NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. What spinal change occurring with pregnancy alters mobility?
- A. Scoliosis.
- B. Kyphosis.
- C. Lordosis.
- D. Ankylosing spondylitis.
Correct answer: C
Rationale: The correct answer is 'Lordosis.' During pregnancy, the enlarging uterus places increased weight on the spine, causing an exaggerated inward curvature known as lordosis. This change alters mobility by shifting the center of gravity forward, leading to a compensatory change in posture. Scoliosis (choice A) is a sideways curvature of the spine, not typically associated with pregnancy. Kyphosis (choice B) is an exaggerated outward curvature of the spine, while ankylosing spondylitis (choice D) is a chronic inflammatory condition affecting the spine, neither of which are directly related to the spinal changes seen in pregnancy.
2. A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
- A. shopping for groceries
- B. house cleaning
- C. transportation to physician's visits
- D. medication instruction
Correct answer: D
Rationale: The correct answer is 'medication instruction.' This service involves educating the client on how to properly take their medications, which requires a certain level of expertise and skill. Grocery shopping, house cleaning, and transportation to physician's visits are considered unskilled services as they do not involve specialized knowledge or training. In contrast, medication instruction is a skilled service that necessitates specific training to ensure the client's safety and adherence to their medication regimen.
3. Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
- A. The client verbalizes knowledge of a maintenance diet.
- B. The client demonstrates assertiveness with family.
- C. The client verbalizes her body size accurately.
- D. The client demonstrates control of obsessive behaviors.
Correct answer: C
Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.
4. Which hormone in the urine is specifically indicative of pregnancy?
- A. estrogen
- B. progesterone
- C. testosterone
- D. human chorionic gonadotropin
Correct answer: D
Rationale: Human chorionic gonadotropin is the hormone specifically indicative of pregnancy as it is produced by the placenta after implantation. It can be detected in urine and blood samples to confirm pregnancy. Estrogen and progesterone play crucial roles in the menstrual cycle and pregnancy but are not specific indicators of pregnancy on their own. Testosterone is a hormone primarily associated with male reproductive functions and is not directly related to pregnancy, making it an incorrect choice in this context.
5. When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?
- A. corner of the mouth to the tragus of the ear
- B. corner of the eye to the top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: B
Rationale: Correct! When sizing an oropharyngeal airway, the nurse should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to reach the pharynx without being too long or too short. Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.
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