NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. What is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct answer: D
Rationale: Altered Family Processes play a significant role in impacting the body image of an infant newly diagnosed with Hemophilia. Infants are highly perceptive of their caregivers' responses, and any changes in family dynamics due to the diagnosis can affect the infant's sense of security and trust, influencing their body image and self-perception. Immobility, while a long-term effect of hemophilia, is not an immediate impact on body image. Altered growth and development would not have manifested immediately post-diagnosis. Hemarthrosis, characterized by bleeding into joint spaces, is a hallmark of hemophilia but does not directly influence body image in the immediate aftermath of a new diagnosis.
2. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?
- A. Hypoactive bowel sounds
- B. Low-pitched bowel sounds
- C. Hyperactive bowel sounds
- D. An absence of bowel sounds
Correct answer: C
Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.
3. During an interview, what action should a nurse conducting an interview with a client take to collect subjective data?
- A. Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors
- B. Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying
- C. Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort
- D. Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable
Correct answer: A
Rationale: During an interview, a nurse should minimize note-taking to focus on the client and not impede the conversation. Taking minimal notes allows the nurse to effectively observe the client's nonverbal behaviors, which provide valuable subjective data. Option B, taking many notes, is incorrect as it can distract the nurse from the client's cues and hinder interaction. Option C, taking notes to break eye contact, is incorrect as it may decrease the client's comfort level and disrupt communication. Option D, taking notes to shift attention away from the client, is incorrect as it diminishes the client's importance and may make them uncomfortable during sensitive discussions. Therefore, the correct approach is for the nurse to take minimal notes, ensuring effective observation of the client's nonverbal behaviors while collecting subjective data.
4. A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client's chest?
- A. Second left interspace
- B. Second right interspace
- C. Left lower sternal border
- D. Fifth left interspace at the midclavicular line
Correct answer: D
Rationale: The correct placement for auscultating the apical heart rate in the area of the mitral valve is the fifth left interspace at the midclavicular line. Placing the stethoscope in the second left interspace would be to listen to the pulmonic valve, the second right interspace is for the aortic valve, and the left lower sternal border is for the tricuspid valve.
5. Assisting with data collection, a nurse notes tenderness while lightly palpating a client's right lower quadrant of the abdomen. The nurse determines that this finding is most likely associated with which anatomic structure?
- A. Liver
- B. Spleen
- C. Pancreas
- D. Appendix
Correct answer: D
Rationale: The correct answer is the Appendix. Tenderness in the right lower quadrant of the abdomen is a classic sign of appendicitis, which is inflammation of the appendix. The appendix is located in the right lower quadrant. The other choices are incorrect. The spleen is located on the posterolateral wall of the abdominal cavity under the diaphragm. The pancreas is located behind the stomach. The liver fills most of the right upper quadrant and extends to the left midclavicular line.
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