NCLEX NCLEX-RN
Health Promotion and Maintenance NCLEX RN Questions
1. The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?
- A. Irregular breathing patterns
- B. Minimal heartbeat, dilated pupils
- C. Relaxed muscles, regular breathing, constricted pupils
- D. Euphoria, drowsiness, dizziness
Correct answer: D: Euphoria, drowsiness, dizziness
Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.
2. Which of the following is an example of intrapersonal conflict?
- A. A nurse feels guilty when she administers essential medication that causes a client to have nausea and vomiting
- B. A nurse is called to testify in court about a client she cared for three years ago
- C. A nurse feels guilty for working overtime
- D. A nurse faces a conflict with a colleague over patient care decisions
Correct answer: A nurse feels guilty when she administers essential medication that causes a client to have nausea and vomiting
Rationale: Intrapersonal conflict involves negative feelings or frustrations within oneself. It may be related to decisions or actions that clash with personal morals or beliefs. Choice A is the correct answer because the nurse is experiencing guilt due to administering medication that causes a client to have negative side effects, which reflects an internal struggle. Choices B, C, and D do not represent intrapersonal conflict. Choice B involves a legal obligation, Choice C is related to external factors like working overtime, and Choice D pertains to a conflict with a colleague.
3. When teaching a client with coronary artery disease about nutrition, what should the nurse emphasize?
- A. Eating three balanced meals a day
- B. Adding complex carbohydrates
- C. Avoiding very heavy meals
- D. Limiting sodium intake to 7 g per day
Correct answer: Avoiding very heavy meals
Rationale: The correct answer is to emphasize avoiding very heavy meals. Eating large, heavy meals can divert blood away from the heart for digestion, potentially endangering clients with coronary artery disease. This practice may lead to an increased risk of plaque accumulation in the arteries, potentially obstructing the delivery of blood and oxygen to vital organs. Choices A, B, and D are incorrect. While eating three balanced meals a day, adding complex carbohydrates, and limiting sodium intake are generally good dietary practices, they are not the primary focus when teaching a client with coronary artery disease about nutrition. The emphasis should be on avoiding heavy meals that can strain the cardiovascular system.
4. During an adolescent examination, the nurse asks a 13-year-old female to bend forward at the waist with arms hanging freely. Which of the following assessments is the nurse most likely conducting?
- A. Spinal flexibility
- B. Leg length disparity
- C. Hypostatic blood pressure
- D. Scoliosis
Correct answer: D: Scoliosis
Rationale: The correct answer is scoliosis. During the assessment for scoliosis, the nurse asks the adolescent to bend forward at the waist with arms hanging freely to observe for any lateral deviation of the spine, uneven rib levels, or asymmetry. This assessment is a routine part of an adolescent examination, especially in females, as scoliosis is more common in this population. Choices A, B, and C are incorrect. Spinal flexibility is usually assessed through different maneuvers, leg length disparity is evaluated by measuring the length of the legs, and hypostatic blood pressure refers to a decrease in blood pressure due to immobility.
5. What consideration is important when caring for a female Muslim patient?
- A. Make eye contact
- B. Provide long-sleeved gowns or allow her to use her own
- C. Touch while talking
- D. Assign male caregivers when possible
Correct answer: Provide long-sleeved gowns or allow her to use her own
Rationale: When caring for a female Muslim patient, providing long-sleeved gowns or allowing her to use her own clothing is crucial. Most Muslim women prefer to cover their whole body, even during examinations. Offering long gowns with long sleeves or allowing the patient to use her own clothing respects her cultural and religious preferences. Making eye contact is not a common practice in some Muslim cultures, so it's important to be mindful of this and respect the patient's preferences. Touching while talking may not be culturally appropriate for some Muslim patients, so it's best to avoid it unless necessary. Assigning female caregivers is often preferred to respect the patient's modesty and religious beliefs. If a male caregiver or physician needs to interact with the patient, the patient's husband may request to be present in the room.
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