NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. 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.
2. If Ms. Barrett's distance vision is 20/30, which of the following statements is true?
- A. The client can read from 20' what a person with normal vision can read at 30'.
- B. The client can read from 30' what a person with normal vision can read at 20'.
- C. The client can read the entire chart from 30'.
- D. The client can read the chart from 20' with the left eye and from 30' with the right eye.
Correct answer: A
Rationale: When Ms. Barrett's distance vision is measured as 20/30, it means that she can read from 20 feet away what a person with normal vision can read at 30 feet. The numerator (20) represents the distance in feet between the chart and the client, while the denominator (30) indicates the distance at which a normal eye can read the chart. In this case, Ms. Barrett's vision is slightly worse than normal, as she needs to be closer to the chart to read it clearly. Therefore, choice A is correct. Choices B, C, and D are incorrect: Choice B reverses the distances, Choice C assumes the client can read the entire chart from 30 feet, and Choice D introduces information not related to the 20/30 measurement.
3. When caring for pediatric clients, the nurse should pay special attention to the psychosocial development stages credited to whom?
- A. Robert Peck
- B. Erik Erikson
- C. Sigmund Freud
- D. Jean Piaget
Correct answer: B
Rationale: Erik Erikson is credited with the psychosocial development theory and eight stages. The nurse should consider these stages when caring for pediatric clients to evaluate their development. Jean Piaget is known for cognitive development, Sigmund Freud for psychosexual development, and Robert Peck for aging theory. Therefore, the correct answer is Erik Erikson.
4. Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration?
- A. CVADs are more expensive than a peripheral IV.
- B. Weekly administration is possible.
- C. Chemotherapeutic agents can be caustic to smaller veins.
- D. The client or family can administer the drug at home.
Correct answer: C
Rationale: The correct advantage of using CVADs for chemotherapeutic agent administration is that chemotherapeutic agents can be caustic to smaller veins. Many chemotherapeutic drugs are vesicants, which can cause tissue damage even in low concentrations. Using a CVAD to administer these agents into a large vein is optimal as it reduces the risk of damage. Choice A is incorrect as CVADs are actually more expensive than a peripheral IV, making it a disadvantage. Choice B is incorrect because the frequency of administration depends on the specific drug being administered, not on the access device, so it does not represent a universal advantage. Choice D is incorrect because IV chemotherapeutic agents are typically not self-administered at home; they are usually given in a hospital, outpatient, or clinic setting, making it an invalid advantage of using CVADs.
5. Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
- A. providing safety measures to prevent falls
- B. taking medications as prescribed
- C. wearing a medical ID indicating Cushing's syndrome
- D. having regular health assessments
Correct answer: C
Rationale: All of the strategies listed are essential components of home care for a client with Cushing's syndrome. However, wearing a medical ID indicating Cushing's syndrome is the correct answer as it can have a negative impact on body image. This choice may constantly remind the client of their condition, potentially affecting their self-image and confidence. On the contrary, providing safety measures to prevent falls (Choice A) would enhance body image by promoting safety and preventing injuries. Taking medications as prescribed (Choice B) is likely to improve body image by managing symptoms effectively. Having regular health assessments (Choice D) demonstrates good self-care and can positively contribute to body image by showing a commitment to maintaining health.
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