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

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: A

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. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?

A. The client has a history of Type II diabetes.
B. The client is on a continuous tube-feeding regimen.
C. The client is on fluid restriction.
D. The pharmacy has provided phenytoin in tablet form.

Correct answer: B

Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.

3. A new mother is being discharged from the maternity unit and provided with information about signs and symptoms to report to her health care provider. Which statement by the mother indicates a need for further information?

A. ''I will call my nurse-midwife if I experience any redness, swelling, or tenderness in my legs.''
B. ''My temperature needs to remain within a normal range.''
C. ''Frequent urination and burning when I urinate are expected.''
D. ''Feelings of pelvic fullness or pelvic pressure are a sign of a problem.''

Correct answer: C

Rationale: The correct answer is 'Frequent urination and burning when I urinate are expected.' This statement by the mother indicates a need for further information because these symptoms are not normal and could indicate a urinary tract infection or another issue that needs medical attention. The other choices correctly reflect signs and symptoms that should be reported to the health care provider. Redness, swelling, or tenderness in the legs can indicate a blood clot, and feelings of pelvic fullness or pressure can be signs of a problem. Monitoring temperature is also important to ensure there is no infection or other complications postpartum.

4. What causes an older female client's hair to turn gray?

A. ''A loss of melanin occurs in the normal aging process.''
B. ''The number of sweat glands and blood vessels decreases in the normal aging process.''
C. ''The skin on the scalp becomes thin, causing moisture to escape.''
D. ''It is caused by hereditary factors.''

Correct answer: A

Rationale: The correct answer is 'A loss of melanin occurs in the normal aging process.' Graying hair in older adults is primarily due to a decrease in the number of melanocytes responsible for providing pigment and hair color. This reduction in melanin production leads to gray hair. The other choices are incorrect. While it is true that the skin becomes thinner with aging and the number of sweat glands and blood vessels decreases, these changes are not directly related to graying hair. Additionally, hereditary factors can influence when graying starts, but they do not cause the graying of hair itself.

5. The client should include all of the following in teaching an obese client about nutritional needs and weight loss except:

A. knowledge of food and food products
B. development of a positive mental attitude
C. adequate exercise
D. starting a fast weight-loss diet

Correct answer: D

Rationale: When educating an obese client about nutritional needs and weight loss, it is crucial to emphasize a holistic approach that involves understanding food and food products, fostering a positive mental attitude, and incorporating adequate exercise. Initiating a fast weight-loss diet is not advisable due to potential health risks and lack of long-term sustainability. Therefore, this option stands out as the exception and should not be part of the client's learning. Choices A, B, and C are essential components of a healthy weight-loss plan and should be included in the client's education.