NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?
- A. Asking the client to stick out his or her tongue and watching for tremors
- B. Touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex
- C. Depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah'
- D. Placing his or her hands on the client's shoulders and asking the client to shrug the shoulders against resistance from the nurse's hands
Correct answer: D
Rationale: To assess the function of cranial nerve XI (spinal accessory nerve), the nurse examines the sternomastoid and trapezius muscles for equal size and strength. The correct method involves asking the client to rotate the head forcibly against resistance to the side of the chin and to shrug the shoulders against resistance from the nurse's hands. Choice A, asking the client to stick out the tongue and watching for tremors, is used to assess cranial nerve XII (hypoglossal nerve). Choice C, depressing the client's tongue with a tongue blade and noting pharyngeal function as the client says 'ah', is the technique for examining cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve). Choice B, touching the posterior pharyngeal wall with a tongue blade and noting the gag reflex, is used to evaluate cranial nerves IX (glossopharyngeal nerve) and X (vagus nerve), not cranial nerve XI.
2. An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?
- A. The client has a low cardiac output.
- B. The client has a high cardiac output.
- C. The client has a normal cardiac output.
- D. The client will need a blood transfusion.
Correct answer: C
Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.
3. A client with Kawasaki disease has bilateral congestion of the conjunctivae, dry cracked lips, a strawberry tongue, and edema of the hands and feet followed by desquamation of fingers and toes. Which of the following nursing measures is most appropriate to meet the expected outcome of positive body image?
- A. administering immune globulin intravenously
- B. assessing the extremities for edema, redness, and desquamation every 8 hours
- C. explaining progression of the disease to the client and their family
- D. assessing heart sounds and rhythm
Correct answer: C
Rationale: Explaining the progression of the disease to the client and their family is the most appropriate nursing measure to promote a positive body image. By educating them about when symptoms are expected to improve and resolve, they can understand that there will be no permanent disruption in physical appearance that could negatively impact body image. While administering immune globulin intravenously may be part of the treatment for Kawasaki disease, it does not directly address body image concerns. Assessing the extremities for edema, redness, and desquamation every 8 hours is important for monitoring the disease but does not directly impact body image. Assessing heart sounds and rhythm is crucial for monitoring cardiac effects of Kawasaki disease but is not directly related to promoting a positive body image.
4. A nurse is preparing to assist the healthcare provider in performing an internal gynecological examination of a client. In which position does the nurse place the client for this examination?
- A. Prone
- B. Left side-lying
- C. Sims
- D. Lithotomy
Correct answer: D
Rationale: An internal gynecological examination is performed with the client in the lithotomy position. In this position, the client is supine, with the feet in stirrups, the knees apart, and the buttocks at the end of the examining table. The client is draped so that only the vulva is exposed. The lithotomy position provides optimal access for the healthcare provider to perform the examination effectively. The prone position refers to lying on the stomach, which is not suitable for a gynecological exam. The Sims position is a left side-lying position primarily used for administering enemas, not for gynecological examinations.
5. Which of the following strategies should the nurse include when planning care for children of migrant workers?
- A. Delay immunizations due to acute illness.
- B. Provide parents with copies of medical records.
- C. Offer preventive services during acute illness visits.
- D. Emphasize the importance of having one primary care provider.
Correct answer: B
Rationale: When planning care for children of migrant workers, providing parents with copies of medical records is essential. This helps ensure continuity of care, especially as migrant families may move frequently. Immunizations should not be delayed due to acute illness; preventive care, including immunizations, should be provided even during acute illness visits to ensure the child stays up to date. While it is important to offer preventive services during routine visits, it is not ideal to provide them only during acute illness visits. Emphasizing the importance of having one primary care provider is valuable in healthcare, but it may not be feasible for migrant families due to their mobility.
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