NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. When caring for pediatric clients, the nurse should pay special attention to the psychosocial development stages credited to whom?
- A. Robert Peck
- B. Erik Erikson
- C. Sigmund Freud
- D. Jean Piaget
Correct answer: B
Rationale: Erik Erikson is credited with the psychosocial development theory and eight stages. The nurse should consider these stages when caring for pediatric clients to evaluate their development. Jean Piaget is known for cognitive development, Sigmund Freud for psychosexual development, and Robert Peck for aging theory. Therefore, the correct answer is Erik Erikson.
2. During a genital examination of a male client, a nurse notices wrinkled skin on the penis and scrotum. What should the nurse do based on this finding?
- A. Documents the normal finding
- B. Checks for penile discharge, as this indicates infection
- C. Palpates for a mass in the scrotum, as wrinkling suggests the presence of one
- D. Obtains additional subjective data from the client, focusing on the scrotal abnormality
Correct answer: A
Rationale: The penile skin typically appears wrinkled and hairless, without lesions, during a normal examination. Also, the scrotal skin naturally has a wrinkled appearance known as rugae. It is common for the left half of the scrotum to be positioned lower than the right, indicating normal asymmetry. Given these normal variations, the nurse should document the finding of wrinkled skin on the penis and scrotum. Checking for penile discharge or palpating for a mass in the scrotum is not indicated based on the presence of wrinkled skin, as this is a normal finding. Obtaining additional subjective data focusing on a scrotal abnormality is unnecessary since the wrinkled appearance is typical.
3. After breast reconstruction secondary to breast cancer, the nurse should recognize which of the following expected client outcomes as evidence of a favorable response to nursing interventions related to disturbed body image?
- A. maintaining adequate tissue perfusion
- B. demonstrating behaviors that reduce fears
- C. restored body integrity
- D. remaining free of infection
Correct answer: C
Rationale: The correct answer is 'restored body integrity.' This outcome is crucial in addressing disturbed body image following breast reconstruction. Restored body integrity reflects a positive perception of one's body after surgery, contributing to improved body image. Choices A, 'maintaining adequate tissue perfusion,' are more related to physiological outcomes and are not directly linked to body image concerns. Choice B, 'demonstrating behaviors that reduce fears,' is associated with anxiety management, not body image. Choice D, 'remaining free of infection,' pertains to preventing infections and does not directly address body image concerns.
4. A nurse is preparing a female client for a rectal examination. Into which position does the nurse assist the client?
- A. Supine
- B. Standing
- C. Lithotomy
- D. Left lateral
Correct answer: D
Rationale: For a rectal examination in a female client, the nurse should assist the client into the left lateral position. This position allows easier access to the rectal area, facilitating the examination. The lithotomy position is used for examining the genitalia and rectum in females, not solely for a rectal examination. The standing position is not appropriate for a rectal examination as it does not provide the necessary access. The supine position would hinder the effectiveness of a rectal examination as it does not optimize access to the rectal area.
5. A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action?
- A. Uses a cotton-tipped swab to carefully clean inside the infant's nose
- B. Uncovers only the body part being washed
- C. Washes the diaper area first
- D. Washes the infant's chest first
Correct answer: B
Rationale: When bathing a newborn, it is crucial to follow a specific sequence for thorough cleaning and safety. The correct sequence includes starting with the eyes and face, then moving to the external ear, areas behind the ears, neck, hands, arms, legs, and finally the diaper area. Keeping the infant warm is essential, so only the body part being washed should be uncovered. Using a cotton-tipped swab to clean inside the infant's nose is not recommended due to the risk of injury if the infant moves suddenly. Washing the diaper area first is incorrect as it should be done towards the end of the bath to prevent contamination. Washing the infant's chest first is also incorrect as it deviates from the recommended bathing sequence for a newborn.
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