a mother brings her 18 month old child to the clinic to receive the next scheduled vaccine the child has previously received the following vaccines th
Logo

Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. After reviewing the child's immunization record, which scheduled vaccine should the nurse prepare to administer next?

Correct answer: D

Rationale: The correct answer is DTaP. DTaP is administered at 2, 4, and 6 months of age; between 15 and 18 months of age; and between 4 and 6 years of age. Since the child has only received three doses of this vaccine, the next dose of DTaP should be administered. The other options are incorrect because Hib is administered at 2, 4, and 6 months of age and between 12 and 15 months; IPV is administered at 2, 4, and 6 months of age and between 4 and 6 years of age; MMR is administered between 12 and 15 months of age and again between 4 and 6 years of age.

2. What is an appropriate nursing goal for a client at risk for nutritional problems?

Correct answer: B

Rationale: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems as it focuses on preventive measures to address the risk of nutritional issues. Choice A is incorrect because providing oxygen is not related to addressing nutritional problems. Choice C is incorrect as it involves treating the consequences rather than preventing nutritional problems. Choice D is incorrect because increasing weight is only suitable if the client is underweight, not as a general preventive measure.

3. A community health nurse is instructing a group of female clients about breast self-examination (BSE). The nurse instructs the clients to perform the examination in which manner?

Correct answer: D

Rationale: Breast self-examination (BSE) should be performed after the menstrual period, specifically on the seventh day of the menstrual cycle, when the breasts are smallest and least congested. This timing facilitates the easier detection of any abnormalities. Performing BSE at the onset of menstruation (Option A) can lead to false results due to hormonal changes affecting breast tissue. Performing it every month during ovulation (Option B) is not recommended as breast tissue may be more tender and lumpy during this time. Conducting weekly examinations at the same time of day (Option C) is unnecessary and can lead to unnecessary anxiety for the client.

4. A nurse suspects that a client has a distended bladder. On percussing the client's bladder, which finding does the nurse expect to note if the bladder is full?

Correct answer: A

Rationale: When percussing a full bladder, the nurse expects to note dull sounds over the symphysis pubis. This is because a full bladder produces a flat or dull sound. Hyperresonance sounds are present with gaseous distention of the abdomen, not a full bladder. Bowel sounds are auscultated, not percussed, so hypoactive bowel sounds or an absence of bowel sounds are unrelated findings when assessing bladder distention.

5. A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant performs which action?

Correct answer: D

Rationale: The correct answer is 'Overarticulates words.' When communicating with a hearing-impaired client who may rely on lip-reading, it is essential to speak clearly at a normal rate and volume. Overarticulating words can distort lip movements, making it harder for the client to understand. Using short sentences helps in conveying information effectively, allowing the client time to process. While facial expressions and gestures provide additional visual cues that aid in communication, overarticulating words can be counterproductive in this scenario. Therefore, the nursing assistant should avoid overarticulating words to ensure clear and concise communication for the client.

Similar Questions

What is the primary theory that explains a family's concept of health and illness?
When should rehabilitation services begin?
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)?
Which of the following values should be monitored closely while a client is on total parenteral nutrition?
A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses