NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. When performing an eye examination, which area can a healthcare provider best visualize using an ophthalmoscope?
- A. Iris
- B. Cornea
- C. Optic disc
- D. Conjunctiva
Correct answer: C
Rationale: An ophthalmoscope is a tool used to visualize the internal structures of the eye during an examination. The optic disc, located on the internal surface of the retina, can be best visualized using an ophthalmoscope. The iris, cornea, and conjunctiva are superficial structures that can be examined without the need for an ophthalmoscope. Therefore, the correct answer is the optic disc. Choices A, B, and D are incorrect because they are external structures that can be examined directly without the use of an ophthalmoscope.
2. A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?
- A. The fingers curl tightly, and the toes curl forward.
- B. The toes flare, and the big toe is dorsiflexed.
- C. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.
- D. The infant turns to the side that is touched.
Correct answer: B
Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.
3. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?
- A. Coffee
- B. A tuning fork
- C. A wisp of cotton
- D. An ophthalmoscope
Correct answer: C
Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.
4. The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?
- A. Make a referral for grief counseling.
- B. Allow the woman to see her baby initially and respect her wishes for further visits.
- C. Provide opportunities for the woman to express her feelings.
- D. Inform the woman she has the right to change her mind about relinquishment.
Correct answer: C
Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.
5. A nurse is palpating a client's sinus areas. Which sensation does the nurse expect the client to indicate that he or she is feeling during palpation if the sinuses are normal?
- A. Firm pressure
- B. Pain behind the eyes
- C. Pain during palpation
- D. Pressure producing an acute headache
Correct answer: A
Rationale: The correct answer is A: Firm pressure. When the sinuses are normal, the client is expected to feel firm pressure during palpation. Pain during palpation of the sinuses is indicative of acute sinusitis, not a normal finding. Pain behind the eyes and pressure producing an acute headache are symptoms of acute sinusitis, not sensations felt during sinus palpation in normal sinuses.
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