NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately perform which action?
- A. Insert a gloved finger into the mother's vagina to feel for cord compression
- B. Position the mother so that her hips are elevated
- C. Notify the registered nurse
- D. Perform a vaginal examination on the mother
Correct answer: B
Rationale: When variable decelerations on the fetal heart rate monitor strip suggest cord compression, the immediate action the nurse should take is to reposition the mother to alleviate the compression. Elevating the mother's hips or changing her position can help shift the fetal presenting part and relieve pressure on the cord. This action aims to improve or resolve the variable decelerations. Contacting the registered nurse may be necessary, but it is not the immediate action required in this situation. Performing a vaginal examination is contraindicated due to the potential risk of further compromising blood flow through the umbilical cord. Inserting a gloved finger into the mother's vagina to feel for the cord is also not recommended as it poses a similar risk of exacerbating the situation.
2. Which of the following foods is a complete protein?
- A. corn
- B. eggs
- C. peanuts
- D. sunflower seeds
Correct answer: B
Rationale: The correct answer is 'eggs.' Eggs are considered a complete protein as they contain all nine essential amino acids required by the body. On the other hand, corn, peanuts, and sunflower seeds are incomplete proteins, meaning they lack one or more of the essential amino acids needed by the body for optimal health. Corn, peanuts, and sunflower seeds are plant-based proteins that are deficient in one or more essential amino acids, unlike eggs, which are a high-quality complete protein source.
3. Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except:
- A. terminating the pregnancy.
- B. preparing for the birth of a child with special needs.
- C. accessing support services before the birth.
- D. completing the grieving process before the birth.
Correct answer: D
Rationale: Diagnostic genetic counseling provides clients with important information to make informed decisions regarding their pregnancy. Clients can choose to terminate the pregnancy, prepare for the birth of a child with special needs, and access support services before the birth based on the genetic testing results. However, completing the grieving process before the birth is not a typical choice during genetic counseling. The grieving process, if needed, may extend beyond the prenatal period, especially if the findings are concerning or indicate potential issues. Therefore, completing the grieving process before the birth is the exception among the provided options.
4. A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct answer: D
Rationale: The ability of a preschooler to move five blocks to a piece of paper and state there are five blocks on the paper is evidence that the preschooler has the ability of conservation. This concept refers to the fact that the quantity of something doesn't change just because the shape, contour, and so on has changed. Five blocks are still five blocks, whether they are lying beside the paper, stacked on the paper, or moved to the paper. Centration is the ability to concentrate on one feature of a situation while neglecting all other aspects. Causality is based on the sequence of events, one event ordinarily following another. Non-reversibility refers to the inability of preschoolers to reverse their operations. They are only able to think forward, not retrace or reverse their thought processes.
5. If a client has chronic renal failure, which of the following sexual complications is the client at risk of developing?
- A. retrograde ejaculation
- B. decreased plasma testosterone
- C. hypertrophy of testicles
- D. state of euphoria
Correct answer: B
Rationale: In chronic renal failure, untreated, the client is at risk of developing decreased plasma testosterone. This condition leads to atrophy of the testicles and decreased spermatogenesis. Retrograde ejaculation is not a complication of chronic renal failure but can occur after transurethral resection of the prostate. The testicles atrophy in chronic renal failure; they do not hypertrophy. Additionally, chronic renal failure often leads to a state of depression, not euphoria.
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