a nurse assisting with data collection plans to perform the romberg test after describing the test to the client the nurse tells the client that it wi a nurse assisting with data collection plans to perform the romberg test after describing the test to the client the nurse tells the client that it wi
Logo

Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. A nurse assisting with data collection plans to perform the Romberg test. After describing the test to the client, the nurse tells the client that it will help reveal which disorder?

Correct answer: A problem with balance

Rationale: The Romberg test is a balance assessment that evaluates cerebellar function. During the test, the client stands with feet together and eyes closed, aiming to maintain balance for about 20 seconds. This test helps identify issues related to balance and proprioception, not hearing acuity or sound discrimination. Choices C and D are incorrect as the Romberg test focuses on balance, not distant hearing or sound discrimination.

2. A 10-month-old child is brought to the Emergency Department because he is difficult to awaken. The nurse notes bruises on both upper arms. These findings are most consistent with:

Correct answer: the child being shaken.

Rationale: The correct answer is 'the child being shaken.' In cases of suspected child abuse, bruises on both upper arms can be indicative of a child being shaken, as children who are shaken are frequently grasped by both upper arms. The presentation of a 10-month-old child being difficult to awaken, along with bruises on the upper arms, raises concern for inflicted injury. Symptoms of brain injury associated with shaking include a decreased level of consciousness. Choices A, C, and D are less likely in this scenario as they do not align with the concerning signs of suspected abuse indicated by the bruises and the child's altered level of consciousness.

3. The client is being assessed for possible pernicious anemia. Which finding would support this diagnosis?

Correct answer: A red, beefy tongue

Rationale: The correct answer is a red, beefy tongue, which is characteristic of pernicious anemia due to the atrophy of the papillae on the tongue. This finding is known as glossitis. A red, beefy tongue is a classic sign of pernicious anemia. Choice A, weight loss of 10 pounds in 2 weeks, is non-specific and not a typical finding in pernicious anemia. Choice B, complaints of numbness and tingling in the extremities, are more indicative of peripheral neuropathy, a common symptom of vitamin B12 deficiency, which can be seen in pernicious anemia. Choice D, a hemoglobin level of 12.0 g/dL, falls within the normal range and does not specifically point towards pernicious anemia, which is characterized by low hemoglobin levels due to impaired absorption of vitamin B12.

4. A patient had a pneumonectomy to the right lung performed 48 hours ago. Which of the following conditions most likely exists?

Correct answer: Decreased breath sound volume

Rationale: After a pneumonectomy, where a lung is surgically removed, there will be a decrease in breath sound volume on the affected side due to reduced airflow. This reduction in breath sound volume is expected as there is less lung tissue to produce sound. Choices B, C, and D are incorrect. Elevated tidal volume and respiratory capacity are not expected after a pneumonectomy, and wheezing is more commonly associated with conditions like asthma or bronchitis, not a recent pneumonectomy.

5. A healthcare professional reviewing the health care record of a client notes documentation of grade 4 muscle strength. The healthcare professional understands that this indicates:

Correct answer: Full ROM against gravity with some resistance

Rationale: Muscle strength is graded on a scale of 0 to 5. A grade of 5 indicates normal strength and is described as full ROM against gravity with full resistance. Grade 4 indicates good strength and full ROM against gravity with some resistance. Grade 3 indicates fair strength and full ROM with gravity. Grade 2 indicates poor strength and full ROM with gravity eliminated (passive motion). Grade 1 indicates trace strength and slight contraction. Grade 0 indicates zero strength and no contraction. Therefore, the correct answer is 'Full ROM against gravity with some resistance.' Choices A, B, and C are incorrect as they do not match the description of muscle strength associated with a grade of 4.

Similar Questions

A home health nurse is making preparations for morning visits. Which one of the following clients should the nurse visit first?
A health care worker is concerned about a new mother being overwhelmed by caring for her infant. The health care worker should:
The client has an order for 0.45 mg of Diltiazem. The medication vial has a concentration of 3 mg/mL. How many mL of the drug should be administered?
Which of the following provides the framework for confidentiality and the client’s right to privacy?
A health care provider asks the nurse caring for a client with a new colostomy to request the hospital’s stoma nurse to visit the client and assist with colostomy care. The nurse initiates the consultation, understanding that the stoma nurse will be able to influence the client because of which type of power?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99