a nurse is assisting with data collection of a client with suspected cholecystitis which finding does the nurse expect to note if cholecystitis is pre a nurse is assisting with data collection of a client with suspected cholecystitis which finding does the nurse expect to note if cholecystitis is pre
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NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?

Correct answer: Murphy sign

Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.

2. Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:

Correct answer: the nail beds and the tissue surrounding the nails.

Rationale: The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances. Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care. Choice B is incorrect as lab work is not directly related to nail and foot assessments. Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.

3. A client is scheduled to undergo a Papanicolaou (Pap) test in 1 week. Which statement does the nurse make to the client?

Correct answer: 'Avoid intercourse for 24 hours before the scheduled examination.'

Rationale: The correct answer is to 'Avoid intercourse for 24 hours before the scheduled examination.' The Pap test is used to screen for cervical cancer. It is not performed during menstruation or if a heavy infectious discharge is present. Before the test, the client should not douche, have intercourse, or insert anything into the vagina within 24 hours. Instructing the client to use pads instead of a tampon when menstruating can interfere with the test results due to the presence of blood. Douching before the exam is discouraged as it can alter the cervical cells' appearance, affecting the test's accuracy. Obtaining a sample of vaginal discharge for inspection is not a standard pre-Pap test instruction and is unnecessary for the test.

4. Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except:

Correct answer: completing the grieving process before the birth.

Rationale: Diagnostic genetic counseling provides clients with important information to make informed decisions regarding their pregnancy. Clients can choose to terminate the pregnancy, prepare for the birth of a child with special needs, and access support services before the birth based on the genetic testing results. However, completing the grieving process before the birth is not a typical choice during genetic counseling. The grieving process, if needed, may extend beyond the prenatal period, especially if the findings are concerning or indicate potential issues. Therefore, completing the grieving process before the birth is the exception among the provided options.

5. A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?

Correct answer: Shortness of breath

Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.

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