NCLEX-PN health promotion practice questions, set 7
NCLEX-PN · health promotion
NCLEX-PN health promotion practice questionsset 7
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 Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?
A. Confirm the medical diagnosis.
B. Make accurate nursing diagnoses.
C. Identify any hereditary traits related to the epilepsy.
D. Determine what the client believes has caused the epilepsy.
Show answer and rationale
Correct answer: D — Determine what the client believes has caused the epilepsy.
The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.
Question 2
A nurse assisting with data collection regarding the client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?
A. Myopia
B. Hyperopia
C. Photophobia
D. Accommodation
Show answer and rationale
Correct answer: D — Accommodation
The correct answer is Accommodation. Accommodation is the process by which the eye adjusts its focus to see objects at different distances. When the pupils get larger when the client looks at an object in the distance and become smaller when looking at a nearby object, it indicates the normal functioning of the eye's accommodation mechanism. Myopia refers to nearsightedness, where distant objects appear blurry. Hyperopia refers to farsightedness, where close objects appear blurry. Photophobia is an abnormal sensitivity to light. Therefore, the correct term to document the finding of the pupils adjusting based on the distance of the object is 'Accommodation.'
Question 3
A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?
A. Notifying the healthcare provider
B. Stopping the oxytocin infusion
C. Checking the woman's blood pressure and pulse
D. Increasing the intravenous (IV) rate of the nonadditive solution
Show answer and rationale
Correct answer: B — Stopping the oxytocin infusion
When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.
Question 4
A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?
A. Primary
B. Secondary
C. Tertiary
D. Health promotion
Show answer and rationale
Correct answer: A — Primary
Primary prevention involves activities that promote wellness or prevent illness or injury. Educating parents about safety measures in the home aims to prevent injuries, making it a primary prevention strategy. Secondary prevention focuses on early detection and intervention in diseases or injuries. Tertiary prevention involves reducing disability and promoting optimal functioning in relation to a disease or injury. Health promotion encompasses activities that enhance a client's overall health and well-being. In this scenario, educating parents about safety in the home falls under primary prevention as it aims to prevent injuries before they occur.
Question 5
A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?
A. The fingers curl tightly, and the toes curl forward.
B. The toes flare, and the big toe is dorsiflexed.
C. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.
D. The infant turns to the side that is touched.
Show answer and rationale
Correct answer: B — The toes flare, and the big toe is dorsiflexed.
To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.
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Question 6
When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?
A. 1+ edema
B. 2+ edema
C. 3+ edema
D. 4+ edema
Correct answer:
The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling. Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.
A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?
A. At the onset of menstruation
B. Every month during ovulation
C. Weekly, at the same time of day
D. One week after menstruation begins
Correct answer:
Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option C) is unnecessary and can lead to unnecessary anxiety for the client.
After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?
A. maintaining adequate tissue perfusion
B. demonstrating behaviors that reduce fears
C. restored body integrity
D. remaining free of infection
Correct answer:
The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.
A new mother is being discharged from the maternity unit and provided with information about signs and symptoms to report to her health care provider. Which statement by the mother indicates a need for further information?
A. ''I will call my nurse-midwife if I experience any redness, swelling, or tenderness in my legs.''
B. ''My temperature needs to remain within a normal range.''
C. ''Frequent urination and burning when I urinate are expected.''
D. ''Feelings of pelvic fullness or pelvic pressure are a sign of a problem.''
Correct answer:
The correct answer is 'Frequent urination and burning when I urinate are expected.' This statement by the mother indicates a need for further information because these symptoms are not normal and could indicate a urinary tract infection or another issue that needs medical attention. The other choices correctly reflect signs and symptoms that should be reported to the health care provider. Redness, swelling, or tenderness in the legs can indicate a blood clot, and feelings of pelvic fullness or pressure can be signs of a problem. Monitoring temperature is also important to ensure there is no infection or other complications postpartum.
A 37-year-old female client asks the nurse about contraception options and expresses interest in oral contraception pills. Which of the following statements would indicate that oral contraception is appropriate for this client?
A. "I quit smoking last year, but I started again recently. Maybe I'll try to quit later this year."?
B. "I am very diligent in taking my thyroid medications at the same time every day."?
C. "I was hospitalized for deep vein thrombosis five years ago."?
D. "I was recently diagnosed with breast cancer."?
Correct answer:
The correct answer is the statement mentioning a history of deep vein thrombosis five years ago. Oral contraceptives are generally not recommended for individuals with a history of deep vein thrombosis due to the increased risk of blood clots. Choice B, about being diligent in taking thyroid medications, does not directly relate to the safety of using oral contraceptives. Choice D, about a recent breast cancer diagnosis, would contraindicate the use of hormonal contraceptives. Choice A, mentioning a recent return to smoking, raises concerns about using hormonal contraceptives due to the increased risk of cardiovascular complications.
A nurse is reviewing the findings of a physical examination documented in a client's record. Which piece of information does the nurse recognize as objective data?
A. The client is allergic to strawberries
B. The last menstrual period was 30 days ago
C. The client takes acetaminophen (Tylenol) for headaches
D. A 1-2-inch scar is present on the lower right portion of the abdomen
Correct answer:
Objective data in a physical examination are findings that the healthcare provider observes or measures directly. In this case, a 1 × 2-inch scar present on the lower right portion of the abdomen is a physical observation. Subjective data are based on what the client reports, such as allergies (Choice A), the date of the last menstrual period (Choice B), and self-reported medication use for headaches (Choice C). While these pieces of information are important for assessing the client's health, they are considered subjective data because they rely on the client's self-report rather than direct observation by the healthcare provider.
A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse makes which determination?
A. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth
B. The results are negative.
C. The results indicate that the mother does not have hepatitis B
D. The client needs to receive the hepatitis B series of vaccines.
Correct answer:
A hepatitis B screen is performed to identify antigens in maternal blood. If antigens are present, it indicates that the mother is a carrier, and the newborn will need to receive hepatitis immune globulin and vaccine soon after birth to prevent transmission. Therefore, choice A is correct. Choices B and C are incorrect because the presence of antigens indicates a positive result, not a negative one or the absence of hepatitis B in the mother. Choice D is incorrect as it suggests the client needs to receive the hepatitis B series of vaccines, which is not the immediate action required when antigens are found in the maternal blood.
The LPN participates in a home visit for a client with Type 2 Diabetes who has been taking Metformin for 3 years. The client states that for the past 3 months, they have been trying a vegan diet and experiencing fatigue, confusion, and mood changes. What is a likely cause of the new symptoms?
A. vitamin B12 deficiency
B. chronic hypoglycemia
C. vitamin D deficiency
D. increased tolerance to Metformin
Correct answer:
The correct answer is vitamin B12 deficiency. Long-term use of Metformin can lead to vitamin B12 deficiency, and a vegan diet is low in vitamin B12. Symptoms of vitamin B12 deficiency include anemia, fatigue, confusion, and mood changes. Chronic hypoglycemia is unlikely in a client with Type 2 Diabetes who has been taking Metformin as it typically causes hyperglycemia. Vitamin D deficiency usually presents with symptoms related to bones and muscles, not confusion and mood changes. Increased tolerance to Metformin does not explain the client's new symptoms, which are more indicative of a nutritional deficiency like vitamin B12.
The LPN needs to determine the client's respiratory rate. What is the best technique to do this?
A. Tell the client you need to count their respiratory rate.
B. Subtly watch the client from across the room when they are doing an activity.
C. Ask the client to sit still for 30 seconds.
D. Count respirations while pretending to check the client's pulse.
Correct answer:
The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client's pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.
An amniocentesis is scheduled for a pregnant client in the third trimester. The nurse informs the client that the most common indication for amniocentesis during the third trimester is for which reason?
A. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
B. Checking the amniotic fluid for intrauterine infection
C. Determination of fetal lung maturity
D. Checking the fetal cells for chromosomal abnormalities
Correct answer:
The most common indication for amniocentesis in the third trimester is the determination of fetal lung maturity. This assessment is essential to evaluate the fetus's readiness for extrauterine life. Checking for alpha-fetoprotein (AFP) in the amniotic fluid is more commonly associated with midtrimester amniocentesis to identify chromosomal abnormalities. Assessing for intrauterine infection is not a primary reason for amniocentesis in the third trimester. While checking fetal cells for chromosomal abnormalities is a common indication for midtrimester amniocentesis, it is not the most common indication in the third trimester.
NCLEX-PN health promotion practice questions, set 7 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
No. Nursier is independent practice. Register through the official path named on the NCLEX-PN exam guide.
The first five questions already include the rationale. Start full practice to unlock the remaining keys, missed-question review, and the rest of the bank.
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