a mexican american client with epilepsy is being seen at the clinic for an initial examination the nurse understands which primary purpose of includin a mexican american client with epilepsy is being seen at the clinic for an initial examination the nurse understands which primary purpose of includin
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Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?

Correct answer: Determine what the client believes has caused the epilepsy.

Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.

2. The client is preparing to learn about the effects of isoniazid (INH). Which information is essential for the client to understand?

Correct answer: Consuming alcohol daily can increase the risk of drug-induced hepatitis.

Rationale: It is crucial for the client to understand that consuming alcohol while on isoniazid can increase the risk of drug-induced hepatitis. Hepatic damage can lead to dark, concentrated urine. To minimize gastrointestinal upset, it is recommended to take isoniazid with meals rather than on an empty stomach. Additionally, the client should avoid taking aluminum-containing antacids like aluminum hydroxide with isoniazid, as it can reduce the drug's effectiveness. Choice A is incorrect because isoniazid should not be taken on an empty stomach to help reduce GI upset. Choice B is incorrect, as prolonged use of isoniazid does not typically cause dark, concentrated urine. Choice C is incorrect as taking aluminum hydroxide with isoniazid does not enhance the drug's effects; in fact, it may decrease its effectiveness.

3. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?

Correct answer: Position the mother so that her hips are elevated

Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.

4. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?

Correct answer: A history of radiation treatment in the neck region

Rationale: The correct answer is a history of radiation treatment in the neck region. Previous radiation to the neck may have damaged the parathyroid glands, which are crucial for calcium and phosphorus regulation. This damage can lead to disruptions in phosphorus levels, increasing the risk of hyperphosphatemia. Choices B, C, and D are not as directly related to phosphorus regulation. Orthopedic surgery, minimal physical activity, and food intake are more closely associated with calcium levels rather than phosphorus regulation. Therefore, it is essential for the nurse to focus on obtaining information about a history of radiation treatment in the neck region when assessing the risk of hyperphosphatemia in a client.

5. Why is client and family communication and education concerning restraints essential?

Correct answer: encourages cooperation with the client and family

Rationale: Client and family communication and education concerning restraints are essential to encourage cooperation. When the client and family understand the purpose and expected benefits of restraints, they are more likely to cooperate. This understanding can help prevent well-meaning family members from releasing restraints due to confusion or lack of information. Therefore, choice C is correct. Choices A, B, and D are incorrect because confusing both groups further, helping with coping and stress levels, and shifting responsibility to the client and family are not the primary goals of communication and education concerning restraints.

Similar Questions

A sexually active married couple, discussing birth control methods with the nurse, expresses the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest?
A nurse preparing to examine a client’s eyes plans to perform a confrontation test. The nurse tells the client that this test measures which aspect of vision?
The nurse is teaching parents of a newborn about feeding their infant. Which of the following instructions should the nurse include?
A client visits the clinic after the death of a parent. Which statement made by the client’s sister signifies abnormal grieving?
A client who had a stroke has left-side weakness and is having difficulty holding utensils while eating. To which of these services does the nurse suggest a referral?

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