NCLEX-PN
Health Promotion and Maintenance NCLEX Questions
1. When teaching parents how their children learn sex role identification, the nurse should include which of the following statements?
- A. Sex role identification begins in infancy.
- B. Sex role identification begins in the preschool years.
- C. Sex role identification begins during the school-age years.
- D. Sex role identification begins during early adolescence.
Correct answer: A
Rationale: Sex role identification begins during infancy as infants can identify body parts by the end of the first year. Preschoolers often engage in masturbation and sex play. School-age children continue to develop awareness of their sexual identity, including behaviors like hugging and kissing. Early adolescence sees further development influenced by sexual maturation and experimentation with sex roles. Therefore, the correct statement is that sex role identification begins in infancy. Choices B, C, and D are incorrect as they misrepresent the timeline of the development of sex role identification in children.
2. A patient reports, "I tore 3 of my 4 Rotator cuff muscles in the past."? Which of the following muscles cannot be considered as possibly being torn?
- A. Teres minor
- B. Teres major
- C. Supraspinatus
- D. Infraspinatus
Correct answer: B
Rationale: The correct answer is Teres major. The Rotator Cuff consists of Teres Minor, Infraspinatus, Supraspinatus, and Subscapularis muscles, not Teres major. Teres major is not part of the rotator cuff, so it cannot be considered as possibly being torn. The other choices, Teres minor, Supraspinatus, and Infraspinatus, are all part of the Rotator Cuff and could potentially be torn in this patient's case.
3. A client is taking phenelzine (Nardil), and their spouse would like to bring lunch from home. Which of the following is most appropriate for the client to eat?
- A. a banana
- B. grapefruit
- C. a salami sandwich
- D. avocado slices
Correct answer: B
Rationale: The correct answer is grapefruit. Clients taking MAO Inhibitors like phenelzine (Nardil) should avoid foods rich in tyramine to prevent hypertensive crisis. Grapefruit is a suitable choice as it is not high in tyramine. Bananas, avocados, and salami are foods that should be avoided due to their tyramine content, which can interact adversely with MAO Inhibitors. Therefore, choosing grapefruit is the safest option for the client.
4. How often should a 5-year-old child undergo a dental examination?
- A. Every 6 months
- B. Whenever a new primary tooth erupts
- C. Once a year
- D. Every 3 months
Correct answer: A
Rationale: For a 5-year-old child, dental examinations should be conducted every 6 months. This frequency allows for early detection of dental issues and promotes good oral health. Choices B, C, and D are incorrect because waiting for a new primary tooth to erupt, having an examination once a year, or every 3 months are not the recommended intervals for dental check-ups in this age group. It is essential to adhere to the standard guideline of every 6 months to ensure regular monitoring and preventive care for the child's dental health.
5. A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?
- A. Contacting the registered nurse
- B. Documenting the findings
- C. Wrapping an extra blanket around the infant
- D. Placing the infant in an oxygen tent
Correct answer: B
Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.
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