at her bedside and eating them before getting out of bed in the morning is a helpful suggestion. D) Avoiding fried or greasy foods is a valid advice to alleviate nausea and vomiting.
The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?
A. I will be most susceptible to an infection between 7 and 12 days after chemotherapy.
B. I should try to get my annual teeth cleaning in before beginning chemotherapy.
C. I should wait until all my hair falls out to purchase a wig.
D. I should try to drink 8-10 glasses of water a day.
Correct answer:
This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig. Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy. Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.
A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?
A. Homan sign
B. Murphy sign
C. Blumberg sign
D. McBurney sign
Correct answer:
The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.
The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
A. "I am nervous about how painful labor will be."?
B. "I need to review my finances and make sure I am prepared to care for a child."?
C. "I hate this nausea that I've been having for a week."?
D. "I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent."?
Correct answer:
The nurse should follow up on the client's lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.
NCLEX-PN health promotion practice questions, set 6 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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