a nurse is preparing to test cranial nerve i which item does the nurse obtain to test this nerve
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NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

1. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?

Correct answer: C

Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.

2. A client complains that her skin is redder than normal. The nurse notes the client's skin, documents hyperemia, and explains to the client that this condition is caused by which factor?

Correct answer: D

Rationale: Hyperemia is an excess of blood in a part of the body. The skin over a hyperemic area usually becomes reddened or warm. The condition is caused by increased blood flow, local relaxation of arterioles, or obstruction of the outflow of blood from an area. Choice A is incorrect because constriction of blood vessels would lead to decreased blood flow, not excess blood. Choice B is incorrect as an increased amount of bilirubin in the blood is related to jaundice, not hyperemia. Choice C is incorrect because increased perfusion of the surrounding tissues would cause redness, not hyperemia.

3. What ethical obligations do professional nurses have according to the ANA Code of Ethics for Nurses?

Correct answer: D

Rationale: The correct answer is 'all of the above.' According to the ANA Code of Ethics for Nurses, professional nurses have ethical obligations to patients (clients), the nursing profession, and providing high-quality care. These elements are fundamental principles outlined in the code of ethics to guide nurses in their practice. Choice A is correct as nurses prioritize the well-being and care of their patients. Choice B is correct as nurses are expected to uphold the values and integrity of the nursing profession. Choice C is correct as providing high-quality care is a core ethical obligation of nurses. Therefore, all the choices align with the ANA Code of Ethics for Nurses.

4. A teenage client is admitted to the hospital because of acetaminophen (Tylenol) overdose. Overdoses of acetaminophen can precipitate life-threatening abnormalities in which of the following organs?

Correct answer: B

Rationale: Acetaminophen is extensively metabolized in the liver. An overdose of acetaminophen can lead to severe liver damage and even liver failure, which can be life-threatening. Choices A, C, and D are incorrect because although prolonged use of acetaminophen may lead to an increased risk of renal dysfunction, a single overdose does not typically cause life-threatening abnormalities in the lungs, kidneys, or adrenal glands.

5. A nurse in a day-care setting is planning play activities for 2- and 3-year-old children. Which toys are most appropriate for these activities?

Correct answer: B

Rationale: The most appropriate toys for 2- and 3-year-old children in a day-care setting are blocks and push-pull toys. Toddlers enjoy objects of different textures like clay, sand, finger paints, and bubbles, as well as push-pull toys, large balls, and sand and water play. They also like activities such as blocks, painting, coloring with large crayons, large puzzles, and playing with trucks or dolls. Finger paints and card games may be more suitable for older children. Videos and cutting-and-pasting toys are generally more appropriate for preschoolers. Blocks and push-pull toys are beneficial for young children as they help in developing fine motor skills, hand-eye coordination, spatial awareness, and creativity. These toys also encourage imaginative play and problem-solving, making them ideal choices for toddlers.

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