a nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression the nurse should immediately
Logo

Nursing Elites

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?

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. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?

Correct answer: C

Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.

3. When meeting nurses for the first time, a new nurse manager makes eye contact, smiles, initiates conversation about their previous work experience, and encourages active participation. This behavior is an example of

Correct answer: D

Rationale: The nurse manager is demonstrating assertive behavior by confidently engaging with the nurses through eye contact, smiling, and encouraging participation. This behavior shows a balance between expressing her own opinions and respecting others. Aggressive behavior would involve dominating or embarrassing others, while passive behavior is characterized by being timid or nervous. Passive-aggressive behavior is indirect and manipulative, which is not demonstrated in this scenario.

4. A client states, "I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?"? The nurse should respond with which of the following statements?

Correct answer: D

Rationale: All of the choices are methods of preventing cancer. Sleep is important in maintaining homeostasis, which helps the body respond to disease. Monthly breast examination can indicate cancer or fibrocystic disease. Stress can have a physiological response that decreases the immune response and increases the risk of disease. Therefore, all the options mentioned are important for cancer prevention, making 'All of the above' the correct response.

5. The LPN on shift notices a client coming into the clinic with bruises on his arm. The client seems very afraid and doesn't speak much, which concerns the nurse because these are signs of physical abuse. The nurse should ____.

Correct answer: B

Rationale: In cases of suspected abuse, healthcare providers have a legal and ethical obligation to report such incidents to the relevant authorities. This not only ensures the safety and well-being of the client but also helps in preventing further harm. Option A is incorrect as attempting to gather evidence of abuse may interfere with the official investigation and is not the nurse's role. Offering support is crucial, but the priority is to report the findings to the appropriate authorities. Option C is incorrect as ignoring signs of abuse goes against the duty of a healthcare provider to protect their clients. Option D is incorrect as reporting suspected abuse to other nurses without involving the appropriate authorities may delay necessary actions and intervention.

Similar Questions

A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction?
A client turns her ankle. She is diagnosed as having a Pulled Ligament. This should be documented as a:
Which of these is not a symptom of Serotonin Syndrome?
The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should provide which response to the parents?
When removing hard contact lenses from an unresponsive client, what should the nurse do?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses