NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self-Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct answer: B
Rationale: The correct answer is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and completeness related to infertility, indicating a disturbance in body image perception. 'Risk for Self-Harm' is not the best choice as there is no indication of immediate self-harm. 'Ineffective Role Performance' is less appropriate since the statement does not directly relate to a disruption in the parent's role. 'Powerlessness' could be considered if the client expressed feelings of powerlessness specifically related to the infertility issue.
2. A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?
- A. Coffee
- B. A tuning fork
- C. A wisp of cotton
- D. An ophthalmoscope
Correct answer: C
Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.
3. How should a nurse listen to the breath sounds of a client?
- A. Ask the client to lie prone.
- B. Ask the client to breathe in and out through the nose.
- C. Hold the bell of the stethoscope lightly against the chest.
- D. Listen for at least one full respiration in each location on the chest.
Correct answer: D
Rationale: To best listen to breath sounds, the nurse should have the client sit, leaning slightly forward, with arms resting comfortably across the lap. The client should be instructed to breathe through the mouth a little deeper than usual, but to stop if feeling dizzy. The nurse should hold the flat diaphragm end piece of the stethoscope firmly against the client's chest wall. It is crucial to listen for at least one full respiration in each location on the chest to assess breath sounds accurately. Side-to-side comparison is essential in breath sound assessment. Therefore, options A, B, and C are incorrect as they do not align with the correct procedure for listening to breath sounds.
4. The nurse is caring for a female client who has recently been diagnosed with cancer and will soon begin chemotherapy. Which of these statements would require additional follow-up and education?
- A. I will be most susceptible to an infection between 7 and 12 days after chemotherapy.
- B. I should try to get my annual teeth cleaning in before beginning chemotherapy.
- C. I should wait until all my hair falls out to purchase a wig.
- D. I should try to drink 8-10 glasses of water a day.
Correct answer: C
Rationale: This client is at risk for altered body image due to chemotherapy-induced hair loss. A wig can assist in coping with this change. It is advisable for the client to shop for a wig before hair loss occurs to better match color and style. Waiting until all hair falls out may lead to stress and limited options in finding a suitable wig. Choices A, B, and D are accurate. Understanding the timing of susceptibility to infection, maintaining oral health before chemotherapy, and staying hydrated are important aspects of care during chemotherapy. Therefore, the statement 'I should wait until all my hair falls out to purchase a wig' requires additional follow-up and education.
5. A healthcare professional is assisting with data collection of a client with suspected cholecystitis. Which finding does the healthcare professional expect to note if cholecystitis is present?
- A. Homan sign
- B. Murphy sign
- C. Blumberg sign
- D. McBurney sign
Correct answer: B
Rationale: The correct answer is B: Murphy sign. The Murphy sign is an indicator of gallbladder disease. It involves the examiner placing fingers under the liver border while the client inhales. If the gallbladder is inflamed, it descends onto the fingers, causing pain. The Homan sign is associated with pain in the calf area upon sharp dorsiflexion of the foot, indicating deep vein thrombosis. The Blumberg sign is the presence of rebound tenderness on palpation of the abdomen, indicating peritoneal irritation. The McBurney sign is indicative of appendicitis, presenting as severe pain and tenderness upon palpation at McBurney's point in the right lower quadrant of the abdomen.
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