NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. How should the nurse proceed with data collection?
- A. Collect health history information first while initiating emergency measures.
- B. Ask health history questions while performing the examination and initiating emergency measures.
- C. Collect all information requested on the history form, including social support, strengths, and coping patterns.
- D. Perform emergency measures and delay health history questions until after treating the fractures in the operating room.
Correct answer: B
Rationale: When a client is alert and cooperative but has sustained multiple fractures, the nurse should prioritize obtaining health history information while performing the examination and initiating emergency measures. This approach allows the nurse to gather essential information without delaying immediate interventions. Option A is incorrect because collecting health history information before addressing the immediate need for treatment may lead to a delay in necessary interventions. Option C is incorrect as it includes non-urgent aspects of data collection that are not a priority in this critical situation. Option D is incorrect because delaying health history questions until after treating the fractures may result in missing crucial information essential for the client's immediate care.
2. When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?
- A. Iris
- B. Cornea
- C. Optic disc
- D. Conjunctiva
Correct answer: C
Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope. Therefore, the correct answer is the optic disc. Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.
3. Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct answer: B
Rationale: The correct answer is 'performing at the minimally acceptable level.' Quality is about meeting or exceeding customer requirements and expectations, as well as conforming to standards. The term 'performing at the minimally acceptable level' implies just meeting the minimum requirements, which falls short of the comprehensive definition of quality in terms of customer satisfaction and excellence. Therefore, this choice is the exception when defining quality. Choices A, C, and D align with the definition of quality as they all involve meeting or surpassing certain criteria for customer satisfaction and product excellence, which are essential components of quality management.
4. The LPN is admitting a client to the unit, and the client has rapidly blinking eyes, a stuck-out tongue, and a distorted posture. Which of these medications is the client most likely taking?
- A. Clozapine
- B. Fluoxetine
- C. Ondansetron
- D. Haloperidol
Correct answer: D
Rationale: The correct answer is Haloperidol. Haloperidol is a first-generation antipsychotic that blocks dopamine receptors and is most likely to cause extrapyramidal symptoms (EPS), such as tardive dyskinesia. Symptoms of tardive dyskinesia include rapid blinking, mouth movements, sticking out the tongue, rapid body movements, and a distorted posture. Haloperidol is associated with a higher risk of EPS compared to other antipsychotic medications like Clozapine. Clozapine is known for having a lower risk of causing EPS. Fluoxetine is a selective serotonin reuptake inhibitor used for depression and anxiety, not typically associated with these movement disorder symptoms. Ondansetron is an antiemetic used to prevent nausea and vomiting, not linked to these extrapyramidal symptoms.
5. A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology?
- A. Anasarca
- B. Ecchymosis
- C. Unilateral edema
- D. Increased vascularity of the skin tissue
Correct answer: A
Rationale: The correct term for generalized edema over the entire body is 'Anasarca.' Anasarca is indicative of a systemic issue such as congestive heart failure or kidney failure. It does not refer to increased vascularity of the skin tissue. Ecchymosis is a bruise caused by capillary bleeding into the tissues, unrelated to generalized edema. Unilateral edema is swelling in a specific area of the body, not the generalized edema observed in anasarca.
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