NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. When preparing to assist the healthcare provider in examining a client's skin with the use of a Wood light, what action should the nurse perform?
- A. Darken the room
- B. Obtain informed consent from the client
- C. Obtain a scalpel and a slide for diagnostic evaluation
- D. Obtain medication to anesthetize the skin area before proceeding with the examination
Correct answer: A
Rationale: When using a Wood light during a skin examination, the room should be darkened to enhance the visibility of fluorescence. The Wood light emits long-wavelength ultraviolet light, highlighting certain skin conditions. Darkening the room aids in better visualization. Obtaining informed consent is a crucial aspect of healthcare but not directly related to using a Wood light. Obtaining a scalpel and a slide is unnecessary for a noninvasive Wood light examination. Anesthetizing the skin area is not required as the procedure is painless and noninvasive.
2. A nurse assisting with data collection regarding the client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?
- A. Myopia
- B. Hyperopia
- C. Photophobia
- D. Accommodation
Correct answer: D
Rationale: The correct answer is Accommodation. Accommodation is the process by which the eye adjusts its focus to see objects at different distances. When the pupils get larger when the client looks at an object in the distance and become smaller when looking at a nearby object, it indicates the normal functioning of the eye's accommodation mechanism. Myopia refers to nearsightedness, where distant objects appear blurry. Hyperopia refers to farsightedness, where close objects appear blurry. Photophobia is an abnormal sensitivity to light. Therefore, the correct term to document the finding of the pupils adjusting based on the distance of the object is 'Accommodation.'
3. When a 25-year-old client complains of chest congestion and cough after previously presenting with cold symptoms, what data should the nurse collect?
- A. Data related to follow-up care
- B. A complete health database
- C. Data related to the respiratory system
- D. Data related to the treatment for the cold
Correct answer: C
Rationale: In this case, the nurse should collect data related to the respiratory system since the client is presenting with symptoms like chest congestion and cough, indicating a respiratory issue. Focusing on the respiratory system will help gather pertinent information to assess the current problem comprehensively. A complete health database involves a detailed health history and full physical examination, which is beyond the immediate scope of the presenting issue. Data related to follow-up care is premature as the primary focus should be on assessing the current respiratory symptoms. Data related to the treatment for the cold is not the priority at this stage, as understanding the underlying respiratory problem is crucial for appropriate intervention.
4. An amniocentesis is scheduled for a pregnant client in the third trimester. The nurse informs the client that the most common indication for amniocentesis during the third trimester is for which reason?
- A. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid
- B. Checking the amniotic fluid for intrauterine infection
- C. Determination of fetal lung maturity
- D. Checking the fetal cells for chromosomal abnormalities
Correct answer: C
Rationale: The most common indication for amniocentesis in the third trimester is the determination of fetal lung maturity. This assessment is essential to evaluate the fetus's readiness for extrauterine life. Checking for alpha-fetoprotein (AFP) in the amniotic fluid is more commonly associated with midtrimester amniocentesis to identify chromosomal abnormalities. Assessing for intrauterine infection is not a primary reason for amniocentesis in the third trimester. While checking fetal cells for chromosomal abnormalities is a common indication for midtrimester amniocentesis, it is not the most common indication in the third trimester.
5. The LPN has been asked to help a client taking Risperdal with activities of daily living in the morning. Which of these tasks is most likely to be potentially impacted by this medication?
- A. eating breakfast
- B. drinking fluids
- C. getting out of bed to use the bathroom
- D. brushing teeth
Correct answer: C
Rationale: The correct answer is 'getting out of bed to use the bathroom.' Risperdal can cause orthostatic hypotension, leading to a drop in blood pressure when changing positions from lying down to standing up. This effect increases the risk of falls, emphasizing the need to assist the client with this task to prevent potential harm. Choices A, B, and D are less likely to be directly impacted by the medication, unlike the significant risk of orthostatic hypotension associated with changing positions.
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