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Health Promotion and Maintenance NCLEX Questions
1. After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?
- A. Reporting the finding to the healthcare provider immediately
- B. Helping the woman stay in bed and rest
- C. Documenting the finding
- D. Performing active and passive range-of-motion exercises
Correct answer: C: Documenting the finding
Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.
2. Which of the following is not one of the four categories related to client care plans?
- A. privacy
- B. evaluation
- C. diagnosis
- D. outcome
Correct answer: privacy
Rationale: The four categories related to client care plans are diagnosis, intervention, outcome, and evaluation. Privacy is not typically considered a distinct category in client care plans, as it is more of a fundamental aspect that underlies all care provided to clients. Choices B, C, and D are directly related to the components of client care plans, making them incorrect answers in this context.
3. A primary belief of psychiatric mental health nursing is:
- A. Most people have the potential to change and grow.
- B. Every person is worthy of dignity and respect.
- C. Human needs are individual to each person.
- D. Some behaviors have no meaning and cannot be understood.
Correct answer: Every person is worthy of dignity and respect.
Rationale: The correct answer is that every person is worthy of dignity and respect. This is a fundamental principle in psychiatric mental health nursing, emphasizing the importance of treating individuals with dignity and respect regardless of their condition. This belief forms the basis of establishing a therapeutic nurse-client relationship. Choice A is a positive belief, but the primary focus in psychiatric mental health nursing is on respecting the worth and dignity of each individual. Choice C is related to understanding individual human needs but does not encompass the core value of dignity and respect. Choice D is incorrect as psychiatric nursing emphasizes the importance of interpreting and understanding all behaviors as meaningful expressions of the client's experience.
4. A client being treated for sickle cell disease has an order for pain medication. Morphine was ordered, but the nurse is having difficulty deciphering the dose. The nurse should ____.
- A. ask the attending physician to clarify the order, including the correct medication, dose, route, and frequency
- B. call the charge nurse to inform the attending physician and verify the order, including the correct medication, dose, route, and frequency
- C. call the attending physician to verbally verify the order, including the correct medication, dose, route, and frequency
- D. refrain from administering the medication until the charge nurse can assist in determining the correct dosage
Correct answer: call the attending physician to verbally verify the order, including the correct medication, dose, route, and frequency
Rationale: In this scenario, when a nurse encounters difficulties in deciphering an order, the appropriate action is to contact the attending physician directly to clarify and verify the medication, dose, route, and frequency. It is crucial for the nurse to have a clear understanding of the order before administering any medication to ensure patient safety and proper treatment. Option A is incorrect as it suggests asking the attending physician to clarify without specifying the urgency of the situation. Option B involves an unnecessary additional step by first contacting the charge nurse before reaching out to the attending physician, potentially delaying the clarification process. Option D is incorrect as it advises refraining from administering the medication, which may not be necessary if the correct dosage can be promptly verified by contacting the attending physician.
5. When helping a client gain insight into anxiety, the nurse should:
- A. help the client relate anxiety to specific triggers.
- B. ask the client to describe events that precede increased anxiety.
- C. encourage the client to practice relaxation techniques.
- D. address the client's resistive behavior.
Correct answer: ask the client to describe events that precede increased anxiety.
Rationale: When assisting a client in gaining insight into anxiety, it is crucial to explore the events that lead to increased anxiety. By asking the client to describe these events, the nurse can help the client recognize patterns and triggers, leading to a better understanding of their anxiety. Option A is incorrect because it refers to triggers rather than exploring the events leading to anxiety. Option C is incorrect as it focuses on relaxation techniques rather than delving into the root causes of anxiety. Option D is inappropriate as addressing resistive behavior may not foster a supportive therapeutic environment for the client.
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