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. A nurse reviewing a client's record notes that the result of the client's latest Snellen chart vision test was 20/80. The nurse interprets the client's results in which way?
- A. The client is legally blind.
- B. The client has normal vision.
- C. The client can read at a distance of 20 feet what a client with normal vision can read at 80 feet.
- D. The client can read at a distance of 80 feet what a client with normal vision can read at 20 feet.
Correct answer: D
Rationale: When interpreting visual acuity testing results using the Snellen chart, the recorded numeric fraction represents the distance the client is standing from the chart and the distance a normal eye could read that particular line. A reading of 20/80 means that the client can read at 20 feet what a client with normal vision can read at 80 feet. This indicates visual impairment but does not meet the criteria for legal blindness, which is defined as best-corrected vision in the better eye of 20/200 or worse. Normal visual acuity is 20/20. Therefore, the correct interpretation is that the client can read at a distance of 80 feet what a client with normal vision can read at 20 feet. Choice A is incorrect because 20/80 does not meet the criteria for legal blindness. Choice B is incorrect as the client's vision is impaired. Choice C is incorrect because it reverses the interpretation of the fraction.
3. A nurse reviewing the physical assessment findings in a client's health care record notes documentation that the Phalen test caused numbness and burning. Which disorder does the nurse, on the basis of this finding, conclude that the client has?
- A. Scoliosis
- B. Bone deformity
- C. Heberden nodules
- D. Carpal tunnel syndrome
Correct answer: D
Rationale: The Phalen test is specifically used to assess for carpal tunnel syndrome. In this test, the client is asked to hold their hands back to back while flexing the wrists 90 degrees, which can reproduce the numbness and burning sensation experienced by individuals with carpal tunnel syndrome. Scoliosis is a condition characterized by abnormal lateral curvature of the spine, not related to the Phalen test. Bone deformity is a general term that does not specifically relate to the symptoms described. Heberden nodules are bony swellings that occur in osteoarthritis and are not assessed through the Phalen test.
4. A teenager is preparing to care for a hospitalized teenage girl who is in skeletal traction. The teenager assists with planning care knowing that which is the most likely primary concern of the teenage girl?
- A. Keeping up with schoolwork
- B. Body image
- C. Obtaining adequate rest and sleep
- D. Obtaining adequate nutrition
Correct answer: B
Rationale: The correct answer is 'Body image.' Adolescents, especially teenage girls, are often preoccupied with their appearance and body image. When facing a situation like being in skeletal traction, which can affect their physical appearance, body image becomes a primary concern. Concerns about body image can significantly impact their self-esteem and emotional well-being. Choice A, 'Keeping up with schoolwork,' is important but typically not the primary concern in this context. Choices C and D, 'Obtaining adequate rest and sleep' and 'Obtaining adequate nutrition,' are crucial for overall health but are secondary to the significant impact that body image concerns can have on a teenage girl in this situation.
5. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
- A. "I should put alcohol on my baby's cord 3-4 times a day."?
- B. "I should put the baby's diaper on so that it covers the cord."?
- C. "I should call the physician if the cord becomes dark."?
- D. "I should wash my hands before and after I take care of the cord."?
Correct answer: A
Rationale: Explanation: Parents should be taught that putting alcohol or other antimicrobials on the cord is no longer recommended for cord care. This can interfere with the natural healing process and may increase the risk of irritation or infection. Washing hands before and after providing cord care is essential to prevent the transfer of pathogens. Placing the baby's diaper below the cord allows it to be exposed to air and promotes drying, reducing the risk of infection. It is normal for the cord to turn dark as it dries, so calling the physician only if the cord becomes red, swollen, or has discharge is appropriate. Therefore, the statement '"I should put alcohol on my baby's cord 3-4 times a day."?' indicates a need for further teaching about cord care.
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