NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. The LPN is caring for a 9-month-old infant. Which of these behaviors exhibited by the child warrants further investigation?
- A. She prefers crawling over walking and makes no attempt to walk.
- B. She seems distressed by new adults.
- C. She does not respond to her own name.
- D. She only babbles "mama"? and "dada."?
Correct answer: C
Rationale: The correct answer is that the child does not respond to her own name. By 9 months, children should be babbling simple words, crawling, and responding to their name. Not responding to one's name can be an early indicator of a potential developmental delay, warranting further investigation. Preferring crawling over walking, being distressed by new adults, and babbling 'mama' and 'dada' are typical behaviors for a 9-month-old and do not necessarily require immediate concern.
2. Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
- A. providing safety measures to prevent falls
- B. taking medications as prescribed
- C. wearing a medical ID indicating Cushing's syndrome
- D. having regular health assessments
Correct answer: C
Rationale: All of the strategies listed are essential components of home care for a client with Cushing's syndrome. However, wearing a medical ID indicating Cushing's syndrome is the correct answer as it can have a negative impact on body image. This choice may constantly remind the client of their condition, potentially affecting their self-image and confidence. On the contrary, providing safety measures to prevent falls (Choice A) would enhance body image by promoting safety and preventing injuries. Taking medications as prescribed (Choice B) is likely to improve body image by managing symptoms effectively. Having regular health assessments (Choice D) demonstrates good self-care and can positively contribute to body image by showing a commitment to maintaining health.
3. While assisting with data collection, the client informs the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing which disorder?
- A. Pyrosis
- B. Anorexia
- C. Eructation
- D. Dysphagia
Correct answer: D
Rationale: The correct answer is 'Dysphagia.' Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia refers to a loss of appetite, not difficulty swallowing. Eructation is the medical term for belching, not difficulty swallowing. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid, not difficulty swallowing.
4. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
- A. "There is some evidence that ginseng may enhance in vitro sperm motility."?
- B. "Some studies show that ginseng enhances in vitro sperm motility."?
- C. "Ginseng is not proven to be effective for infertility; have you considered other options?"?
- D. "It's probably not going to hurt you, but it's also probably not going to help. Let's look at some other alternatives."?
Correct answer: B
Rationale: Some studies have shown that ginseng enhances in vitro sperm motility, making Choice B the correct response. It directly addresses the client's comments about taking ginseng and provides valuable information regarding its potential effect on sperm motility. Alternative therapies are often sought by couples struggling with infertility, and acknowledging the potential benefits of ginseng can empower the client. Choice A is incorrect as it slightly misrepresents the evidence by overgeneralizing its effectiveness. Choice C dismisses ginseng without acknowledging its potential benefits, potentially closing off a fruitful discussion with the client. Choice D, while neutral, misses the opportunity to validate the client's choice and explore further options collaboratively. It is crucial for nurses to respect clients' choices, provide accurate information, and guide them effectively in exploring different alternatives.
5. What is the threshold of dextrose concentrations that can safely be administered through a peripheral IV?
- A. Dextrose concentrations below 20% can be safely administered through a peripheral IV; dextrose concentrations above 20% should not be administered through a peripheral IV.
- B. Dextrose concentrations below 5% can be safely administered through a peripheral IV; dextrose concentrations above 5% should not be administered through a peripheral IV.
- C. Dextrose concentrations below 10% can be safely administered through a peripheral IV; dextrose concentrations above 10% should not be administered through a peripheral IV.
- D. Dextrose concentrations above 5% can be safely administered through a peripheral IV; dextrose concentrations below 5% should not be administered through a peripheral IV.
Correct answer: C
Rationale: Dextrose concentrations below 10% are considered safe for administration through a peripheral IV, as concentrations above this threshold can lead to phlebitis, causing inflammation of the vein. Concentrations above 10% should not be administered through a peripheral IV to prevent vein irritation. Choice A is incorrect because concentrations above 20% are too high for a peripheral IV. Choice B is incorrect as dextrose concentrations below 5% are too low to be effective. Choice D is incorrect because the statement is reversed, suggesting that concentrations above 5% are safe, which is not true.
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