NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. Which of these is not a symptom of Serotonin Syndrome?
- A. edema
- B. fever
- C. confusion
- D. tremors
Correct answer: A
Rationale: Serotonin syndrome, caused by an excess of serotonin, typically presents with symptoms such as altered mental status (confusion), neuromuscular abnormalities (tremors), and autonomic dysfunction (fever). Edema, which refers to swelling caused by fluid retention in the body tissues, is not a common symptom associated with serotonin syndrome. Therefore, the correct answer is 'edema.' Choice A, 'edema,' is the correct answer as it is not typically seen in serotonin syndrome. Choice B, 'fever,' is a symptom of serotonin syndrome, as it can cause autonomic dysfunction. Choice C, 'confusion,' is a common symptom due to altered mental status in serotonin syndrome. Choice D, 'tremors,' is also a common symptom due to neuromuscular abnormalities in serotonin syndrome.
2. The parents of a 2-year-old child ask the nurse how they can teach their child to stop taking toys away from other children. Which of the following statements by the nurse offers the parents the best explanation of their child's behavior?
- A. "Your child is egocentric. Egocentricity is normal for 2-year-old children. He believes other children want him to have their toys."?
- B. "Your child is showing negativity. He doesn't want other children to have the toys he wants."?
- C. "Your child is demonstrating magical thinking. He believes he can make the other children want him to play with their toys."?
- D. "Your child is engaging in domestic imitation. He is doing what he has seen other children do."?
Correct answer: A
Rationale: Two-year-old children are very egocentric, believing everything revolves around them. They think other children want them to have their toys, which explains why they may take toys from others. This behavior is typical for children at this age as they lack the ability to see things from another's perspective. Option B is incorrect because negativity in children this age is more related to refusal of requests rather than taking toys. Magical thinking, as described in option C, is usually seen in preschool-age children and involves unrealistic beliefs. Option D is incorrect as domestic imitation refers to imitating adult household tasks, not other children's behavior.
3. If a client has chronic renal failure, which of the following sexual complications is the client at risk of developing?
- A. retrograde ejaculation
- B. decreased plasma testosterone
- C. hypertrophy of testicles
- D. state of euphoria
Correct answer: B
Rationale: In chronic renal failure, untreated, the client is at risk of developing decreased plasma testosterone. This condition leads to atrophy of the testicles and decreased spermatogenesis. Retrograde ejaculation is not a complication of chronic renal failure but can occur after transurethral resection of the prostate. The testicles atrophy in chronic renal failure; they do not hypertrophy. Additionally, chronic renal failure often leads to a state of depression, not euphoria.
4. While assessing a client’s skin, the nurse notes the presence of several large red-blue and purple areas on the client’s body that do not blanch when pressure is applied. The nurse documents this finding using which term?
- A. Psoriasis
- B. Anasarca
- C. Petechiae
- D. Ecchymosis
Correct answer: D
Rationale: Ecchymosis refers to a large patch of capillary bleeding into the tissues, commonly known as a bruise. The color of such an area changes from red-blue or purple to green, yellow, and brown before the area disappears. Pressure on the area will not cause it to blanch. Psoriasis is characterized by scaly erythematous patches with silvery scales on top, usually found on specific areas like the scalp, elbows, knees, low back, and anogenital area. Anasarca is bilateral or generalized edema, indicating a central problem like congestive heart failure or kidney failure. Petechiae are tiny purple or red spots resulting from tiny hemorrhages within the dermal and subdermal areas. Therefore, in this case, the correct term to document the described finding is Ecchymosis.
5. When assessing Mr. Lee's eye condition, what general information should the nurse seek?
- A. Type of employment.
- B. Burning or itchy sensation in the eyes.
- C. Position of the eyelids.
- D. Existence of floaters.
Correct answer: A
Rationale: When assessing a patient's eye condition, the nurse should seek general information such as the type of employment, activities, allergies, medications, lenses, and protective devices used. This information helps in understanding potential exposures to irritants and risks related to activities. While the presence of burning or itchy sensation in the eyes, position of the eyelids, and existence of floaters are important aspects to assess during a focused eye examination, during the initial assessment, the type of employment is more relevant for understanding possible environmental factors affecting eye health.
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