a nurse in the emergency department is assisting with data collection of a client the presence of which condition would cause the nurse to avoid testi a nurse in the emergency department is assisting with data collection of a client the presence of which condition would cause the nurse to avoid testi
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Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?

Correct answer: Neck trauma

Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.

2. A client is diagnosed with HIV. Which of the following antiviral drug classes are used in the treatment of HIV/AIDS?

Correct answer: all of the above

Rationale: All of the provided choices are antiviral drug classes used in the treatment of HIV/AIDS. Nucleoside reverse transcriptase inhibitors, such as tenofovir and emtricitabine, work by interfering with the virus's ability to replicate. Protease inhibitors, like atazanavir and darunavir, block an enzyme that HIV needs to make copies of itself. HIV fusion inhibitors, for instance, enfuvirtide, prevent HIV from entering human cells. Therefore, 'all of the above' is the correct answer as all the listed drug classes are commonly used in managing HIV infections. Choices A, B, and C are all essential components of antiretroviral therapy for HIV, targeting different stages of the virus's life cycle. The combination of drugs from these classes is often recommended to effectively control HIV replication and reduce viral load.

3. Around what age do children typically start to develop 'stranger anxiety'?

Correct answer: 6 months

Rationale: The correct answer is '6 months.' At around this age, children typically start to develop 'stranger anxiety' as they become more aware of unfamiliar faces and may start showing signs of distress or anxiety around strangers. At 3 months, infants are still very young and unlikely to display stranger anxiety. While by 9 or 12 months, children have usually already developed some level of stranger anxiety, it typically starts around 6 months, making it the most appropriate answer in this context.

4. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?

Correct answer: restored body integrity

Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.

5. Due to a high census, it has been necessary for a number of clients to be transferred to other units within the hospital. Which client should be transferred to the postpartum unit?

Correct answer: A 40-year-old female with a hysterectomy

Rationale: The best client to transfer to the postpartum unit is the 40-year-old female with a hysterectomy. The nurses on the postpartum unit will be knowledgeable about postoperative care and can manage any complications related to the surgery. Choices A and D would be more appropriately cared for on a medical-surgical unit due to their conditions. Choice C should be transferred to a psychiatric unit for specialized care related to severe depression.

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