a muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant when planning for the physical asses
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Nursing Elites

NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. When planning for the physical assessment of the woman, the nurse ensures that which occurs?

Correct answer: A

Rationale: In many cultures, including Muslim, Hindu, and Latino, modesty is important, and exposure of a woman's genitals to men is considered demeaning. To respect the patient's cultural beliefs and modesty, it is best for a female health care provider to perform the examination. This practice helps to ensure the patient's comfort and adherence to cultural norms. Having the woman examined without any other people in the room (Choice C) may not address the cultural sensitivity required for this situation. Having the woman's husband remain in the examining room at all times (Choice B) may not align with the patient's cultural preferences and may cause discomfort. Written permission from the woman to obtain subjective health data (Choice D) is not directly related to ensuring a culturally sensitive physical assessment in this context.

2. A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse provides which information?

Correct answer: B

Rationale: The correct answer is that the client may need to drink fluids before the test and may not void until the test has been completed. For a transabdominal ultrasound, the woman is positioned on her back with her head elevated and turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure typically takes 10 to 30 minutes, making choice A incorrect. Choice C is incorrect because a probe is not inserted into the vagina for a transabdominal ultrasound. Choice D is incorrect because the woman is positioned on her back with her head elevated and turned slightly to one side, not specifically on her back.

3. What ethical obligations do professional nurses have according to the ANA Code of Ethics for Nurses?

Correct answer: D

Rationale: The correct answer is 'all of the above.' According to the ANA Code of Ethics for Nurses, professional nurses have ethical obligations to patients (clients), the nursing profession, and providing high-quality care. These elements are fundamental principles outlined in the code of ethics to guide nurses in their practice. Choice A is correct as nurses prioritize the well-being and care of their patients. Choice B is correct as nurses are expected to uphold the values and integrity of the nursing profession. Choice C is correct as providing high-quality care is a core ethical obligation of nurses. Therefore, all the choices align with the ANA Code of Ethics for Nurses.

4. When assisting the physician in performing transillumination of a client's scrotum, how should the nurse prepare for this procedure?

Correct answer: A

Rationale: When preparing for transillumination of the scrotum, the nurse should obtain a flashlight and darken the room. This is done to allow the strong flashlight to be shined from behind the scrotal contents. Normal scrotal contents do not appear on transillumination. Instructing the client to drink fluids or to take deep breaths and bear down is not part of the preparation for this procedure. Additionally, it is not necessary to inform the client that the procedure is uncomfortable as transillumination is a painless procedure.

5. When reviewing a client's medical notes to confirm pregnancy, a nurse should look for which finding to determine that pregnancy is confirmed?

Correct answer: C

Rationale: To confirm pregnancy, the presence of palpable fetal movement is a positive indicator. Palpable fetal movement is a certain sign of pregnancy, known as a fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy as it is reported by the woman but is not confirmatory. Thinning of the cervix (Hegar sign) is a probable sign of pregnancy, which is not confirmatory. A positive result on a home urine test for pregnancy is also a probable indicator. However, a positive pregnancy test result can sometimes yield false-positive results due to various factors like medication, recent pregnancy, or errors in reading.

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