NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct answer: D
Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
2. 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
Rationale: 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.
3. 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
Correct answer: D
Rationale: 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.
4. 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: C
Rationale: 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.
5. Which of the following vaccines is not part of the regular schedule of immunizations for children?
- A. DTaP
- B. MMR
- C. Hib
- D. hepatitis A
Correct answer: D
Rationale: The correct answer is hepatitis A. DTaP, MMR, and Hib are all part of the regular schedule of immunizations for children to protect them against diseases like diphtheria, tetanus, pertussis, measles, mumps, rubella, and Haemophilus influenzae type b. Hepatitis A vaccine is not included in the routine childhood immunization schedule but may be recommended in certain situations or regions where the disease is more prevalent. Hepatitis A is generally considered an optional vaccine for children but can be administered based on specific risk factors or regional guidelines.
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