a nurse reviewing the physical assessment findings in a clients health care record notes documentation that the phalen test caused numbness and burnin a nurse reviewing the physical assessment findings in a clients health care record notes documentation that the phalen test caused numbness and burnin
Logo

Nursing Elites

NCLEX NCLEX-PN

Health Promotion and Maintenance NCLEX Questions

1. A nurse reviewing the physical assessment findings in a client’s health care record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has?

Correct answer: Carpal tunnel syndrome

Rationale: The Phalen test is specifically used to assess for carpal tunnel syndrome. In this test, the client is asked to hold their hands back to back while flexing the wrists 90 degrees, which can reproduce the numbness and burning sensation experienced by individuals with carpal tunnel syndrome. Scoliosis is a condition characterized by abnormal lateral curvature of the spine, not related to the Phalen test. Bone deformity is a general term that does not specifically relate to the symptoms described. Heberden nodules are bony swellings that occur in osteoarthritis and are not assessed through the Phalen test.

2. Which microorganism is most commonly associated with gastritis?

Correct answer: C

Rationale: H. pylori is the most common microorganism associated with gastritis, present in over 80% of cases. While syphilis, cytomegalovirus, and mycobacterium can also cause gastritis, they are much less prevalent compared to H. pylori. Therefore, the correct answer is H. pylori.

3. A client has been diagnosed with Disseminated Intravascular Coagulation (DIC) and transferred to the medical intensive care unit (ICU) following an acute bleeding episode. In the ICU, continuous Heparin drip therapy is initiated. Which of the following assessment findings indicates a positive response to Heparin therapy?

Correct answer: increased fibrinogen

Rationale: Effective Heparin therapy should halt the process of intravascular coagulation, leading to increased availability of fibrinogen. Heparin interferes with thrombin-induced conversion of fibrinogen to fibrin. Therefore, an increased fibrinogen level indicates a positive response to Heparin therapy. While increased platelet count and decreased bleeding are positive outcomes, the specific indicator for Heparin therapy response is the increase in fibrinogen level. Decreased fibrin split products would also be a positive response, but an increase in fibrinogen directly reflects the impact of Heparin therapy.

4. While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client’s necklace?

Correct answer: Ask the client for permission to lock the necklace in the hospital safe

Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.

5. The nurse is caring for a dying client who has persistently requested that the nurse 'help her to die and be in peace.' According to the Code of Ethics for Nurses, the nurse should:

Correct answer: Try to make the client as comfortable as possible, but refuse to assist in death.

Rationale: The correct answer is to try to make the client as comfortable as possible but refuse to assist in death. According to the Code of Ethics for Nurses, nurses are committed to providing compassionate care, respecting the dignity and rights of the dying person. In this situation, it is important for the nurse to focus on providing comfort and support to the client while upholding ethical standards. Choice A is incorrect because discussing advance directives does not address the immediate request for assistance in dying. Choice B is incorrect as it does not address the ethical dilemma presented. Choice C is incorrect because instructing the client that only a physician can assist in suicide does not fully address the complexity of the situation or the nurse's role in providing end-of-life care.

Similar Questions

While assisting with data collection of an adult client, a nurse asks the client to identify various odors. In this technique, which cranial nerve is the nurse assessing?
In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?
Following the change of shift report, when can or should the nurse's plan be altered or modified during the shift?
How can the nurse best communicate to a client that he or she has been listening?
Which electrolyte imbalance would be the nurse's priority concern in the burn client?

Access More Features

NCLEX Basic

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access @ $69.99

NCLEX Basic

  • 5,000 Questions and answers
  • Comprehensive NCLEX Coverage
  • 90 days access @ $69.99