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. When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?
- A. Palpating the carotid artery in the upper third of the neck
- B. Palpating both arteries simultaneously to compare amplitude
- C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits
- D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery
Correct answer: C
Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.
3. The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible
- B. taking care of the whole person"?body, mind, spirit, heart, and soul
- C. no interventions are needed because the client is near death
- D. supporting the needs of the family and client
Correct answer: C
Rationale: The goals of palliative care include choices A, B, and D. Choice C, 'no interventions are needed because the client is near death,' is not part of palliative care. Palliative care involves giving clients with life-threatening illnesses the best quality of life possible, taking care of the whole person"?body, mind, spirit, heart, and soul, and supporting the needs of the family and client. Interventions are crucial in palliative care to ensure the comfort and well-being of the client until the end of life. Therefore, the correct answer is that no interventions are needed because the client is near death.
4. An assessment of the skull of a normal 10-month-old baby should identify which of the following?
- A. closure of the posterior fontanel.
- B. closure of the anterior fontanel.
- C. overlap of cranial bones.
- D. ossification of the sutures
Correct answer: A
Rationale: The correct answer is the closure of the posterior fontanel. By 10 months of age, the posterior fontanel should be closed. The anterior fontanel typically closes around 12-18 months of age. Overlapping of cranial bones is not a normal finding and may indicate craniosynostosis, a condition where the sutures close too early. Ossification of the sutures is also not a normal finding in a 10-month-old baby as the sutures should remain open to allow for the growth of the skull.
5. A nurse is preparing to assess a client for the presence of the Tinel sign. Which action does the nurse take to elicit this sign?
- A. Testing for the strength of each muscle joint
- B. Percussing at the location of the median nerve
- C. Checking for repetitive movements in the joints
- D. Asking the client to flex the wrist 90 degrees while holding the hands back to back
Correct answer: B
Rationale: The Tinel sign is elicited by percussing at the location of the median nerve at the wrist. In carpal tunnel syndrome, this test can produce burning and tingling along the nerve's distribution. Choices A, C, and D are incorrect. Testing for the strength of each muscle joint and checking for repetitive movements in the joints involve different assessments unrelated to the Tinel sign. Asking the client to flex the wrist 90 degrees while holding the hands back to back is associated with the Phalen test, which is another evaluation for carpal tunnel syndrome.
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