NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. 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?
- A. Testing for the strength of each muscle joint
- B. Percussing at the location of the median nerve
- C. Checking for repetitive movements in the joints
- D. Asking the client to flex the wrist 90 degrees while holding the hands back to back
Correct answer: Percussing at the location of the median nerve
Rationale: The Tinel sign is elicited by percussing at the location of the median nerve at the wrist. In carpal tunnel syndrome, this test can produce burning and tingling along the nerve's distribution. Choices A, C, and D are incorrect. Testing for the strength of each muscle joint and checking for repetitive movements in the joints involve different assessments unrelated to the Tinel sign. Asking the client to flex the wrist 90 degrees while holding the hands back to back is associated with the Phalen test, which is another evaluation for carpal tunnel syndrome.
2. In performing a psychosocial assessment, the nurse begins by asking questions that encourage the client to describe problematic behaviors and situations. The next step is to elicit the client’s
- A. feelings about what has been described.
- B. thoughts about what has been described.
- C. possible solutions to the problem.
- D. intent in sharing the description.
Correct answer: thoughts about what has been described.
Rationale: In performing a psychosocial assessment, the nurse follows a structured approach, starting with encouraging the client to describe problematic behaviors and situations. The next step is to elicit the client’s thoughts about what has been described. This step helps gather more assessment data and understand how the client interprets the situation. Asking about feelings, exploring possible solutions, and understanding the client's intent in sharing the description are more complex processes that come later in the assessment. Therefore, the correct next step after describing behaviors and situations is to inquire about the client's thoughts.
3. Signs of impaired breathing in infants and children include all of the following except:
- A. nasal flaring
- B. grunting
- C. seesaw breathing
- D. quivering lips
Correct answer: quivering lips
Rationale: Signs of impaired breathing in infants and children can manifest in various ways. Nasal flaring, grunting, and seesaw breathing are all indicative of respiratory distress in pediatric patients. Nasal flaring is the widening of the nostrils with breathing effort, grunting is a sound made during exhalation to try to keep the airways open, and seesaw breathing involves the chest moving in the opposite direction of the abdomen. However, quivering lips are not typically associated with impaired breathing in this context. Lip quivering is a distracter and not a common sign of respiratory distress in infants and children. Therefore, the correct answer is 'quivering lips.'
4. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
- A. Trendelenburg position
- B. Ice to the entire extremity
- C. Buck’s traction
- D. An abduction pillow
Correct answer: Buck’s traction
Rationale: The correct answer is Buck’s traction. This intervention is used to realign the fractured femur, reduce spasms, and alleviate pain. Placing the client in the Trendelenburg position is inappropriate for a femur fracture, making answer A incorrect. While ice may be used post-repair, applying it to the entire extremity is unnecessary, so answer B is wrong. An abduction pillow is typically employed following a total hip replacement, not for a fractured femur, rendering answer D incorrect.
5. A client newly diagnosed with Diabetes Mellitus needs education. Which of the following statements should the nurse include in this education?
- A. “You can eat anything you want, but avoid foods with sugar.”
- B. “You need to lose weight, so your diet must be controlled.”
- C. “You need a diet and exercise program.”
- D. “You must reduce salt, fat, and sugar intake in your diet.”
Correct answer: “You need a diet and exercise program.”
Rationale: A client newly diagnosed with Diabetes Mellitus requires education on managing their condition. Choice C is the correct answer because it emphasizes the importance of a comprehensive approach involving both diet and exercise. This holistic approach is crucial in managing blood sugar levels and overall health for individuals with diabetes. Choice A is incorrect as it provides misleading information by suggesting that the client can eat anything as long as it doesn't contain sugar, which is not accurate for diabetes management. Choice B is not the best option as it focuses solely on weight loss rather than addressing the holistic needs of a diabetic individual. Choice D is incorrect as it suggests eliminating all salt, fat, and sugar, which is an extreme approach and not a realistic or balanced way to manage diabetes.
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