NCLEX-PN
Health Promotion and Maintenance NCLEX PN Questions
1. What is the primary nutritional deficiency of concern for a strict vegetarian?
- A. vitamin C
- B. vitamin B12
- C. vitamin E
- D. magnesium
Correct answer: B
Rationale: Vitamin B12 is the primary nutritional deficiency of concern for a strict vegetarian. While all mentioned vitamins are essential for overall health, vitamin B12 is particularly important for vegetarians as it is mainly found in animal products. A strict vegetarian diet may lack sufficient vitamin B12 intake, leading to potential health issues like anemia and neurological problems. Vitamin C deficiency is more commonly associated with scurvy, which is preventable with a diet rich in fruits and vegetables. Vitamin E deficiency is rare and usually only seen in specific medical conditions. Magnesium deficiency is not typically a primary concern for strict vegetarians as magnesium can be obtained from a variety of plant-based sources.
2. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?
- A. The client should remove all scatter rugs from the floor and minimize clutter.
- B. The client should not limit her movement within the home unless advised by the physician.
- C. The client should have a raised toilet seat and grab bars available in the bathroom.
- D. The client should not wear a robe and socks while walking in the house.
Correct answer: A
Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.
3. A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse provides the client with which information?
- A. She must have been exposed to the rubella virus at some point in her life.
- B. The test will need to be repeated during the pregnancy.
- C. She has not developed immunity to the rubella virus.
- D. The test results are normal.
Correct answer: B
Rationale: A rubella titer of less than 1:8 indicates that the client is not immune to rubella. In such cases, retesting will be necessary during the pregnancy. If the client is found to be non-immune, rubella immunization is required post-delivery. Therefore, choices A, C, and D are incorrect. Choice A suggests exposure, which cannot be confirmed by the titer result. Choice C wrongly implies that the client has not developed immunity, which is not accurate. Choice D is incorrect as the titer result is not within the normal immune range.
4. What causes an older female client's hair to turn gray?
- A. ''A loss of melanin occurs in the normal aging process.''
- B. ''The number of sweat glands and blood vessels decreases in the normal aging process.''
- C. ''The skin on the scalp becomes thin, causing moisture to escape.''
- D. ''It is caused by hereditary factors.''
Correct answer: A
Rationale: The correct answer is 'A loss of melanin occurs in the normal aging process.' Graying hair in older adults is primarily due to a decrease in the number of melanocytes responsible for providing pigment and hair color. This reduction in melanin production leads to gray hair. The other choices are incorrect. While it is true that the skin becomes thinner with aging and the number of sweat glands and blood vessels decreases, these changes are not directly related to graying hair. Additionally, hereditary factors can influence when graying starts, but they do not cause the graying of hair itself.
5. 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.
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