NCLEX NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. Assisting with data collection, a nurse notes tenderness while lightly palpating a client’s right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?
- A. Liver
- B. Spleen
- C. Pancreas
- D. Appendix
Correct answer: D: Appendix
Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.
2. A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client’s vital signs include BP 160/110, HR 42, Cheyne-Stokes respirations. Based on this assessment, the nurse anticipates the client to be in which acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: Respiratory acidosis
Rationale: In this scenario, the client is exhibiting Cheyne-Stokes respirations, which are characterized by periods of deep breathing alternating with apnea. This pattern indicates respiratory insufficiency, resulting in an accumulation of carbon dioxide in the blood. The elevated BP and slow heart rate further support the respiratory insufficiency, leading to respiratory acidosis. Therefore, the correct answer is Respiratory acidosis. Choices B, C, and D are incorrect. Respiratory alkalosis is characterized by decreased carbon dioxide levels in the blood, which is not indicated by the client's presentation. Metabolic acidosis results from conditions such as renal failure or diabetic ketoacidosis and is not the primary imbalance in this case. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels, which are not present in the client's vital signs.
3. A male client is learning about testicular self-examination (TSE) from a nurse. Which statement should the nurse make to the client?
- A. 'A good time to examine the testicles is during or after you take a shower.'
- B. 'If you notice an enlarged testicle or a lump, you need to notify the physician.'
- C. 'The testicle is round and smooth. It feels firm and without lumps.'
- D. 'Perform a testicular exam monthly to detect early signs of testicular cancer.'
Correct answer: 'If you notice an enlarged testicle or a lump, you need to notify the physician.'
Rationale: The correct statement for the nurse to make to the client is 'If you notice an enlarged testicle or a lump, you need to notify the physician.' During a shower or bath is the best time to examine the testes because warm temperatures make the testes hang lower in the scrotum. The testes should feel round and smooth, without lumps. Self-examination should be performed monthly to detect any abnormalities early. The physician needs to be notified immediately if any abnormal findings are noticed. Choice A is incorrect because the best time for TSE is during or after a warm shower or bath, not just before. Choice C is incorrect as the testicle should feel round, smooth, and without lumps, not egg-shaped and lumpy. Choice D is incorrect as monthly self-examinations are recommended, not every 2 months.
4. Which microorganism is most commonly associated with gastritis?
- A. Syphilis
- B. Cytomegalovirus
- C. H. pylori
- D. Mycobacterium
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.
5. Spirituality affects a client’s life in all of the following areas except:
- A. nutritional intake.
- B. ability to handle stress.
- C. sexual expression.
- D. genetic makeup.
Correct answer: genetic makeup.
Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy. It can influence areas such as nutritional intake, the ability to handle stress, and sexual expression by providing comfort, guidance, and a sense of purpose. However, spirituality does not have any effect on genetic makeup, as genetics are determined by biological inheritance and not influenced by spiritual beliefs. Choices A, B, and C are directly influenced by an individual's spiritual beliefs and practices, impacting their overall well-being and behavior.
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