NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. To improve overall health, the nurse should place the highest priority on assisting a client to make lifestyle changes for which of the following habits?
- A. drinking a six-pack of beer each day
- B. eating an occasional chocolate bar
- C. exercising twice a week
- D. using relaxation exercises to deal with stress
Correct answer: A
Rationale: To improve overall health, the nurse should prioritize assisting the client in making lifestyle changes that have the most significant impact on health. Drinking a six-pack of beer each day can have serious negative effects on health, including liver damage, increased risk of chronic diseases, and addiction. By addressing this habit first, the nurse can make a substantial positive difference in the client's health. Eating an occasional chocolate bar, exercising twice a week, and using relaxation exercises to deal with stress are beneficial habits, but they are not as detrimental to health as excessive alcohol consumption. Therefore, they are not the highest priority for immediate lifestyle changes to improve health.
2. A nurse assisting with data collection of the peripheral vascular system performs the Allen test. The nurse understands that this test is used to determine the patency of which blood vessel(s)?
- A. Capillaries
- B. Pedal pulses
- C. Femoral arteries
- D. Radial and ulnar arteries
Correct answer: D
Rationale: The nurse performs the Allen test to determine the patency of the radial and ulnar arteries. During the test, the nurse applies pressure over the client's ulnar and radial arteries simultaneously. The client is then asked to open and close the hand repeatedly, causing the hand to blanch. Subsequently, the nurse releases pressure from the ulnar artery while compressing the radial artery and checks the color of the extremity distal to the pressure point. If pinkness fails to return within 6 seconds, it indicates that the ulnar artery is insufficient, suggesting that the radial artery should not be used for obtaining a blood specimen. Choice A (Capillaries) is incorrect as the Allen test assesses the patency of larger arteries, not capillaries. Choice B (Pedal pulses) is incorrect as the Allen test specifically evaluates the radial and ulnar arteries, not the pedal pulses in the foot. Choice C (Femoral arteries) is incorrect as the Allen test focuses on the radial and ulnar arteries in the hand, not the femoral arteries in the leg.
3. A healthcare professional is using an otoscope to inspect the ears of an adult client. Which action does the professional take before inserting the otoscope?
- A. Pulling the pinna up and back
- B. Pulling the pinna down and forward
- C. Tipping the client's head down and toward the examiner
- D. Tipping the client's head down and away from the examiner
Correct answer: A
Rationale: In an adult client, the healthcare professional should pull the pinna up and back before inserting the otoscope. This action helps straighten the S shape of the ear canal, making it easier to insert the otoscope directly and comfortably. Tipping the client's head down and toward or away from the examiner is not the correct action when using an otoscope in an adult. Pulling the pinna down and forward is typically done when examining an infant or a child younger than 3 years old to straighten their ear canal for better visualization.
4. During a home visit, the LPN finds a client taking Amiodarone. Which statement by the client indicates an understanding of potential drug side effects?
- A. "It is normal if I have numbing or tingling in my feet."?
- B. "I need to make sure I wear sunblock when going outdoors."?
- C. "I need to take supplemental vitamin B12."?
- D. "I should avoid eating leafy vegetables."?
Correct answer: B
Rationale: The correct answer is B. Amiodarone can cause increased photosensitivity, making it essential for the client to wear sunblock when exposed to sunlight. Choice A is incorrect because numbing or tingling in the feet is not a common side effect of Amiodarone. Choice C is unrelated as the drug does not typically require supplemental vitamin B12. Choice D is also incorrect as there is no need to avoid leafy vegetables specifically due to Amiodarone.
5. A clinic nurse about to meet a new client plans to gather subjective data regarding the client's health history. Which action does the nurse take to help ensure the success of the interview?
- A. Ensuring that the room is private
- B. Having the client sit across from the nurse without a desk or table between them
- C. Maintaining a distance of 4 to 5 feet between the nurse and client
- D. Adjusting the room lighting to ensure it is comfortable and conducive for the client
Correct answer: A
Rationale: The physical environment of an interview room should provide optimal conditions to encourage a smooth interview and make the client feel comfortable. The nurse ensures that privacy is maintained to avoid interruptions during the interview. This helps create a safe space for the client to share sensitive information. Having the client sit across from the nurse without a desk or table between them is also important to promote open communication and build rapport. Maintaining a distance of 4 to 5 feet from the client respects their personal space and helps prevent the client from feeling overwhelmed. While adjusting the room lighting is beneficial for creating a comfortable atmosphere, ensuring privacy is crucial for establishing trust and confidentiality. Therefore, ensuring that the room is private is crucial for the success of the interview, making choice A the correct answer. Choices B, C, and D are incorrect as they do not directly address the importance of privacy in creating a conducive environment for the interview.
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