NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A nurse is telling a pregnant client about the signs that must be reported to the health care provider. The nurse tells the client that the health care provider should be contacted if which occurs?
- A. Puffiness of the face
- B. Breast tenderness
- C. Morning sickness
- D. Urinary frequency
Correct answer: Puffiness of the face
Rationale: During pregnancy, it is important to be aware of danger signs that warrant contacting the healthcare provider. Puffiness of the face, especially around the eyes, can indicate a serious condition like preeclampsia. Other danger signs include vaginal bleeding, rupture of membranes, severe abdominal pain, visual disturbances, persistent vomiting, and changes in fetal movements. Morning sickness, breast tenderness, and urinary frequency are common symptoms of pregnancy and are not typically concerning unless they become severe or persistent, and do not usually require immediate medical attention.
2. When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?
- A. polyandry
- B. sororal
- C. nonsororal
- D. soronal
Correct answer: D
Rationale: The correct answer is 'soronal.' The practice of polygamy refers to having multiple wives or husbands. When there are multiple wives who are sisters, the polygamy is designated as sororal. Polyandry refers to multiple husbands, which is rare. Nonsororal polygamy is when the wives are not sisters. Sororate polygamy specifies that a husband must marry his wife’s sister if she dies. Therefore, in this scenario, the family structure described by the client fits the definition of soronal polygamy.
3. When preparing a client for a neck x-ray, what is the most appropriate action for the nurse to take if the client expresses concern about removing a religious medal worn around the neck?
- A. Telling the client that the medal and chain will be kept at the nurse's station for safekeeping while the client is undergoing the x-ray
- B. Asking the client to remove the medal until the x-ray has been completed
- C. Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms
- D. Asking the client to place the medal in the top drawer of the bedside stand just before leaving for the radiology department
Correct answer: Assisting the client in pinning the medal and chain to the waistband of the client's pajama bottoms
Rationale: When a client undergoing a neck x-ray expresses concern about removing a religious medal worn around the neck, the nurse should assist the client in pinning the medal and chain to the hospital gown or in another area where it will not appear on the x-ray image. This action allows the client to keep the medal close without interfering with the x-ray procedure. It is important to ensure that the radiology department staff is informed about this arrangement. Asking the client to remove the medal, keeping it at the nurse's station, or placing it in the bedside stand is not appropriate. These actions may lead to the loss of the medal and chain and do not address the client's concerns about the religious significance of the item.
4. Regarding maternal and infant mortality and morbidity, a concern is that:
- A. a segment of the population is not receiving prenatal care.
- B. families may not prioritize quality health care.
- C. there might be an increase in the shortage of personnel in the maternity field.
- D. maternal-child health workers may lack adequate preparation.
Correct answer: a segment of the population is not receiving prenatal care.
Rationale: The correct answer is that a segment of the population is not receiving prenatal care. This is a significant concern as lack of access to prenatal care can lead to adverse outcomes for both the mother and the infant. Choice B is incorrect as it generalizes families as unconcerned, which may not be the case for all families. Choice C is also incorrect as there is no evidence or indication in the prompt to suggest an increase in the shortage of personnel. Choice D is not directly related to the concern mentioned in the prompt, which specifically focuses on the lack of prenatal care.
5. What happens if folic acid is administered to treat anemia without determining its underlying cause?
- A. Erythropoiesis is inhibited
- B. Excessive levels of folic acid might accumulate, causing toxicity
- C. The symptoms of pernicious anemia might be masked, delaying treatment
- D. Intrinsic factor is destroyed
Correct answer: The symptoms of pernicious anemia might be masked, delaying treatment
Rationale: When folic acid is given without determining the underlying cause of anemia, the symptoms of pernicious anemia may be masked, potentially delaying the correct treatment. Folic acid alone does not protect against the central nervous system changes seen in pernicious anemia, which are related to Vitamin B12 deficiency. Folic acid and Vitamin B12 are both crucial for cell growth and division. Administering folic acid without knowing the specific type of anemia could lead to a delay in addressing the root cause. Option A is incorrect because folic acid is essential for erythropoiesis, the production of red blood cells. Option B is incorrect as excessive folic acid can cause toxicity, but it is not the primary concern in this context. Option D is incorrect because folic acid treatment for anemia does not directly impact intrinsic factor, which is related to Vitamin B12 absorption.
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