NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A healthcare professional reviewing a client’s health care record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the healthcare professional determine that the client has?
- A. Scoliosis
- B. Osteoarthritis
- C. Rotator cuff lesions
- D. Carpal tunnel syndrome
Correct answer: Osteoarthritis
Rationale: The correct answer is Osteoarthritis. Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes. In this disorder, when these nodes occur on the proximal interphalangeal joints, they are called Bouchard nodes. Heberden nodes are not associated with scoliosis, rotator cuff lesions, or carpal tunnel syndrome. Therefore, choices A, C, and D are incorrect.
2. Why is padding on a restraint helpful?
- A. To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
- B. To help the client feel more secure.
- C. To keep infection and wounds at bay.
- D. To keep restraints in place.
Correct answer: To distribute pressure so that bony prominences do not receive pressure when a client pulls against the restraints.
Rationale: Padding on a restraint helps distribute pressure to prevent bony prominences from bearing excessive pressure when a client pulls against the restraints. This is crucial to avoid tissue damage caused by ischemia. The correct answer focuses on the physiological benefit of padding in reducing pressure on vulnerable areas to prevent harm. Choice B is incorrect as the primary purpose of padding is not emotional comfort but preventing physical harm. Choice C is incorrect as while padding can indirectly help prevent infection and wounds by reducing pressure, its primary function is pressure distribution. Choice D is incorrect as the main purpose of padding is not to keep the restraints in place but to protect the client's skin and tissues from pressure-related injuries.
3. Which of the following client groups should the nurse recognize as the fastest-growing segment of the homeless population?
- A. single, adult men
- B. single mothers with 2 or 3 children
- C. runaway adolescents
- D. single, adult women
Correct answer: single mothers with 2 or 3 children
Rationale: Single mothers with two or three children are indeed the fastest-growing segment of the homeless population. These families, where the majority of children are under the age of five, make up more than one-third of the homeless population in the United States. While single, adult men have traditionally been the largest group in the homeless population, single mothers with children have been increasing in numbers. Runaway adolescents, although a significant group of homeless children, do not represent the fastest-growing segment of the homeless population. Single, adult women are not specified as the fastest-growing segment.
4. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?
- A. Anger
- B. Mania
- C. Depression
- D. Psychosis
Correct answer: Mania
Rationale: The correct answer is 'Mania.' A client with a serum sodium level of 170 meq/L has hypernatremia, which can lead to manic behavior. Hypernatremia is associated with irritability, restlessness, confusion, and in severe cases, manic symptoms. Choices A, C, and D (Anger, Depression, Psychosis) are not typically associated with hypernatremia and are, therefore, incorrect in this context.
5. Which of the following actions should the LPN perform for a client with an active digoxin IV order? Select all that apply.
- A. Monitor ECG rhythm throughout administration.
- B. Administer the medication over at least 5 minutes.
- C. Monitor respirations during administration.
- D. Monitor the client’s pulse for 1 minute prior to administration.
Correct answer: A, D
Rationale: The correct actions for the LPN to perform for a client with an active digoxin IV order are to monitor ECG rhythm throughout administration and monitor the client’s pulse for 1 minute prior to administration. These actions are crucial as digoxin affects the heart's electrical activity, and it should not be administered if the client's pulse is less than 60 bpm. Monitoring respirations and blood pressure are not directly associated with digoxin administration. Administering IV medications is typically outside the LPN's scope of practice.
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